Care Home: Beacon Court

Similar services:

• The Vicarage
• Fairfields Country Rest Home
• 7 Hyde Road
• 5 Seafield Road
• Poldhu
• Queensmount
• Trevaylor Manor
• Didsbury Court Rest Home

What the care home does well Good admission procedures and relevant information ensures that people know what to expect from the home and that their needs will be met. Everyone living at the home has a care plan that is reviewed regularly and tells staff how to meet the needs of the individual. There is evidence that the home works with other professionals to ensure the health care needs of people are satisfactorily met. People are supported in a caring and respectful manner by a well trained stable staff group. Staff are available in sufficient numbers to be able to meet the needs of individuals and take care to respect the privacy and dignity of individuals. There is a good range of activities and entertainments of offer to stimulate and occupy people and visitors are welcomed into the home. People are actively involved in the running of the home. Good food is provided, that is nutritious and offers people variety and choice. Complaints are generally well managed and people feel confident that any concerns will be taken seriously and acted upon. People live in a lovely environment that is comfortable and well maintained. There is a good quality assurance programme in place that ensures the quality of care provided at the home is monitored and maintained. One person commented via their survey form that `I often hear reports of poor homes on the radio. This is not one of them`. What has improved since the last inspection? Mrs Sharon Mewis has recently been registered as manager of the home. New care plans have been introduced and the home plans to purchase a mini bus to enable more outings to take place What the care home could do better: No immediate requirement were made at this visit, but one requirement was made relating to the availability of staff records.Several recommendations were made including, ensuring the new care plans are fully completed as soon as possible and that personal recordings are made in line with the Data protection Act. Hand written entries on MAR (Medication Administration Records) need to be double signed and the home should be more proactive in enabling people to self medicate, even if only partially. The recording of concerns should be improved and a policy relating to the fitting of Doorguards should be drawn up. The staff training programme should be improved to ensure all staff receive the training they need to be able to meet the varied needs of individuals. CARE HOMES FOR OLDER PEOPLE Beacon Court 4 Church Road Dartmouth Devon TQ6 9HQ Lead Inspector Sue Dewis Unannounced Inspection 27th August 2008 09:45 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 Beacon Court DS0000051573.V367875.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. Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beacon Court Address 4 Church Road Dartmouth Devon TQ6 9HQ 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) 01803 832672 01803 832672 Thurlestone Court Limited Sharon Mewis Care Home 34 Category(ies) of Dementia - over 65 years of age (34), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (34), Old age, not falling within any other category (34), Physical disability (34), Physical disability over 65 years of age (34) Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD from age 50 years Date of last inspection 29th August 2007 Brief Description of the Service: Beacon Court is a large detached house situated on a hill in a quiet residential area, and on a bus route going into Dartmouth town centre. There are 29 bedrooms, five of which are large enough to be used as twin rooms, though all are currently in single occupation. Most have an en suite toilet. Many rooms have views over the town and countryside. Accommodation is over four floors. Three of the floors are accessed via a shaft passenger lift and there is a stair lift to the lower ground floor (bottom floor). Two rooms on the first floor require the resident to be able to negotiate two steps to access the rooms. There are two lounges and a dining room, part of which easily converts to form a quiet craft area. A conservatory leads on to a sun terrace, which has far reaching views over Dartmouth and the surrounding area. There is a garden area at the rear of the property and a car parking area at the front. The home cares for older people, including those with dementia. The home may also offer care for residents with physical disabilities from the age of fifty years. The weekly fees range from £450 to £600. There may be a charge for escorted travel outside the home, including medical appointments. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at http:/www.oft.gov.uk . An up to date Service Users’ Guide may be obtained on request from the office, and the latest Inspection Report of the Commission for Social Care Inspection was on display in the entrance hall. Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced visit took place over 8 hours, one day towards the end of August 2008. The home had been notified that a review of the home was due and had been asked to complete and return an AQAA (Annual Quality Assurance Assessment). This shows us how the home has managed the quality of the service provided over the previous year. It also confirms the dates of maintenance of equipment and what policies and procedures are in place. Information from this document was used to write this report. During the inspection 3 people were case tracked. This involves looking at peoples’ individual plans of care, and speaking with the person and staff who care for them. This enables the Commission to better understand the experience of everyone living at the home. As part of the inspection process CSCI likes to ask as many people as possible for their opinion on how the home is run. We sent questionnaires out to people living at the home, health and social care professionals (including GPs and care managers) and staff. At the time of writing the report, responses had been received from people living at the home and 5 staff. Their comments and views have been included in this report and helped us to make a judgement about the service provided. During the inspection 3 people living at the home were spoken with individually and several others in a group setting, as well as observing staff and people living at the home throughout the day. We also spoke with 4 staff and the manager. A full tour of the building was made and a sample of records was looked at, including medications, care plans, the fire log book and staff files Mrs Sharon Mewis has recently been registered as manager for the home. Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: No immediate requirement were made at this visit, but one requirement was made relating to the availability of staff records. Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 7 Several recommendations were made including, ensuring the new care plans are fully completed as soon as possible and that personal recordings are made in line with the Data protection Act. Hand written entries on MAR (Medication Administration Records) need to be double signed and the home should be more proactive in enabling people to self medicate, even if only partially. The recording of concerns should be improved and a policy relating to the fitting of Doorguards should be drawn up. The staff training programme should be improved to ensure all staff receive the training they need to be able to meet the varied needs of individuals. 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. Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admission procedures at the home ensure people have sufficient information on which to base a decision and assessment procedures ensure that their care needs can be met. EVIDENCE: There is a detailed Statement of Purpose available that sets out the Aims and Objectives of the home, and tells people what can be expected from the home. One person commented via their survey form that ‘Information about the home was comprehensive’. Following an initial referral, information about the home is sent out and the person invited to visit the home, although this may not always be possible due to the person living some distance away or being in hospital. Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 10 Three people’s files were looked at, including that of the most recently admitted person. All of the files contained detailed pre-admission assessments. The home does not provide intermediate care. Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are generally well formulated and generally give clear information to ensure the consistency of care is maintained. Medicines are stored securely and administered appropriately to ensure the safety of people living at the home. EVIDENCE: Three care plans were looked at. They had been regularly reviewed and showed evidence of some involvement of the person and/or their representatives. Care plans are currently being changed over to a new recording format. All three plans that were looked at had copies of the new format in them, but they Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 12 were not all fully completed. In particular there were gaps in the ‘My history’ sections. The plans are produced from the pre-admission assessments and adjusted as people’s needs change. The new format is written in the ‘first person’ and includes sections on ‘My dietary needs’, ‘My bedtime routine’ and ‘How to help with my care’. However, whilst the plans were quite detailed, they are not specific as how to how the day to day needs of the individual are to be met. For example the ‘specific behaviour’ section for one individual said ‘tends to wander regardless of time or attire’, but did not tell staff how they were to deal with behaviour, if at all. Good, clear written instructions to staff are essential to ensure consistency of care. The plans also contain risk assessments for several areas including self medication, moving and handling and pressure areas. Good records are maintained showing the involvement of healthcare professionals and it was possible to see where they had been called in for advice. For example a Community Psychiatric Nurse has recently given a talk about dementia. One GP commented via their survey form that ‘The home is well led by Sharon who raises issues productively with GP’s and is aware of any problems raised by her staff. When I have contact with support staff they are generally aware of the problems involved and have familiarity with the patient. I am happy that this home is well run’. Many recordings relating to individuals are made in a ‘handover book’. Whilst references are made only to room numbers personal information is recorded in this book. Recording in this manner contravenes the data protection Act as individuals who wished to see information about themselves would also be able to see personal information about other people. The home currently uses a monitored dose ‘Nomad’ system for the administration of medicines. Only senior staff administer medicines and they have received appropriate training that tested their knowledge. Administration records were generally well maintained, though handwritten entries to MAR (Medication Administration Record) sheets were not double signed. Creams and eye drops are marked with the date of disposal, after opening. All medicines were stored securely, with a small fridge available for medication that needs refrigeration. Risk assessments for self medication are completed for everyone. Some people do administer their own inhalers but there is little evidence that ways are sought to enable people to be more independent in this area. The home does not keep any ‘homely remedies’. Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 13 Staff were seen offering personal care in a discreet manner, they spoke with people in a friendly and respectful way, and always knocked on doors before entering. All bedrooms, toilets and bathrooms have suitable locks fitted to the doors to ensure people’s privacy is maintained. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the agency intends to ask Funeral Directors to visit to enable staff to complete their knowledge in after care of the dying. Also to introduce new measures to combat chronic UTIs (Urinary Tract Infections). Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home offers an excellent range of activities and entertainments to stimulate and occupy people. Links with visitors and the community are good, giving opportunities to support and enrich people’s social life. Meals provide nutritious variety and choice for individuals. EVIDENCE: Three people were spoken with in private and several others were observed and spoken with in the lounge and conservatory. All appeared happy and relaxed, and good interaction that promoted wellbeing was seen between staff and individuals. Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 15 Regular activities and entertainments are on offer including Bingo, Scrabble and arts and crafts sessions. One person commented via their survey form that there is ‘a wide variety of activities and entertainment available every day’. Staff who are on duty are allocated the task of activities each morning and afternoon. Staff and people living at the home told us there is also time for staff to sit chatting with individuals, although one person said they wished staff had more time to spend with them. There is a reminiscence session that is organised by an individual living at the home as well as regular music therapy sessions. We were told by the manager that the music therapy sessions are very popular and that about 17 people attend each session. The therapist also holds some 1:1 sessions with people who do not attend the group sessions. We were told by staff and also observed through the visit, that people are regularly offered choices. Choices include what time people get up and go to bed, what they want to eat and where they sit. Regular meetings are held so that people who live at the home can be consulted about on a variety of subjects. On the day of the visit a meeting was held to discuss where people would like to go on outings once the new minibus had been obtained. One individual told us that they go out about three times a week to visit friends and to see their hairdresser. The cook and the manager told us that they are always talking to individuals to find out what they like to eat and use this information to prepare menus. Menus show that a good balance diet is offered to people and that there is always an alternative on offer if someone doesn’t like something on the menu. Fresh fruit is on offer at all times and a sweet trolley is taken to the dining room at tea-time so people can see the selection on offer. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the agency intends to provide a minibus. Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are confident that any complaints would be dealt with appropriately. They are protected by staff that are able to recognise abuse and generally know their duty to report poor practice. EVIDENCE: There is a simple complaints procedure contained displayed in the hallway, but the address and telephone number for The Commission needs to be changed to show the new details. Although people were generally not able to tell us anything about the ‘complaints procedure’, they were able to say who they would talk to if they had any concerns, and felt that if they did, issues would be dealt with immediately. One representative commented via the survey form they had completed on behalf of their relative that ‘Mom wouldn’t be able to make a complaint, but staff are always very helpful when I point anything out to them’. Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 17 A complaints log book is kept where no complaints have been recorded since 2006. There is still no record kept of any minor concerns raised by anyone living in working at or visiting the home. An incident book is kept where any untoward incidents involving people living at the home are recorded. Both books contain information on several people on the same page. This contravenes the Data protection Act as people would not be able to see information about themselves without seeing information about other people. No complaints have been received by the Commission since the last visit. Not all staff have received training in recognising and dealing with abuse. However, all four were able to describe a variety of differing kinds of abuse, including ignoring someone who is asking for help or unexplained bruising. Staff were aware of the correct procedures for reporting any suspicions to someone within the home but were unsure about involving other agencies such as the police or The Commission. Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 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 people with a good place in which to live, being clean, safe, comfortable and homely. EVIDENCE: We made a full tour of the communal areas of the home and saw some bedrooms. We saw that the home is safe, comfortable and well maintained. There are several communal areas around the home for the use of everyone. These communal areas are homely, with many ornaments and pictures around them. They are decorated and furnished in a very comfortable and pleasant manner to an excellent standard that meets the needs of individuals. Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 19 There are two lounges a dining area and conservatory joined together in open plan, but laid out and furnished in such a way as to give a choice of areas for people to be either quiet or sociable. There is a very pleasant conservatory with beautiful views across Dartmouth that people were enjoying during the visit. Some bedrooms were looked at, each had the individual’s possessions displayed and reflected the personalities of the occupant. The rooms contained all the items that people require in order to have their needs satisfactorily met and had suitable locks fitted to the doors to ensure their privacy. People who wish to have their bedroom doors open throughout the day are expected to pay to have an approved device fitted to their door to enable this. There is still no written policy regarding this, that outlines what would happen for example, if a person moved from a room where they had paid to have a device fitted, into a room where one was not fitted. There are two bathrooms and a shower, equipped for people with mobility problems. The laundry is small but well equipped to deal with the washing from people living there, and has an impervious floor covering to prevent cross infection from soiled laundry. Care staff are responsible for dealing with laundry items. Staff confirmed that they have access to disposable gloves and aprons, and were aware of good basic hygiene procedures. Staff were seen to be wearing disposable gloves and aprons where necessary. The home was clean, tidy and well maintained throughout, and there were no unpleasant odours. One person commented via their survey form that ‘the cleanliness of the home is excellent’. We were told that there is a regular programme of maintenance and upgrading and a maintenance man is employed to ensure any issues are dealt with straight away. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the agency intends to provide a treatment room. Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The deployment and numbers of staff available throughout the day and night are sufficient to meet the needs and numbers of the people currently living at the home. However, training could be improved. The procedures for the recruitment of staff are generally robust and offer full protection to people living at the home. EVIDENCE: During the morning of the visit there were 4 care staff on duty, including a senior, plus a cook, a cleaner, a handyman and the manager. During the afternoon there are usually 3 care staff on duty with a kitchen assistant and the manager. At night there are two staff awake. The care staff said that generally they did not feel rushed at any time and had time to spend chatting to individuals. There was a relaxed and unhurried atmosphere around the home, with staff meeting the needs of individuals in a quiet and competent manner. However, very mixed comments were received from staff and people living at the home about staffing levels. These included ‘I find the staff very helpful even though they are always very busy’, ‘Sometimes Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 21 it is difficult to find a member of staff when I visit’, ‘Staff generally available when needed – only emergencies prevent this’, ‘not always enough staff’,’ ‘(we have) struggled recently with staffing levels’ and ‘if we don’t have enough staff they get agency staff in’. Staff were well aware of the individual care needs of people living at the home and were able to describe these and how they are met on a day to day basis. Staff spoke with enthusiasm about the individuals and their work with them. One staff member told us that they liked it when they could see people progress and enjoyed talking to people to find out what their lives had been like. Staff files were available for inspection and three staff files were looked at. All contained recent photographs of the staff member. However, much information about staff is kept at the company’s head office and was not available for inspection. This included information relating to overseas employees and copies of police checks. One file for one staff member contained only one written reference and one testimonial. All information required in Schedule 2 of the Care Homes regulations should be available for inspection at the home at all times. There is a regular training plan provided by a qualified trainer employed by the Court group. Staff said and records showed that training had been provided in Infection Control, Moving and Handling and Effective Communication. Two staff told us that they had received some training relating to the Protection Of Vulnerable Adults (POVA) though two had not. Two staff had received training in dementia related matters and both had found this very useful. One member of staff said that they had almost completed NVQ level 3. The AQAA (Annual Quality Assurance Assessment) submitted prior to the inspection showed that 7 members of staff currently have NVQ level 2 or above. There is a thorough induction training for new staff and one recently employed staff member confirmed they had completed this. They also said that had not yet written care plans or given out medication The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the agency intends to continue to monitor and evaluate the training programmes. Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed resulting in practices that promote and safeguard the health, safety and welfare of people living and working at the home. EVIDENCE: Beacon Court is owned by Thurlestone Court Limited which is part of a group of loosely affiliated companies and partnerships collectively known as The Court Group. This group has a number of homes in the Torbay and South Hams areas of Devon and promotes a corporate identity and ethos. The manager Sharon Mewis has many years experience of working with older people and has Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 23 recently been registered with The Commission. She told us that she received good support from the organisation and encouraged to do a good job. Staff spoke positively about Mrs Mewis, with one saying that they thought she was ‘excellent’. However, mixed responses were received on survey forms with one saying ‘we can go into the office at any time to speak to the manager’, but others saying ‘not always good support from manager’ and ‘(staff) sometimes given the brush off like they don’t know anything or opinion is not needed’. There is a detailed quality assurance system in place to monitor the quality of care provided at the home. Regular meetings are held so that people living in the home can express their views about the home. Such a meeting was held on the day of the visit to ask people about activities and outings they would like. A representative of the owning company visits the home unannounced each month and prepares a report in line with Regulation 26. These reports covered many aspect of the running of the home and contained good detail. Health and Safety and training audits are also regularly completed and lack of training has been identified and is due to be addressed. The manager told us that she regularly ‘walks the floor’ and uses feedback from staff and visitors to identify any areas for improvement. Questionnaires are also regularly sent out to visitors, staff, health care professionals as well as people living in the home to gain their views about the quality of care provided by the home. The home has also gained the Investors In People Award (IIP). Small amounts of money is managed on behalf of some people living at the home. Records were clear and well maintained, but it would be good practice to obtain 2 signatures for all transactions. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit, provided evidence that Beacon Court complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. The fire logbook, record of fire safety training and accident and incident records were found to be accurate and up to date. Policies and procedures are not always inspected during the visit but the information provided on the AQAA helps us form a judgement as to whether the home has the correct policies to keep people living and working at the home safe. Information provided by the home, evidenced that policies and procedures are in place and along with risk assessments are reviewed regularly and updated where necessary, to ensure they remain appropriate and reduce risks to people living and working at the home. Staff confirmed that they receive regular training in fire precautions as well as Health and Safety. Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 24 The manager told us that so that the risk of burning from hot surfaces is minimised, radiators within the home have been covered. She also said that all windows above ground floor level are fitted with restrictors, in order to minimise the risk of anyone falling from these windows and that so that the risk of burning from hot water is minimised temperature controls are fitted to bath taps. Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 25 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 26 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 OP29 Regulation 17 (2)(3)(b) Requirement Staff records specified in Schedule 4 must be complete and available for inspection at all times. Timescale for action 30/11/08 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 OP7 OP9 Good Practice Recommendations You are recommended to complete new care plans for everyone living at the home as soon as possible. You are recommended to ensure handwritten entries that are added to MAR (Medication Administration Records) are double signed. You are recommended to be more proactive in enabling people to self medicate. You are recommended to ensure information relating to individual’s daily care is recorded in line with the Data protection Act. 3. 4. OP9 OP10 Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 27 5. OP16 You are recommended to improve the recording of all concerns that are raised and ensure they meet the Data Protection Act. You are recommended to ensure there is a full and complete policy relating to the purchase and fitting of Doorguards to individual’s bedroom doors. You are recommended to ensure staff receive appropriate training relevant to their post and especially relating to POVA (Protection Of Vulnerable Adults). 6. OP24 7. OP30 Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Beacon Court DS0000051573.V367875.R01.S.doc Version 5.2 Page 29 - 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!