Care Home: Beacon Farm Care Centre

What the care home does well Residents said, and it was seen, that staff were kind, considerate and supportive. There is a good complaints policy and procedures in place to make sure that any concerns or complaints are fully investigated with a full response of the findings given to the complainant. The home was clean with no offensive odours in the home on the day of inspection and communal areas appeared satisfactory. The laundry was clean, tidy and well organised and staff had good knowledge of hygiene and infection control. During the visit the relatives visiting were chatting in a very positive way with the staff and made positive comments about the management improvements. The home has a good system in place for accounting for personal allowances that are held for the residents. What has improved since the last inspection? Work to enrich the environment of the home has taken place to give a more stimulating and appropriate living space for the residents taking into account their dementia care needs. The meal times have been reviewed to make sure that they are supportive to residents having a pleasant and positive experience when having their meals. The home has undergone a refurbishment and redecoration programme providing comfortable and pleasant surroundings. A staff training programme is now available and includes the dates of completion for mandatory, safeguarding, NVQ and other training. This confirms Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.2 that the staff team are developing the skills and training which is required to meet the needs of residents. Staff have received training in the safe moving and handling of residents and were observed using safe practices this will ensure the safety of all involved The residents, relatives and staff made positive comment about the manager and staff team. The manager had made steps to address the majority of the previous requirements and recommendations from the last inspection. What the care home could do better: Ensure that all pre-admission information is developed into a care plan that will support staff to meet the individual needs of residents. Ensure that nutritional risk assessments are undertaken and that fluid and nutritional records are kept for those assessed as being at nutritional risk. All of this will help reduce the risk of weight loss, illness and infection. The care plans must be more person centred and improved further to fully show the complex mental health care needs of the residents and must include more detail as to the way they will be met. Ensure residents have their pressure risk assessments are undertaken, changes identified and timely actions taken this will help prevent pressure damage. Ensure that all residents are given the opportunity for meaningful social activities and choice in their daily routines and are treated with respect and dignity. This will improve their health and wellbeing. Ensure that all residents are given the opportunity for choice in their daily routine and risk assessed under current legislation if their access to their bedrooms/areas of the home is restricted. To further develop the environment to help support people with dementias. Ensure that the heating within communal areas can be thermostatically controlled to prevent the areas being excessively hot and uncomfortable for residents, staff and visitors. To undertake a review of staff deployment on an evening and to reassure residents and families that staff are available. To submit an application to CQC for the registration of the manager this will help provide consistent leadership for residents and staff.Beacon Farm Care CentreDS0000000546.V378200.R01.S.doc Version 5.2 Ensure that testing of fire prevention/detection equipment is undertaken at the appropriate timescales and records kept of this. Ensure that all staff undertakes fire drills at three monthly intervals for night staff and six monthly for day staff. This will help improve the safety for residents, staff and visitors. Key inspection report CARE HOMES FOR OLDER PEOPLE Beacon Farm Care Centre Beacon Lane Cramlington Northumberland NE23 8AZ Lead Inspector Mary Blake Key Unannounced Inspection 12th October 2009 09:00 DS0000000546.V378200.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beacon Farm Care Centre Address Beacon Lane Cramlington Northumberland NE23 8AZ 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) 01670 - 715000 01670 590567 Beacon.Farm@fshc.co.uk Cotswold Spa Retirement Hotels Limited (wholly owned subsidiary of Four Seasons Healthcare Ltd) Manager post vacant Care Home 55 Category(ies) of Dementia (55) registration, with number of places Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Dementia - Code DE, maximum number of places: 55 The maximum number of service users who can be accommodated is: 55 22nd August 2008 Date of last inspection Brief Description of the Service: Beacon Farm Care Centre is set in its own grounds with a secure garden area, situated on the outskirts of Cramlington, with pleasant views over surrounding countryside. Entry to the home is via a country type road. It is within easy reach of local shops, public transport and other useful amenities including a popular garden centre. The home is registered to provide mental health nursing and social care to an older client group who have dementia. The fees charged by the home range between £376.00 and £460.00 plus the free nursing care component. But do not include the following; hairdressing, chiropody and toiletries. Residents pay for these in addition to the basic fee. Beacon Farm Care Centre DS0000000546.V378200.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 one star adequate service. This means that the people who use this service experience adequate quality outcomes. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations. This will only happen when it is considered that people who use the service are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. An unannounced visit was made on the 12th October 2009 with a further announced visit on the 13th and 16th October 2009. A CQC pharmacy inspector will also visit. The acting manager was present for part of the inspection. Before the visit: We looked at: • Information we have received since the last random inspection in February 2009. • How the service dealt with any complaints and concerns. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff and other professionals, including surveys. • The Annual Quality Assurance Assessment (AQAA), which is a selfassessment document, was sent to the home for their completion and was returned to CQC. “Have your say” questionnaires were sent out to people who have used or had interest in the home, seven of which were returned to us. During the visits we: • Talked with people who use the service, relatives, staff, acting manager and provider representatives. • Looked at information about the people who use the service and how well their needs are met. • Looked at other records which must be kept. • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. • Looked around parts of the building to make sure it was clean, safe and comfortable. • Checked what improvements had been made since the last visit. Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.2 Page 6 We told the acting manager and provider representative what we found. What the service does well: Residents said, and it was seen, that staff were kind, considerate and supportive. There is a good complaints policy and procedures in place to make sure that any concerns or complaints are fully investigated with a full response of the findings given to the complainant. The home was clean with no offensive odours in the home on the day of inspection and communal areas appeared satisfactory. The laundry was clean, tidy and well organised and staff had good knowledge of hygiene and infection control. During the visit the relatives visiting were chatting in a very positive way with the staff and made positive comments about the management improvements. The home has a good system in place for accounting for personal allowances that are held for the residents. What has improved since the last inspection? Work to enrich the environment of the home has taken place to give a more stimulating and appropriate living space for the residents taking into account their dementia care needs. The meal times have been reviewed to make sure that they are supportive to residents having a pleasant and positive experience when having their meals. The home has undergone a refurbishment and redecoration programme providing comfortable and pleasant surroundings. A staff training programme is now available and includes the dates of completion for mandatory, safeguarding, NVQ and other training. This confirms Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.2 Page 7 that the staff team are developing the skills and training which is required to meet the needs of residents. Staff have received training in the safe moving and handling of residents and were observed using safe practices this will ensure the safety of all involved The residents, relatives and staff made positive comment about the manager and staff team. The manager had made steps to address the majority of the previous requirements and recommendations from the last inspection. What they could do better: Ensure that all pre-admission information is developed into a care plan that will support staff to meet the individual needs of residents. Ensure that nutritional risk assessments are undertaken and that fluid and nutritional records are kept for those assessed as being at nutritional risk. All of this will help reduce the risk of weight loss, illness and infection. The care plans must be more person centred and improved further to fully show the complex mental health care needs of the residents and must include more detail as to the way they will be met. Ensure residents have their pressure risk assessments are undertaken, changes identified and timely actions taken this will help prevent pressure damage. Ensure that all residents are given the opportunity for meaningful social activities and choice in their daily routines and are treated with respect and dignity. This will improve their health and wellbeing. Ensure that all residents are given the opportunity for choice in their daily routine and risk assessed under current legislation if their access to their bedrooms/areas of the home is restricted. To further develop the environment to help support people with dementias. Ensure that the heating within communal areas can be thermostatically controlled to prevent the areas being excessively hot and uncomfortable for residents, staff and visitors. To undertake a review of staff deployment on an evening and to reassure residents and families that staff are available. To submit an application to CQC for the registration of the manager this will help provide consistent leadership for residents and staff. Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.2 Page 8 Ensure that testing of fire prevention/detection equipment is undertaken at the appropriate timescales and records kept of this. Ensure that all staff undertakes fire drills at three monthly intervals for night staff and six monthly for day staff. This will help improve the safety for residents, staff and visitors. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.3 Page 9 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 Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.3 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have their needs assessed by care staff and have opportunities to visit before admission to the home but this information is not always developed into the care plan. EVIDENCE: Pre-admission assessments are undertaken and reflect the needs of the residents. The manager is involved in the decisions and in the majority of instances visits the residents herself prior to their admission. Residents and relatives spoke of visiting the home prior to admission and that this was useful to reduce anxiety and make the settling in process easier. A Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.3 Page 11 number of the residents relied upon their relatives to go to the home and advise them if it was suitable for them. The pre-admission information had not been transferred into the care plans which in turn did not contain sufficient information to ensure that the home can meet the overall needs of the resident. Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.3 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 and 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive care and support but this does not always promote their privacy and dignity. The residents’ health, personal and social care needs are not consistently set out in their individual plan of care and some individuals health needs are not fully met. EVIDENCE: Four care plans were examined and three were case tracked. This means that we spoke to the individual residents or observed their care and then matched our observations to what was written in the care plan. There has been improvement in the consistency and amount of information which was recorded in some of the care plans. However the standard of care planning was still inadequate and we found evidence of failure to review, maintain, update and revise individual people’s care plans in order to Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.3 Page 13 accurately reflect their health and welfare needs. The preadmission information for the last admission had not been transferred into the care plan There were a number of assessment tools in place such as nutrition, pressure sore risk, moving and handling and dependency. However these had not been consistently completed, reviewed or updated. Risk assessments had been completed but actions had not been recorded to help reduce risk such as weight loss. Nutritional assessments were undertaken for some residents and risks identified but action has been inconsistent, for example one resident identified as at risk did not have her weight loss evaluated for two months and it was unclear if any weights had been recorded during this time, this also shows a significant weight loss but no evidence of timely actions. Staff could not find fluid or food recording charts and when found these had not been consistently completed. We found examples where the quality of recording was inadequate and information was out of date. The recorded information was inconsistent and important details found within the daily reports had been omitted from some plans. There was inadequate emphasis on people’s strengths and abilities and what staff should do to maintain these. Risk assessments had been completed but actions had not been recorded to help minimise risks such as pressure damage. For example one resident identified as at risk from pressure damage did not have any actions taken until the damage occurred even though concerns had been highlighted within the daily record. Staff had completed medication training and undergone competency assessments. A full assessment of medication systems was not undertaken as a CQC pharmacist inspector will undertake an inspection at a later date. Residents and relatives told us they were well looked after and staff gave the support to bath or shower people on a regular basis. Residents appeared clean and well dressed. Staff were kind and caring and were giving the residents the support and care they needed. The majority of bedrooms and bathrooms were locked restricting individuals and preventing them from returning to their rooms when they wished. The acting manager had no clear explanation of why, this was not adequately risk assessed or recorded within the care plans. This is a restriction on the liberty of individuals with the home. Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a developing range of activities to meet people’s social needs and residents can maintain contact with family, friends and the local community. Residents are supported to receive wholesome diet and sufficient fluids but this is not always recorded. EVIDENCE: An activities coordinator has recently been employed in the home and a developing range of activities is available. Residents’ social needs are not assessed or recorded within the care plan but some progress is being made. Staff commented “more trips out for residents who are able and want to although activities are arranged daily I feel trips would also be very welcome” “could improve on social activities but new activities person starting soon”. Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.3 Page 15 Arrangements for residents to maintain contact with their family and friends are supported and family are encouraged to take residents out and about. Residents and relatives told us that they could have visit at any reasonable time. We noticed visitors in the home coming and going freely. Residents commented “the staff keep contact with relations” “always informing of updates”. Staff commented “the home offers a range of support, advice for residents, families and staff”. The lunchtime was observed. Staff managed the dining rooms and serving of food well, offering choices and with good staff support evident. We observed that residents appeared to enjoy the food and the atmosphere in the dining rooms was pleasant and relaxed. Residents were offered hot or cold drinks with the meal and throughout the day. Residents commented “food is good” “choice of meals”. Staff commented “gives residents lots of choices”. Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are procedures in place to make sure that complaints are dealt with satisfactorily and that residents are safeguarded from harm. EVIDENCE: The complaints procedure is displayed in the home and available to each resident. Residents and relatives said that they knew problems were dealt with and how this would be done. Three complaints had been investigated by the provider and appropriately managed and documented. The manager stated that staff were aware of the whistle blowing policy and informing the manager of any incidents or issues of concern. Staff confirmed this during discussion. A number of staff had received safeguarding of vulnerable adults training with further training planned. Safeguarding issues had been appropriately managed. Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,25 and 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home offers accommodation that is clean and maintained and has design features to help people of this client group but restricted access to individual bedrooms/bathrooms does not promote their dignity, comfort and welfare. EVIDENCE: The home is a two storey purpose build care home only the ground floor is occupied by the residents. The home has undergone a refurbishment and redecoration programme providing comfortable and pleasant surroundings. Each unit has access to the enclosed garden area which are pleasant and residents said they enjoyed being able to use these areas. Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.3 Page 18 The manager reported that the majority of bedrooms have been refurbished and redecorated and offer people living in the home pleasant, comfortable personnel space. However the majority of these and the bathrooms were locked. It was very hot in the communal areas and residents, staff and visitors all complained about this being a constant problem. The home was clean with no offensive odours in the home on the day of inspection and communal areas appeared satisfactory. The laundry was clean, tidy and well organised and staff had good knowledge of hygiene and infection control. Residents commented “the laundry service is good” “home does the laundry well”. Staff commented “ I can get new linen whenever I need it” “to make sure all staff including domestic, know when residents may have infections” “Beacon Farm gives a well supported, safe, clean and friendly environment for all its residents and families”. Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager ensures there are adequate numbers of staff on duty to care for the residents. Staff training is provided and the recruitment processes in place protect residents. EVIDENCE: The home operates with the following staffing levels two qualified nurses and six carers during the day and one qualified nurse and three carers during the night. The numbers of staff on duty were two qualified nurses and six carers. There is good ancillary staff support. Residents commented “sometimes seems like no staff around on an evening” “more staff on the floor” “on an evening seems like staff vanish”. Relatives commented “staff are very kind” “they are there to help” “been some changes but settling down now” “this manager has made some positive changes to how the home runs”. Staff commented “I believe is had great management and staff, who try at all times to give the best quality of care and understanding” “I think training could Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.3 Page 20 be better given across all members of staff not just focus on carers” “Beacon Farm is a lovely home I would recommend it to anyone”. Staff said that they are undertaking or had completed National Vocational Qualifications in Care (NVQ) level 2 or over, the number with an actual qualification exceeds the fifty percent target. A staff training programme is now available and includes the dates of completion for mandatory, safeguarding, NVQ and other training. This confirms that the staff team are developing the skills and training which is required to meet the needs of residents. The home has an induction and training programme for all staff working in the home. Staff spoke knowledgably about the individual needs of residents. Staff recruitment files were examined and were satisfactory. Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place to organise the home taking into account the needs and wishes of the residents. Quality systems have been established and are being developed but the health, safety and welfare of residents and staff are not protected. EVIDENCE: The home was without a registered manager for a period and the acting manager is about to leave. Any new manager must apply to the Care Quality Commission to become the registered manager. Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.3 Page 22 The acting manager takes the necessary action to ensure the general health and safety of the service users. This is supported by the policies and procedures and by discussion with the manager and the staff. During the visit the relatives visiting were chatting in a very positive way with the staff and made positive comments about the management improvements. Formal supervision for care staff has started and a programme is in place to make sure it remains up to date. Quality assurance systems are in place with audits for a range of areas and remedial actions plans in place. Regulation visits by the provider representative had been undertaken. The personnel records kept in the home of residents who are receiving assistance to manage their finances are detailed, logical and appropriate. Receipts were in place for purchases made on behalf of residents and signatures of either two staff or one and the service user were in place. The personal allowance records examined allowed the audit of individual resident’s monies to ensure that it is being managed effectively. The home have taken steps to limit the amount of money held by them and have sought alternative ways of achieving this depending upon the individual residents financial situations. The residents, relatives and staff made positive comment about the manager and staff team. The manager had made steps to address the majority of the previous requirements from the last inspection. Accidents are recorded with accident analyses being completed and risk preventions being undertaken to safeguard residents. The health and safety checks carried out by the handyman were mostly up to date. The fire drills had not been carried out at the timescales of six per year for night staff and two per year for day staff. Fire prevention/detection equipment testing had not been undertaken on the required timescales. Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.3 Page 23 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 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 2 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 3 X 2 Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.3 Page 24 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 OP4 Regulation 14 Requirement Ensure that all residents preadmission assessment of needs is developed within their care plan Ensure that all residents have a person centred plan of care and that this is regularly reviewed. Ensure residents are weighed, nutritional risk assessments are undertaken, changes identified and actions taken. Fluid and nutritional records are kept for those at risk Ensure residents have their pressure risk assessments are undertaken, changes identified and timely actions taken. Ensure that all residents are given the opportunity for meaningful social activities. Ensure that all residents are given the opportunity for choice in their daily routine and risk assessed under current legislation if their access to their bedrooms/areas of the home is restricted Ensure that the heating within communal areas can be DS0000000546.V378200.R01.S.doc Timescale for action 01/02/10 2 3 OP7 OP8 15 12 (1) 01/02/10 01/12/09 4 OP8 13 (4) 01/12/09 5 6 OP12 OP14 16 (2)(m)(n) 12(3) 01/02/10 01/12/09 7 OP25 23 (2)(p) 01/01/10 Beacon Farm Care Centre Version 5.3 Page 25 8 9 OP31 OP38 39 13 (4) (c) 10 OP38 13 (4) (c) thermostatically controlled to prevent the areas being excessively hot. To submit an application to CQC for the registration of the manager Ensure that all staff undertake fire drills at the intervals of three monthly for night staff and six monthly for day staff Ensure that testing of the fire prevention equipment is carried out at the given timescales. 01/03/10 01/12/09 01/12/09 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 OP22 OP27 Good Practice Recommendations To further develop the environment to support people with dementias To undertake a review of staff deployment on an evening Beacon Farm Care Centre DS0000000546.V378200.R01.S.doc Version 5.3 Page 26 Care Quality Commission North Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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