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Inspection on 10/10/06 for Beaufort Hall Nursing Home

Also see our care home review for Beaufort Hall Nursing Home for more information

This inspection was carried out on 10th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

What the care home does well

The staff ensure the well-being and comfort of the residents` and treat them with great respect and kindness. For example all of the residents spoken with said, "the home is lovely, the staff are kind and caring, and the food is good." Surveys returned spoke of "a very happy staff that will always help". Residents live in a very comfortable, safe and homely environment. It is decorated and furnished to a high standard and there are many homely touches. Meals are varied, well balanced and nicely presented offering choice and variety. An activities co-ordinator works hard to provide a lively programme of activities to meet the varied needs and wishes of the residents. Meeting residents` needs is given priority. There are good communications systems and there is strong leadership. Staff training is encouraged Residents feel that if they had something to complain about they would speak to a member of staff. All residents spoken with said they had nothing to complain about. Three residents said `the home is excellent`.

What has improved since the last inspection?

Work recommended at the last inspection to provide good fire safety precautions by renewing fire doors and renovating the fire escape, has been completed. The outside of the building has been painted and stonework repaired to prevent further rainwater leaks at the front of the house. Residents` contracts for terms of residency have been amended to show the breakdown of fees, as to who pays what, to make up the weekly amount due.

What the care home could do better:

The home is an old building and needs to obtain a certificate of safety for the electrical wiring throughout the home, to ensure the safety of residents from potential fire or electrocution. Despite attention having been given earlier in the year to the fire doors; a number of fire doors were not closing flush to the frame, especially those near the kitchen thus causing a potential hazard for resident. These should be adjusted to ensure close fitting to prevent smoke and fire spreading and for the protection of residents.

CARE HOMES FOR OLDER PEOPLE Beaufort Hall Nursing Home 28 & 30 Birnbeck Road Madeira Cove Weston Super Mare North Somerset BS23 2BT Lead Inspector Patricia Hellier Unannounced Inspection 10th October 2006 12:10 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 Beaufort Hall Nursing Home DS0000050501.V316751.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. Beaufort Hall Nursing Home DS0000050501.V316751.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaufort Hall Nursing Home Address 28 & 30 Birnbeck Road Madeira Cove Weston Super Mare North Somerset BS23 2BT 01934 620857 01934 414426 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) Boyack Enterprises Ltd Mrs Jacqueline Margaret Bowen Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability over 65 years of age (6) of places Beaufort Hall Nursing Home DS0000050501.V316751.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 6 persons aged 65 years and over with physical disabilities May accommodate up to 33 persons aged 65 years and over requiring nursing care Date of last inspection Brief Description of the Service: Beaufort Hall Nursing Home is registered for 33 elderly people aged 50 years or over. The home is on Weston-Super-Mare seafront and occupies a prominent position overlooking Marine Lake. The approach to the main entrance of the home is up a steep slope. Wheelchair access is available at the other end of the building. The home has 25 rooms used as single occupancy and four double rooms. All rooms have en suite toilets. Beaufort Hall is a four-storey building and has a six-person passenger lift accessing all floors. The home has been suitably adapted for the current resident group with handrails in corridors and grab rails in toilet facilities. There is a large dining room on the ground floor and two spacious lounges on the first floor, each of which has a small dining area. The home has a nurse call bell system throughout. There is a Registered Nurse on duty at all times. The home is well maintained, comfortably furnished and has a homely atmosphere. It is close to local amenities and the town centre. The current fees are £495 per week with additional charges being made for hairdressing, chiropody, newspapers, escorts, toiletries and social therapy entrance fees. This information was provided in September 2006. Beaufort Hall Nursing Home DS0000050501.V316751.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection, which is the 2nd for this inspection year, took place over seven hours and the manager was present throughout. The inspection was made in response to concerns raised that a complaint from early in the year had not been fully investigated and an outcome reached. Two other complaints had been received by CSCI about poor care practices, and residents being got up early, at the home from the period August to October 2006. Before the inspection the information about the home was received from a review of the last inspection report and all correspondence and regulatory activity since the last inspection. The accumulated evidence for this report comes from the above and also fieldwork that included the following: discussions with 14 residents, 3 relatives and 8 staff, observation of practices, tour of the premises, review of documents relating to care, recruitment and health and safety; review of policies; inspection of medication records and storage. As part of the inspection the recent complaints regarding poor care practices and very early rising for some residents were investigated. The complaints were partially upheld. All residents and staff spoken with told the inspector that the home was very good and the staff very kind. Comments received were “it is very homely and comfortable”; “I would recommend it to anyone”, “the staff are very kind and I can chose what I do”, “my relatives care needs are well met”. What the service does well: The staff ensure the well-being and comfort of the residents’ and treat them with great respect and kindness. For example all of the residents spoken with said, “the home is lovely, the staff are kind and caring, and the food is good.” Surveys returned spoke of “a very happy staff that will always help”. Residents live in a very comfortable, safe and homely environment. It is decorated and furnished to a high standard and there are many homely touches. Meals are varied, well balanced and nicely presented offering choice and variety. An activities co-ordinator works hard to provide a lively programme of activities to meet the varied needs and wishes of the residents. Meeting residents’ needs is given priority. There are good communications systems and there is strong leadership. Staff training is encouraged Beaufort Hall Nursing Home DS0000050501.V316751.R01.S.doc Version 5.2 Page 6 Residents feel that if they had something to complain about they would speak to a member of staff. All residents spoken with said they had nothing to complain about. Three residents said ‘the home is excellent’. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beaufort Hall Nursing Home DS0000050501.V316751.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 Beaufort Hall Nursing Home DS0000050501.V316751.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): 1,2,3,4,5 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 Residents’ guide is comprehensive and provides prospective residents with information to make an informed choice. The home’s assessment process is thorough and ensures that it is able to meet residents’ needs. Prospective residents and relatives are encouraged to visit the home to assess suitability. EVIDENCE: Residents are provided with a comprehensive Residents’ booklet containing the Statement of Purpose and all the information required to ensure they or their relatives have access to the relevant information at all times. The manager showed the inspector the revised Contract and Terms of Residency agreement in which the way the fees are made up are clearly specified, so that residents, or their relatives are aware of what is being paid and by whom. Beaufort Hall Nursing Home DS0000050501.V316751.R01.S.doc Version 5.2 Page 9 Care needs are well met through a full assessment process and the completion of a care plan from this information. The assessment documentation has been changed since the last inspection and this does not record full and informative information regarding the resident’s needs and preferences. This is recommended to support practice and knowledge of resident’s needs and wishes, as described by care staff and supported by relatives. One resident who had been admitted for respite care said that the care was “excellent.” The staff were “very attentive, kind and caring and fully meet my needs”. Social services care plans had been obtained where relevant. Care practices observed showed that staff were fully aware of the residents needs as stated in their assessments. Beaufort Hall Nursing Home DS0000050501.V316751.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): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from care plans that are well formulated and give clear information to enable staff to meet residents’ health care needs. Social needs and preferences are not so well identified. Personal and environmental risks are well managed. The systems in place for the management of medicines are poor. Respect and dignity are well maintained by kind and caring staff. EVIDENCE: Individual records are kept for each of the residents, which include a social history. Four of the six care plans inspected reflected clearly current identified health and social care needs. Clear actions to met identified needs were recorded and regular evaluation noted. All care plans showed resident or relative involvement. Two of the care plans of recently admitted residents did not contain a social or personal history, and did not reflect personal preferences or choices. Since the last inspection there have been changes in documentation that may in part account for this. Beaufort Hall Nursing Home DS0000050501.V316751.R01.S.doc Version 5.2 Page 11 As part of the complaint investigation, from the names given by staff who identified residents that liked to get up early, these residents were case tracked. In one of the six care plans inspected an early rising preference had been recorded, and when interviewed the resident told the inspector that she liked to get up early. The other five care plans did show any preferences or sleeping / waking patterns and three of the residents lacked capacity to express choice. It is recommended that this practice of social history taking and seeking resident choices and preferences, from themselves or relatives, be re-implemented for all new residents into the home. All care plans contained well-formulated risk assessments for Manual Handling, Falls, Nutrition and Pressure areas. These risks had been translated into the care plans to meet the need identified, and reduce the risk. Daily records were up to date and written in a respectful manner. The system for the management of medicines was not fully inspected, but the administration practices were observed and discussed. As part of the investigation into the complaint that tablets are left with residents and not administered in the correct manner, the teatime medication practices were observed and seen to be satisfactory. During interviews with staff some said that they had seen medication left beside residents for them to take later. Two other members of staff said they “do leave medication beside residents for them to take later, sometimes”. This is unsafe practice and does not provide the necessary safeguards for the protection of residents. Consent for use of bed rails and recliner chairs had been obtained from residents or their relatives to protect residents from potential restraint against their wishes. All residents spoken with said “the staff are excellent”, “I am well looked after”, “I can do what I want when I want”, they are always there when I need them”. All residents spoken with felt that kind and caring staff respected their dignity and privacy. The home has an Equality and Diversity policy that recognises the cultural and social needs and differences that are present in society. In discussion with the manager and staff these issues have not yet arisen within the service provision. Both management and staff demonstrated clear knowledge and desire to meet cultural and diversity needs as and when they should arise. Beaufort Hall Nursing Home DS0000050501.V316751.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): 12,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. Residents right to choice and control over their lives is respected, and encouraged for the most part. Autonomy and personal choice is promoted. Friendly staff always welcome relatives and visitors. EVIDENCE: A range of activities is provided with posters displaying information of forthcoming events throughout the home. One of the care staff is a part time activities organiser and seeks to provide an interesting and varied programme. It is evident from discussion with residents their relatives’ and the staff that personal choice and preferences are respected, and social activities to suit differing temperaments arranged. As mentioned above, preference and choice regarding sleeping and waking routines are not evidenced. Residents spoken with said, “we have plenty of choice and variety, the staff do various things with us, and the regular outings are nice.” “The staff are always willing to accommodate what we want”. Spiritual needs are catered for and local clergy visit as requested. Beaufort Hall Nursing Home DS0000050501.V316751.R01.S.doc Version 5.2 Page 13 Several visitors were seen coming and going during the inspection. Relatives spoken with said they could come any time and felt that their relatives were well looked after by friendly staff. One relative said, “the staff are so patient and residents never look untidy or uncomfortable”; another said, “the staff are lovely and care for Mum well. They couldn’t do more for her – I can’t fault them”. All the residents said that the ‘food is good’ and they “liked the daily choices offered”. For example one resident said ’if you don’t like something they’ll change it’. Menus showed a varied, balanced and nutritious diet. The dining room is homely and tables well presented. For residents that need assistance with their food a pleasant area in one of the lounges is used. Good practice was observed in this area where care staff were helping residents with their meal. Beaufort Hall Nursing Home DS0000050501.V316751.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): 16,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are confident that they are listened to and their requests acted upon, when made to the Registered Manager. Complaints made to the Provider are not always investigated within the framework of the complaints policy. Residents are protected from abuse by knowledgeable and competent staff EVIDENCE: The home has a complaints procedure which all residents have a copy of. It is not publicly displayed however residents and relative spoken with said they knew whom to complaint to – “they would speak to the manager”. There have been three complaints since the last inspection. The two referred to at the beginning of the report and which triggered this inspection; and one the provider was investigating. The complaint was made in May of this year and an outcome to the complaint has not yet been received from the provider. This is not within the detailed timescales within the complaints policy, or the timescales given when information regarding the delay was received. Despite further requests from the complainant, and CSCI, an outcome on completion of the investigation has never been received, and the complainant remains unsatisfied. This is not in accordance with the homes complaints policy, is unsatisfactory and not compliant with the law. Beaufort Hall Nursing Home DS0000050501.V316751.R01.S.doc Version 5.2 Page 15 Residents stated that if they were not happy about anything they would speak to the manager. Staff and residents spoken to, say the manager is very approachable and understanding. One resident said ‘I’ve nothing to complain about, it’s the best home I’ve been in”. A clear record of complaints received with actions taken and outcomes is kept, but does not include the outstanding complaint. The home has a copy of the ‘No Secrets’ in North Somerset guide and a comprehensive local policy and procedure for responding to allegations of abuse for the protection of residents. Staff interviewed were conversant with the homes Adult Protection policy and demonstrated good knowledge of the adult protection procedure that should be followed, if abuse is suspected. The home also has a Whistleblowing policy and staff said they would report any concerns to the manager. Staff said they had never seen any signs of abuse in the home. Eight residents said ‘the staff are very kind and take time, I have no complaints, I am very happy here”. Beaufort Hall Nursing Home DS0000050501.V316751.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): 19,22,24,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with homely, safe and comfortable surroundings. The home has suitable equipment to maximise resident independence. Robust Infection control practices are followed. EVIDENCE: The property is well maintained, with homely and comfortable communal spaces. Residents’ rooms are personalised and comfortable. Despite work earlier in the year some fire doors were not closing properly to safeguard residents from fire hazard. It is required these are adjusted to close properly. The home has grab rails situated at relevant points and a shaft lift that is easily used to assist resident mobility and aid independence within the home. All resident rooms are provided with locks that are accessible to staff in an emergency. Beaufort Hall Nursing Home DS0000050501.V316751.R01.S.doc Version 5.2 Page 17 The home was clean and free from offensive odours throughout. The laundry facilities are generally well organised, however staff said that there had been occasions recently when residents clothes had gone missing and some resident had been dressed in other resident’s clothes. This is poor practice and needs to be stopped. Staff interviewed said a new member of staff was now doing the laundry and things had improved. Staff interviewed and observed demonstrated good understanding of Infection Control procedures and practices and maintained a clean and hygienic environment. Beaufort Hall Nursing Home DS0000050501.V316751.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): 27,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s staffing levels are sufficient to manage the current care needs of residents. Staff access specific training to meet needs of residents EVIDENCE: Copies of two weeks staffing rosters were inspected. Staffing levels rostered were sufficient to meet residents’ needs. All of the residents spoken with told the inspector “staff are always there when you need them”, “ you only have to ring the bell and they come”. A sufficient team of ancillary workers supports care and nursing staff to ensure the smooth running of the service. The staff team are resident focussed but lack of teamwork at times can affect working practices. Staff interviewed spoke of times when there are difficulties in the team and standards of care delivered slip. The manager is aware of these issues and is working to build the team. This was reflected in the 2 complaints received between August and October. Staff observed, approached residents with directness, openness and consideration. Each of the residents with whom inspectors spoke said how nice the staff are, and many people gave examples of particular instances of kindness. One person said, being helped kindly makes all the difference in Beaufort Hall Nursing Home DS0000050501.V316751.R01.S.doc Version 5.2 Page 19 the world. Several of the resident’s are frail and were unable to make comment to the inspector. A number of staff from overseas are employed at the home and form part of the close-knit team. Staff and residents said their presence brought a breadth of experience and interest to the home. Three residents told the inspector they “liked the mixture of races and cultures represented as they reflected the areas they had come from, and thus made them feel at home”. Other residents and staff said, “Communication can sometimes be difficult”. The home supports staff to attend college to develop their language skills. Overseas staff interviewed said they ‘felt very welcomed in the home, enjoyed their jobs and were improving their English’. Evidence of specialist training accessed through the Primary Care Trust and other sources was seen e.g. stroke awareness. The manager and staff informed the inspector that the staff team are commencing some training in palliative care. Staff interviewed are keen to learn and all are undertaking one of the NVQ level qualifications. Beaufort Hall Nursing Home DS0000050501.V316751.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): 31,32,33,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager provides clear leadership and guidance to staff to ensure residents receive consistent care in a safe environment. Residents’ views are sought and acted on, but a formalised system is not in place. Health and safety issues are monitored in the home to ensure that issues are identified and addressed where they arise. EVIDENCE: The manager has a wealth of experience in care of the elderly. She gives clear leadership, guidance and direction to staff. Residents feel the manager is approachable, available and seeks to ensure all their needs are met. Staff interviewed stated that they felt well supported by an approachable manager. Beaufort Hall Nursing Home DS0000050501.V316751.R01.S.doc Version 5.2 Page 21 While the provider supports the manager he is slow to respond to his management responsibilities. A formal quality assurance tool was not available however residents and relatives told the inspectors that their views were sought and acted upon. Residents and relatives told the inspector that they were always encouraged to express their view and “to air the grumbles”. One resident said “they always do something about a grumble if you tell them”. A formalised quality assurance process is required. Records inspected indicated regular safety and fire checks are carried out. Staff spoken to confirmed that regular fire instruction and drills had taken place. As stated in the environment section some fire doors are ill fitting and need attention to ensure full closure for the protection of residents. A certificate of safety for the electrical wiring throughout the building was not available. This is required to ensure the safety of the system for the protection of residents. Beaufort Hall Nursing Home DS0000050501.V316751.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 3 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 X X 3 3 1 Beaufort Hall Nursing Home DS0000050501.V316751.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13.2 Timescale for action The registered person shall make 12/11/06 arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. This relates to the poor practice of leaving medication for resident’s to take later The registered person shall 30/11/06 ensure that any complaint made under the complaints procedure is fully investigated. This relates to the outstanding complaint from May 2006 The development of a formalised 31/01/07 system of Quality Assurance that analyses the results of a resident survey produces an action plan and feedback to residents and staff. Previous timescale of 28/08/06 not met The registered person shall after consultation with the fire authority (a) make adequate arrangements DS0000050501.V316751.R01.S.doc Requirement 2 OP16 22.3 3 OP33 24 4. OP38 23.4 (c) (i) 20/11/06 Beaufort Hall Nursing Home Version 5.2 Page 24 (i) for detecting containing and extinguishing fires This relates to the ill fitting fire doors within the home. 5 OP38 13.4 & 23.2 (b) The registered person shall 30/11/06 having regard to the number and needs of the service users ensure that: (b) the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally This relates to the need to obtain a certificate of safety for the electrical wiring of the home. Previous timescale of 20/07/06 not met 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 OP3 OP7 Good Practice Recommendations Assessments contain full information regarding social care needs and preferences to inform the care plan. Residents wishes regarding death to be recorded to ensure all staff have the knowledge to provide sensitive care at this point. Carried forward from last inspection – not inspected on this occasion That resident’s social needs and preferences are recorded in the care plans. Standards of care delivery are maintained when the manager is not on duty. 3 4 OP7 OP7 Beaufort Hall Nursing Home DS0000050501.V316751.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Beaufort Hall Nursing Home DS0000050501.V316751.R01.S.doc Version 5.2 Page 26 - 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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