Inspection on 22/08/08 for Belmont View

This is the latest available inspection report for this service, carried out on 22nd August 2008.

CSCI found this care home to be providing an Good service.

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

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Extracts from inspection reports are licensed from CQC, this page was updated on 20/03/2009.

CARE HOMES FOR OLDER PEOPLE Belmont View Fountains Place Guisborough Cleveland TS14 7JA Lead Inspector Jackie Herring Key Unannounced Inspection 22nd August 2008 09:00 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 Belmont View DS0000071664.V370185.R02.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. Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belmont View Address Fountains Place Guisborough Cleveland TS14 7JA 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) 01287 638 979 01287 637 032 Belmont View Limited Mrs Joan Corinne Parvin Care Home 50 Category(ies) of Dementia (50), Old age, not falling within any registration, with number other category (50) of places Belmont View DS0000071664.V370185.R02.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 only Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 50 2. Dementia - Code DE, maximum number of places 50 The maximum number of service users who can be accommodated is: 50 This is the first inspection of the service. Date of last inspection Brief Description of the Service: Belmont View is a new 50 bedded care home providing care for both older people and older people with dementia. It is set out on three levels, with the service area including kitchen on the top floor. The home has two separate units for the different categories of care provided. The older person’s unit is on the first floor and the dementia unit is on the ground floor. All bedrooms and single with ensuite shower facilities. There is a very good range of communal rooms and the corridors are spacious and airy with a number of pleasant sitting areas. There is a choice of shower and bathing facilities available. Belmont View is very well located near to the high street of Guisborough. It is very close to local shops, transports and amenities and has views overlooking the Cleveland Hills. The fees for Belmont View are to be confirmed. Belmont View DS0000071664.V370185.R02.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 two stars. This means the people who use this service experience good quality outcomes. This is the first time Belmont View has been inspected since being registered in March 2008. This Key Unannounced Inspection was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use the services, and that it does what the Care Standards regulations say it must. This inspection was conducted in one inspection day. During the visit to the home, a number of records were looked at, including records of people who use the service, along with medication records, staff records, training records and maintenance information. A number of surveys from people who live at the home as well as from staff were received. Time was spent talking to people who use the service, relatives and staff. Time was also spent walking around the home, observing interactions and generally finding out what Belmont View was like for the people who live there and staff. Discussion also took place with the Manager and Director of Care. The Director of Care has completed the Annual Quality Assurance Assessment (AQAA), the services self-assessment of how well they think they are meeting standards. This was received prior to the inspection and some of information has been reflected within the report to support the judgements made. The AQAA was extremely well completed. This was an extremely positive first inspection of the service. It was evident from speaking to a number of people that they are committed to providing the best possible care to people living at the home. What the service does well: Belmont View provides people with an extremely pleasant and homely environment, in which there is a good amount of communal space and very pleasantly appointed bedrooms. People spoken to said they were very pleased with the environment and the care provided. One person said, “I am very happy here, it is a life of luxury, every single thing is done for you and what is good is the love that the carers and manager show you”. Another person said, “We are definitely treated with dignity, they are courteous and also have a real sense of humour”. Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 Page 6 Care plans are very well written and clearly person centred. Regular reviews and evaluations are taking place. There is an enthusiastic staff team and training is well promoted within the home. 95 of staff are either qualified in NVQ level 2 or above or currently completing this qualification. There is a good management structure in place with clear leadership of the home and care provided along with systems for continuously monitoring this. When staff were asked about what the service does well, they said, “The care that is given, the staff are brilliant and I believe we are all meeting the residents needs, it’s not just a job”. Another person said, “Belmont View provides a good services, we do well in the care we provide and the attitude of people. It is also good for training, management support and the sense of continuous improvement”. 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. Belmont View DS0000071664.V370185.R02.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 Belmont View DS0000071664.V370185.R02.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): Standards assessed 3 and 6 People who use this service experience good quality outcomes in this area. Assessments of people who are to use the service are carried out to ensure that the home can meet their needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA detailed with assessment and admission process. It was stated, “We carry out comprehensive pre-admission assessment whereby the care manager visits them at home, in hospital, wherever the individual is living at the time, both for prospective long-term permanent residents and for those requiring short-term respite care”. Care records for four people living at Belmont View were looked at, two from each of the units. In all, there was a copy of the assessment that had taken place prior to admission and also a copy of the care manager’s assessment. Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 Page 9 There was some discussion about the process for respite admissions as some previous concerns had been raised. It was acknowledged that there was a need to ensure that full and thorough assessments were undertaken prior to people being admitted to Belmont View to ensure that their needs can be fully met during any respite period. The assessment procedure for people being admitted for respite care has been now been reviewed and improved. One of the files for someone receiving respite care was looked at and there was comprehensive information in place. The home does not provide intermediate care and as such standard 6 does not apply. Belmont View DS0000071664.V370185.R02.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): Standards assessed 7, 8, 9 and 10 People who use this service experience good quality outcomes in this area. The home provides a good standard of care, people using the service are happy and care received is based on their individual needs. In general good systems are in place for the management of medication. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The same four people’s records were looked at in more detail and some of the people were spoken to about the care they received at Belmont View. The information in place was very much person centred. An example of this is, “I wear dentures but only choose to wear the bottom set”. Everyone had the same range of core care plans in place, these were however clearly personalised and there were additional care plans in place where additional needs had been identified. It was good to see that care plans were Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 Page 11 gender specific particularly in relation to bathing, showering and personal care. In discussion with the Director of Care, she said that they had made a decision for everyone to have a core set of care plans to ensure that the full range of activities of daily living were being attended to, evaluated and reviewed regularly. It was confirmed that evaluations were taking place on a monthly basis. Both the person concerned or their relative and their keyworker had signed the care assessments and plans. One person said, “I am aware of my keyworker and they have gone through the care plan with me”. People also had ‘My Life” Story Books, which contained information about their lives and significant people and events. This information is particularly important when caring for a person with dementia. Once admitted to the home staff carry out other assessments on people using the service. Assessments carried out include, dependency, moving and handling, nutritional, and an assessment to see if people are at risk of falling or developing pressure sores. These assessments are updated on a monthly basis or more often if required. Evidence of GP, district nurses and other professionals was in place. When staff were asked about their role as keyworkers, one person said, “It means you see to those particular residents a little more, such as liaising with the family, look after toiletries and wardrobes and it’s about finding out about people more and more”. Staff also spoke of people having choices and making decisions. One member of staff said, “People can have a shower or bath when they want, if someone prefers a bath in the afternoon then they will have one, we also give reassurance, support and encouragement to people”. One of the people living at the home said, “They make such as fuss over us all, we are all treated the same”. Another person said, “If I am not feeling well I will have a lie in. Sometimes I get cramps through the night and they bring me a cup of horlicks”. Some one said, “Everything is so natural, I don’t feel like a patient, I feel like an individual in my own right, you can lock your door and no one invades your privacy”. The medication system was looked at. Both unit has it’s own dedicated medication room. Medication records were looked at and had been well completed with no gaps. Photographs were in place and allergies were being recorded. There were some occasions when items that had been handwritten on the medication administration record had not been double signed by two people. Audits have been developed and are taking place. Those staff who are involved in the administration of medication have completed a safe handling of medicines course. One staff member said, “I have completed the safe handling of medicines course and also had my competencies assessed here prior to being able to administer”. Currently no one living in the home Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 Page 12 self medicates. There was discussion about this, particularly for people who are admitted for respite care and the need for them to maintain their independence. This was acknowledged and procedures would be implemented if this were needed. Care is also needed to ensure that any items that are kept in the fridge are dated when opened. Care is needed with medication that is not contained within the monitored dosage system. One person had three bottles of oral suspension opened, all with different dates. The way in which controlled drugs are recorded needs to be strengthened further to ensure that at all times balances are correct. When returns are made to the pharmacy these need to be fully recorded. Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 Page 13 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): Standards assessed 12, 13, 14 and 15 People who use this service experience good quality outcomes in this area. Appropriate and enjoyable activities do take place at the home and people who use the service are able to exercise choice and control. Visitors are encouraged and made to feel welcome at anytime. Food provided is enjoyed and provides residents with a wholesome balanced diet. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The Director of Care said that the home have just appointed an activity coordinator. The AQAA detailed that their role was to, “Arrange a daily activities programme which includes various different activities for the residents which is person centred”. It also details that the person, their family or friend is asked to complete an activities social information sheet, which details information about activities they like, experiences they have enjoyed and some details about them and their life. It also details that activities are planned for the month on a weekly activity plan on display on notice boards in the home. Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 Page 14 A staff member said of the activities co-ordinator, “She is doing well, activities are being developed all the time”. Another member of staff said that people had been out to Kirkleatham Museum, that there has been a singer, bingo, a game called higher and lower and some chair exercises. One person said of the activities, “It is still early days, they are developing more” People who use the service are encouraged and supported to practice their religion. A worship group takes place on a regular basis. People spoken to said, “We are definitely treated with dignity, they are courteous and also have a real sense of humour”. People also confirmed that they were able to have visitors and that this was actively encouraged. Several visitors were seen on the day of inspection. A member of staff said, “I think it is good here for the residents, they get choices with their meals and alternatives, there is plenty for them to do, the environment is good and there are large TV’s”. There is a three week menu, which has been checked by a dietician who offered some advise. The cook was spoken to and they were very enthusiastic about the catering provision within the home. The cook meets with all of the people living at the home to determine their individual needs, these are recorded in the kitchen. The home has received Five Star award for Food Hygiene. When asked about the meals in the home, people said, “The food is excellent”. “They are home cooked meals with tons of veg and home made sponge, the only fault is that they give you too much”. Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 Page 15 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): Standards assessed 16 and 18 People who use this service experience good quality outcomes in this area. People who use the service were confident their complaints would be listened to, taken seriously and acted upon. Adult protection procedures are in place, which helps to protect people that use the service from abuse. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA detailed that there had been three complaints since opening, one of which had been upheld. The home has a complaints procedure, which informs people who use the service and relatives of their right to complain, timescales for action and who to contact, which needed some slight amendment. The home keeps a record of complaints. The complaints records were looked at and contained evidence of the investigations that had taken place and the outcomes and responses were also recorded. People who use the service who were spoken to during the inspection said that they could approach staff and the manager in relation to any concerns that they may have. People living at the home said, “If I had a problem I would speak to a member of staff”. Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 Page 16 It was confirmed through discussion with people working at the home that they were aware of the complaints procedure and had also received training in respect of abuse and protection of vulnerable adults. Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 19 and 26 were looked at during this inspection. People who use the service experience excellent quality outcomes in this area. People have a safe and very well maintained environment in which to live. The home was clean, well decorated and extremely homely. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Belmont View is a new care home. There are two specific units. The ground floor unit provides dementia care and the first floor unit provides personal care to older people. The home is beautifully presented, it is tastefully decorated has good quality furnishings with a good amount of communal space. The dining rooms each have their own small kitchen, which is a benefit and means that where appropriate people can make their own refreshments. The ground and first floor mirror in design, with wide corridors that include several seating Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 Page 18 areas on both floors for the people who use the service to sit and relax. There are many homely touches, including the lighting, furnishings and fish tanks. All of the bedrooms and single rooms with ensuite shower facilities and are spacious. The garden is also nicely presented with a range of furniture in place. The rear of the building has views over the cricket pitch and Cleveland Hills. The top floor at Belmont View houses the service areas such as kitchen, along with staff facilities. The organisations office is also situated within the area as well are a large meeting/training room. One person said, “I am very satisfied here, they are nice rooms, couldn’t be better, with nice shower rooms”. Another person said, “It is warm and comfortable and I have a lovely comfortable bed”. One person spoken to was so pleased with the spacious room, which had a lot of their own personal furniture and was warm, comfortable and extremely homely. There were also facilities within the room in the event that people wanted to have their meals there. The home has a policy in respect of control of infection. Staff spoken to during the inspection said that there was always a plentiful supply of protective clothing. Appropriate laundry facilities are in place. On the day of the inspection the home was extremely clean and odour free. Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 27, 28, 29 and 30 People who use this service experience good quality outcomes in this area. The homes recruitment procedure is generally good, which helps to ensure that people are protected, although care is needed with references. Staff are trained, skilled and in sufficient numbers to meet the needs of people living at the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Four staff files were looked at. All had completed application forms, references and Criminal Records Bureau checks along with copies of certificates of training and qualifications. Care is needed with the uptake of references, as there are occasions when these have not been from the most recent/present employer. The induction training is in line with the Skills for Care induction as well as extra training information that is thought relevant. Individual training records were also seen to be in place. In the records looked at there was evidence of ongoing mandatory training such as health and safety, fire, infection control and moving and handling including a theoretical and practical session. A training matrix is also in place detailing the training that has been undertaken. Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 Page 20 A duty rota is in place and skill mix of the staff team is specified. Staff spoken to had mixed views about whether there are sufficient staff on duty to meet the needs of people living at the home. They said that there were times when an extra member of staff would be helpful particularly for GP and hospital appointments or if there were people who were poorly. This was also echoed by someone living at the home who said, “Don’t think there is enough staff, two girls running up and down, and think they could do with more staff”. One person said, “If you work as a team it goes smoothly”. One person said, “The staff are excellent, kind and they treat me with respect, they are all so friendly”. Another person spoken to said of the staff, “It is a team night and day, they have the knowledge and skill and I feel safe”. The AQAA detailed that 45 of staff were already qualified to NVQ level 2, a further 18 staff members were in the process of completing this meaning that 96 of care staff had either completed or were working towards NVQ level 2, which is good. One of the staff surveys contained the following information, “Training is very good and ongoing, I have lots of choices”. Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed 31, 33, 35 and 38 People who use this service experience good quality outcomes in this area. The home is very well run. Health and safety is promoted. Quality assurance systems are in place to ensure that the home is run in the best interest of people who use the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The registered manager is a Registered Mental Nurse with a significant number of years experience, they also have a Masters in Business Administration. There is a good management structure within the home, with a Director of Care and a Care Manager, along with department manager such as housekeeping, catering, accounts and human resources. The AQAA details Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 Page 22 that all staff have clear roles and responsibilities. One of the staff surveys stated, “I feel the management team are very fair and supportive”. When staff were asked about what the service does well, they said, “The care that is given, the staff are brilliant and I believe we are all meeting the residents needs, it’s not just a job”. Another person said, “Belmont View provides a good services, we do well in the care we provide and the attitude of people. It is also good for training, management support and everyone is aware of the need for continuous improvement”. One person living at the home said, “I am very happy here, it is a life of luxury, every single thing is done for you and what is good is the love that the carers and manager show you”. One person also spoke very highly about the proprietors, they said, “Mr and Mrs Parvin are lovely people, they are very concerned to ensure that you are happy”. The home does not have any personal monies for people who use the service. Individual records of accidents are kept and analysed by the manager on a monthly basis. It was also confirmed that other health care professionals are involved when needed for example falls and that specialist equipment is in place where needed, such as sensory pads. Records were available to confirm that water temperatures are being monitored. It was however noted that some of the temperatures might be too low. It was agreed that this would be looked at further. Weekly fire checks were also taking place. Fire drills were also taking place randomly each month. It was recommended that there was the need to specify the time of the drills and list the staff in attendance. The AQAA detailed that a full range of policies and procedures are in place and were last reviewed throughout 2007. A range of in house audits take place, including audit of the environment ensuring health and safety, care plan audits, medication audits and audits in regard to dementia care which looks at the environment and activities. Questionnaires have recently been distributed as part of the quality assurance process, once these have been returned, the Director of Care said, they will be analysed and a report produced and any action needed would be taken. A copy Belmont Views Continuous Quality Improvement plan and action was also made available, which was very comprehensive. A regular newsletter is also produced which shows activities that have taken place along with information about the staff and events that effect the home and people living there such as Birthdays. Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X 4 X X 4 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 4 X 3 X N/A X X 3 Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 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 OP9 Regulation 13 Requirement The control drug book must be kept up to date and stock balances must be accurate. When items are returned to the pharmacy there must be records of this. This will ensure safe systems are in place and that there are clear audit trails if needed. Timescale for action 30/08/08 Belmont View DS0000071664.V370185.R02.S.doc Version 5.2 Page 25 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. Refer to Standard OP9 Good Practice Recommendations Handwritten entries and changes to MAR charts should be checked by a second person and there should be double signatures in place. Fridge items should be dated when opened. Care is needed with medication that is not contained within the monitored dosage system. One person had three bottles of oral suspension opened, all with different dates. 2. 3. 4. OP27 OP38 OP38 Staffing levels should continue to be monitored to ensure they are sufficient to meet people’s needs on a day to day basis. The water temperatures should continue to be monitored to ensure that the temperature is at an appropriate level for comfortable showering and bathing. When fire drills are conducted, the time of the drill and list of staff in attendance should be recorded. 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