Random inspection report
Care homes for adults (18-65 years)
Name: Address: Belmar Nursing Home 25 Clifton Drive Lytham St Annes On Sea Lancashire FY8 5QY one star adequate service 12/02/2010 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Lesley Plant Date: 1 9 0 4 2 0 1 0 Information about the care home
Name of care home: Address: Belmar Nursing Home 25 Clifton Drive Lytham St Annes On Sea Lancashire FY8 5QY 01253739534 01253796447 belmarnh@gmail.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mr Stephen Paul Taylor Type of registration: Number of places registered: Conditions of registration: Category(ies) : Belmar Care Home Ltd care home 44 Number of places (if applicable): Under 65 Over 65 0 0 dementia mental disorder, excluding learning disability or dementia Conditions of registration: 4 44 The maximum number of people who can be accommodated is: 44. The registered person may provide the following category of service only: Care home only: Code N. To service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE (maximum number of places: 4), Mental disorder, excluding learning disability or dementia: Code MD. Date of last inspection 1 2 0 2 2 0 1 0 Care Homes for Adults (18-65 years) Page 2 of 9 Brief description of the care home Belmar Nursing Home is situated in a residential area of Lytham St Annes. The home provides a number of lounge and dining rooms plus a conservatory, which is the designated smoking room. There are gardens to the front and side of the building plus a small area at the rear of the home where vegatables are grown. The home is currently registered to provide personal and nursing care to up to 44 people, with 40 places for people with mental health problems and four places for people over 65 with dementia. Details of the fees can be obtained by contacting the manager of the home. Care Homes for Adults (18-65 years) Page 3 of 9 What we found:
This inspection visit was carried out in response to concerns raised by the Fire and Rescue service following a recent incident at the home. Records were viewed and a joint discussion took place with the manager, the area manager for the provider organisation and a representative from the Fire and Rescue service. The Fire and Rescue service had recently been called out to attend a fire at the home. The fire crew had reported that no evacuation had taken place, service users were walking around in the part of the home affected by smoke, staff did not seem aware of the policy for evacuation and did not know how to operate or silence the fire panel. The representative from the Fire and Rescue service provided a tape recording of the call to the emergency services, which indicated that there was confusion at the home and that essential information was not provided in a clear or timely manner. The manager explained that the lead staff member on duty was a new employee. The induction record for this member of staff was viewed. Although this included certain areas of health and safety it did not adequately cover actual fire procedures. The manager had explained the operation of the fire panel to the member of staff and this had been confirmed by the individual concerned. On the evening of the incident one service user had been exhibiting extremely challenging behaviour and the lead staff member on duty had explained that she had been trying to move this individual away from the affected area and that the individuals responses had been very difficult to manage. Most staff at the home have completed a training package regarding fire safety, which includes a video and makes reference to fire doors and the safety they provide if people are evacuated to an area protected by a fire door. Since the incident further fire training has taken place which has included staff walking around the building, identifying the fire doors and additional explanation of their function. The area manager felt that this familiarisation and actually relating the information provided in the training package to the home had perhaps been lacking from previous training. It was also felt that staff who do not use English as their first language may need longer to assimilate the information. At present agency staff do not receive any fire training or induction regarding fire safety at the home. Discussion took place regarding service users smoking in their bedrooms, with the representative from the Fire and Rescue service explaining that this should be addressed within the fire risk assessment for the home and that staff should know the reasoning behind this. Separate risk assessments should also be in place for certain service users. At present there is no clear evacuation plan or procedures for horizontal evacuation to parts of the home protected by fire doors. Service users should be involved in fire training and fire drills, with the aim of helping service users to understand key information regarding the fire risk assessment for the home. Agency staff also need this information. The representative from the Fire and Rescue service explained that an action plan addressing training, drills and procedures will be drawn up and that compliance with this will be monitored. Care Homes for Adults (18-65 years) Page 4 of 9 The inspector discussed risk management regarding the challenging behaviour of a service user at the home, with the manager and area manager. Discussions had been held with the social worker and it had been agreed that alternative accommodation and support would be required in order to meet this persons needs and in order to protect others living at the home. In the meantime the manager confirmed that additional staffing levels would be in place to provide one to one oversight and that this included the nighttime period. A risk management plan had been drawn up and the manager was going to strengthen this with more specific details regarding triggers, de escalation and diversionary techniques. What the care home does well: What they could do better: 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 set out on page 2. Care Homes for Adults (18-65 years) Page 5 of 9 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 20 13 There must be arrangements 31/03/2010 for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. In order for service users health to be protected. 2 39 24 Quality assurance and quality 30/05/2009 monitoring systems must be established. (Previous timescale not met.) Care Homes for Adults (18-65 years) Page 6 of 9 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 9 12 Risk management plans must 28/05/2010 be in place for all service who pose risks to themselves or others. This will help to protect and promote the safety of both service users and staff. 2 42 23 The registered person shall, 28/05/2010 after consultation with the fire authority; Take adequate precautions against the risk of fire, including the provision of suitable fire equipment. Provide adequate means of escape. Make adequate arrangements for detecting, containing and extinguishing fires, for giving warning of fires, for the evacuation, in the event of fire, of all persons in the care home and safe placement of service users. For the maintenance of all fire equipment and for reviewing fire precautions and testing fire equipment at suitable intervals. Make
Page 7 of 9 Care Homes for Adults (18-65 years) Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action arrangements for persons working at the home to receive suitable training in fire prevention and to ensure by means of fire drills and practises at suitable intervals that the persons working at the care home and so far as practicable, service users, are aware of the procedure to be followed in case of fire, including the procedure for saving life. This will help to protect and promote the safety of both service users and staff. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 8 of 9 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or got 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 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Adults (18-65 years) Page 9 of 9 - 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!
