Inspection on 21/02/08 for Belmont Villa Care Home

This is the latest available inspection report for this service, carried out on 21st February 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.

Other inspections for this house

Belmont Villa Care Home 22/08/06

Belmont Villa Care Home 23/11/05

Belmont Villa Care Home 15/09/05

Belmont Villa Care Home 01/03/05

Belmont Villa Care Home 29/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Belmont Villa Nursing & Residential Home 58-62 Weymouth Road Frome Somerset BA11 1HJ Lead Inspector Barbara Ludlow Unannounced Inspection 21st February 2008 10:00 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 Villa Nursing & Residential Home DS0000003242.V359561.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. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belmont Villa Nursing & Residential Home Address 58-62 Weymouth Road Frome Somerset BA11 1HJ 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) 01373 471093 Belmontvilla@aol.com Belmont Villa Residential & Nursing Home Ltd Mrs Sharon Welsh Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 31 places for elderly persons of either sex, not less than 60 years, who require nursing care. Up to five persons of either sex, in the age range 45 - 60 years, who require nursing care. 27th September 2007 Date of last inspection Brief Description of the Service: Belmont villa is a family run care home set in a residential area of the town of Frome. The home is registered with the Commission for Social Care Inspection (CSCI) for 31 service users with nursing care needs. Currently there are twenty-nine single rooms with en-suite facilities. The service has five bathrooms, two shower rooms and eight separate W.C’s. In addition there are five day/quiet rooms. The service also has accessible gardens to the rear. All laundry is done in house. The current fees range from: £504 per week. Hairdressing, chiropody, newspapers, personal installation of telephones and calls, escorting residents to appointments, checking and stamping personal electrical equipment, and toiletries are not included within the fee. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Annual Quality Assurance Assessment was completed for the commission prior to the first key inspection carried out in September 2007 when deficits in care planning were found. This is the second key inspection of the service under the CSCI ‘Inspecting for Better Lives 2’ framework. The focus is on outcomes for service users and the quality of the service is measured under four general headings. These are; excellent, good, adequate and poor for the seven chapter outcome groups and an overall quality rating is then calculated: : The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Questionairres were sent by CSCI to people living at the service, relatives and staff working at the home. Responses were received from 6 people in residence, 12 relatives, and 10 staff. The analysis of their view of the service provision is incorporated in the inspection report. This inspection visit was undertaken over the period of one day by an inspector for CSCI and an expert by experience. The expert by experience was asked to look at the social care and outcomes for people living at Belmont Villa. The inspection was well received. The registered manager Mrs S Welsh was on duty throughout the day and proprietor Mr S Twohig was available during the morning and early afternoon. The expert by experience looked around the home and met with people living here, speaking with them and asking for their views on the service provision. Activities and social events were also focussed upon. A tour of the premises was made by the inspector and records were selected for examination. These included the care plans as part of the case tracking of people living at the home, staff recruitment , training and supervision and maintenance records for fire safety and nursing equipment. Staff were spoken with and lunch was observed in the dining room. Visitors to the home were asked for their experience and views on the home and the care of their relatives. Positive feedback was received. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 6 Inspection feedback was given by the expert by experience to Mrs Welsh and Mr Twohig after lunch. At the close of the visit the inspector gave feedback to Mrs Welsh and her deputy manager. The inspector would like to thank the people in residence, their relatives and carers, the management and staff for their help and their contributions towards the inspection process. What the service does well: What has improved since the last inspection? What they could do better: The work on the care planning should continue and incorporate best practice guidance for conditions and ill health episodes such as epilepsy. Care planning strategy and monitoring was discussed. Medication prescribed to be given as required must be clearly documented on the MAR charts to provide an accurate audit trail. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 7 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 Villa Nursing & Residential Home DS0000003242.V359561.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 Belmont Villa Nursing & Residential Home DS0000003242.V359561.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): 3, 6 is N/A Quality in this outcome area is good Pre admission assessments are undertaken to ensure care needs can be met at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a statement of purpose and service user guide for prospective people to read all about the home and service offered. These are available at the home along with other information in the entrance hall to the home. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 10 Pre admission assessments are undertaken by the manager to ensure that care needs can be met at the service. Community care records, ‘single assessment process’ (SAP) are obtained to inform the care planning. Since the last inspection the home has withdrawn it’s two, ‘step up, step down’ short stay beds to concentrate on care planning and managing the paperwork for people coming into the home on a longer term basis. One person who has recently come into the home said they are satisfied with the care and service they receive. Visiting relatives spoken with said they had proactively ‘sought a place at the home’ and were very pleased with their decision and choice of Belmont Villa. Feedback on comment cards from people living at the home indicated that all had received a contract of residence and that information about the home was available prior to them moving in allowing them to make an informed choice. Two people indicated that their families had chosen the home on their behalf. Belmont Villa Nursing & Residential Home DS0000003242.V359561.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): 7,8,9,10 Quality in this outcome area is good Care plans have been reviewed and are more person centred. Health and personal care needs are met. Routine medication administration is safely managed. People are treated kindly and with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home no longer offers short stay rehabilitation in two ‘step up/ step down’ funded places. This decision was taken to focus on the care planning for people choosing Belmont Villa for a longer stay. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 12 The care plans were sampled for people whose needs were case tracked and to follow up on the requirements made at the last inspection where poor wound care planning was found. Since the last inspection the registered manager and the registered nurses have concentrated on reviewing the care plans and adopting a more person centred focus in their presentation. Three care plans were sampled in detail. Pre admission assessment had been undertaken to ensure care needs could be met at the home. Personal details and contacts were recorded. Risk assessments had been undertaken for pressure sore risk identification using the Waterlow scoring system. Equipment was identified for use such as a pressure relieving mattress and gel cushion. Where people had pressure area breakdown the wound management and progress was documented. Activities of daily living were assessed, for a safe environment and manual handling. Bed rails were risk assessed for use. Individual environmental risk assessments had been undertaken for bedrooms and included open windows and fire hazards. The new style care plans were sampled and they were presented and written in a more personalised way. Staff are keen to get this right and the trained nurses on duty joined the inspector to look at specific areas where improvements could be made. Action was taken with the doctor’s input at the inspection and one care plan was further developed. The work on the care planning should continue and incorporate best practice guidance for conditions and ill health episodes such as epilepsy in a person centred way. One care plan was examined where end of life care had been given. There was good evidence of the monitoring of the persons condition and of pain relief being given. Dietary and fluid intake was recorded. All care interventions were recorded. CSCI had received the corresponding regulation 37 notification. People seen at the inspection looked clean and well cared for. People in bed looked comfortable and received regular care and attention. Three visitors were spoken with who had made a positive choice of Belmont Villa for their relative. Their comments included that it is ‘home from home’ an ‘excellent home’, they felt able to raise any concerns and said they felt ‘part of the family’ as they are ‘made welcome’ and there are no visiting restrictions, they were alerted when their relative was unwell and they were informed when the doctor visited. One person said it is ‘positively very good’. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 13 The expert by experience observed that staff answered the call bell promptly and that staff were polite and respectful. It was noticed that the dependency level was quite high and that ‘Several people remained in bed all the time due mainly to their age or infirmities, but they were regularly checked and moved as necessary’. ‘All rooms had charts in them for staff to note any help they had to give when visiting a particular resident.’ Laundry is well managed in house and clothes are labelled to prevent them being mislaid. Medications management was examined. All 27 people in residence Medication Administration Records (MAR’s) were seen. All were neatly recorded and there were no administration gaps found. There were two hand transcribed entries were seen that had only one signature and one alteration from a variable dose to set to the lowest amount, had not been signed. One entry where emergency medication had been given was recorded in the care plan but had not added to the MAR chart to complete the audit trail. The chart was updated at the inspection and the manager arranged to meet with the staff concerned to review the clarity and standard of their record keeping practice. A requirement is made for careful monitoring of medication that is administered to urgently control a health condition. Controlled drugs and temazepam which is recorded as a controlled drug were checked, all were correct and the amounts tallied with the records. Skin creams in use seen in bedrooms were with one exception, seen to be labelled with opened on dates. The manager was alerted to this discrepancy. Comment cards indicated that eight relatives felt the needs of their relative or friend are always met, four said usually met. One relative commented that their relative ‘always looked clean and tidy, fresh clothes, hair done, nails done by the staff here’. Eight relatives said the home always helps their relative keep in touch with them and one said usually. Ten relatives said they are informed of important issues One said usually. One relative commented that ‘I cannot fault the care that staff are giving’ their relative who was described as unwell. Three people living at the home said they receive the care and support they need, three said usually. All respondents living at the service said that staff act on what they say. Relatives commenting under what the home does well said: ‘They are a caring first class home’, can ‘always talk to a senior member of staff or have a phone call’, ‘well managed, aware of responsibilities and the Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 14 staff are very caring’, ‘good all round care’, ‘ respond well to the call bell but sometimes bell not in reach’ and providing ‘constant care’. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 15 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): 12,13,14,15 Quality in this outcome area is good Activities are arranged in house. Families and friends are made welcome and visiting is not restricted. Well presented home cooked food is served. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home offers a range of activities and entertainment to come into the home. There are trips out and notices are displayed to inform people and their visitors of forthcoming events. Easter preparations were underway. The home does not have dedicated activities staff. Care staff organise the activities on a rota basis each day. Staff had arranged to play dominoes during the afternoon but had no one wanted to participate. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 16 People asked said they had enough to do, the three main lounges were seen and people were sitting together and had the televisions on for some of the time. One person seen in their room said they ‘love watching television’ and usually watch it in their own room. People had visitors during the day, three were spoken with and they gave very positive feedback about the care and service offered at Belmont Villa. People said they felt welcomed and found visiting to be unrestricted. People commented on the good relationships between staff and people living and visiting the home. There is a Holy Communion held each month and two people go out to Church each week. The manager has introduced a monthly meeting with people living at the home. Plans had been made for meetings over a six month period and it had been agreed that relatives would be invited along. Five coffee mornings were planned although they will be held as preferred by the people in residence, in the afternoon. People had said they would like a tour of the home, as they had not seen the entire home only the areas they live in and use. The manager hopes to build on this positive feedback and have more input into home life from the people living at the there. The inspector discussed setting up a ‘Link Resident’ with CSCI, the manager was hopeful that one of the people would feel able to take up this role. This will be followed up after the inspection. A flexercise training programme will be accessed for staff in May or September to train on delivering this exercise programme as part of the activities. Comment cards were returned and they indicated that there is usually enough to do and the food is good. The kitchen was clean and organised. The cook following a list of people’s menu choices served lunch from the hot trolley in the kitchen, the food is taken and served by the staff to people in the adjacent the dining room. The meal was served hot. Lunchtime was unhurried and was a social occasion with people dining together. People asked said they enjoyed the food, one relative commented that the ‘food is very good.’ One relative stays to lunch each day and they commented that they were enjoying their lunch. The lunchtime meal was roast chicken with stuffing, mashed potato, cabbage, cauliflower and gravy followed by semolina pudding. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 17 The expert by experience observed that: The meals are served mainly in the dining room. There is no choice of meals but anyone needing a special diet is accommodated. The food served was wholesome and suitable for the person concerned. Quite a few of the residents required help with eating and drinking and it was noticeable that the staff were very caring in giving assistance. There are regular interests taking place in the house and a list of them is on a notice board in the front hall. An Easter bonnet competition is taking place in March. Comment cards indicated a mixed response to the question: Are there activities arranged by the home that you can take part in? One said always, two said usually, one said sometimes, one said never. People responded usually to the question Do you like the meals? One relative commented that there is ‘good cooked fresh food’ and ‘various entertainment’. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good The home has a complaints policy and procedure. Staff receive training and are aware of their responsibilities towards the safety and welfare of people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no complaints raised with CSCI or the home since the last inspection. The home has a complaints policy and procedure to follow on receipt of a complaint. Staff recruitment was checked and there was good evidence of a safe standard of recruitment practice. Staff had 2 references and criminal record Bureau checks in place before they commenced working at the home. Staff spoken with were clear about their role in safeguarding people in their care and they understood what abusive behaviour is and what they would do if they suspected abuse had occurred. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 19 Visitors said they felt confident t complain or raise any concerns with the staff or management of the home. Comment cards indicated that people did know who to speak with if unhappy. 12 relatives all responded that they know how to make a complaint. One relative commented that they have never had to raise a concern about their relatives care and they had been there for more than two years. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 20 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): 19,26 Quality in this outcome area is good The home was purposefully adapted as a care home and is safely and well maintained. Infection control measures are in place and the standard of hygiene is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was made and communal rooms were seen and bedrooms were sampled. The communal sitting and dining rooms are well decorated and comfortable. The dining tables were nicely laid for dinner with condiments and napkins. The vases of artificial flowers on the dining tables needed cleaning, some were becoming dusty and one was sticky. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 21 Corridors are wide and have handrails to assist people to move around more independently. There is a large person passenger lift between the three floors of the home. There are sufficient toilets and bathrooms with assisted baths and showers situated close to the bedrooms around the home. All twenty seven bedrooms have en suite facilities and there are two double rooms for couples or people choosing to share. The home has pressure relieving equipment such as special air / pad mattresses and special cushions. These were seen in use and were recorded in the care plans for people identified to be at risk of developing a pressure sore. There are manual handling aids including equipment such as patient hoists and bath hoists. The records showed that this equipment is safely maintained with regular servicing. One bed rail bumper was seen that required cleaning, the housekeeper attended to this at the time. The home was otherwise very clean and hygienic. Staff have access to gloves, aprons when required for their protection and there are good hand washing facilities throughout the home. The home has sluice facilities and waste is appropriately managed. There is a programme of ongoing redecoration and maintenance of the home. The home is fitted with fire safety equipment. The fire alarm and emergency equipment such as emergency lighting and extinguishers are tested and records inspected indicated that they are regularly maintained. There is ramped wheelchair access to the front of the home. The home has a conservatory and a garden at the back of the home some rooms have an outlook onto this. Rooms at the front of the house look onto a community park on the opposite side of the road. One relative commented that they take their relative out to the park in warmer, fine weather. The expert by experience commented that the smell of cooking vegetables was apparent at the start of the inspection in the main entrance. No other discernable odours were detected during the day and the ventilation seemed good. The decoration received praise and the timely response to the call bells. People all responded positively to the question ‘Is the home kept clean and fresh?’ One person said their waste bin is not emptied at the weekend. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 22 One relative commented under what the home does well, stating the ‘general appearance of the care home’. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 23 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): 27,28,29,30 Quality in this outcome area is good. The home has a well trained and skill mixed workforce. The home was sufficiently staffed at the inspection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were 27 people in residence on the day of the inspection and a sufficient number of staff in all departments. The home has a skill mixed staff team. The registered manager Mrs Welsh was on duty, a registered nurse was in charge of care with a team of six carers. Other staff on duty in the morning included the cook, the laundry person, the housekeeper and the handyman. Mr Twohig (proprietor) and the homes administrator were also working. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 24 In the afternoon the home staff with three carers and one nurse until 5 pm when 2 more care staff come on duty. Overnight there is a registered nurse and three carers. The expert by experience noted that: Most of the residents are able to get up each day but need varying amounts of assistance with toiletries and dressing. The staff carry a big responsibility for their care, comfort and stimulation. This they manage very well indeed and work with care and cheerfulness. Most of the Carers were well trained having obtained NVQ 3. I have to say that they all gave a high level of support and I was impressed with the way they went about their duties. The feedback given to the homes manager by the expert by experience included observation that staff were ‘fantastic and very caring’. One person spoken to about their care at the home said it was ‘perfect’ and staff are ‘kind’ and ‘would respond if you asked for something’ and answered the call bell promptly. Visitors to the home made the ‘staff are lovely’ and they felt to be made welcome when visiting. Staff recruitment files were sampled for one new starter since the last inspection. This person had been safely recruited. The procedure included two satisfactory references being obtained and a Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) check being carried out prior to them commencing work at the home. Training has been available to staff and this month the manager reported that Dementia training, first aid training and capillary blood sugar monitoring training had been accessed for staff. Further training planned included diabetes updating, Diet and nutrition, and manual handling. Trained staff confirmed that they had attended palliative care and continence training recently. Staff were seen and spoken with during the inspection those asked confirmed that they had undertaken NVQ training and have received fire and manual handling training recently. At the last key inspection in September 2007 it was reported that: The residents survey conducted by the home demonstrated that some people living at the home found communication difficult at times. The manager has addressed this issue with the nurses and concluded that this was due to cultural differences and accent. The staff are now aware of this issue and are working hard to improve. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 25 Comment cards had praise for the staff as ‘very caring’, ‘I appreciate what the home does for my’.. relative. Staff give ‘constant care’. ‘Looked after very well’. ‘Very friendly staff’. Very dedicated staff’, ‘I cannot fault the care that the staff’ give and they show ‘kindness’. Ten staff comment cards were returned, all spoke positively about working at the home, one said it was a lovely place to work. Staff confirmed having their induction and ongoing training. All commented that when they had been recruited all checks were carried out before they commenced working at the home. Staff confirmed having supervision and were happy to go to the manager with any problems. Staff said they felt supported in their roles by the management and felt they deliver a good service to the people they care for. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 26 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): 31,33,35,38 Quality in this outcome area is good The home has an experienced registered nurse manager. The premises and equipment are safely and well maintained. People’s views of the care and the service are used to make changes and improve the experience of living in the care home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager is Sharon Welsh a First Level Registered Nurse with considerable experience in managing the care home. She keeps herself up to date with current legislation and attends training updates regularly to enable Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 27 her to pass her knowledge on to care staff as part of their in-house training. She is a qualified NVQ Assessor, and is currently enrolled on a Level 4 NVQ management course. The management has positively responded to the findings at the last inspection. The management have taken action to more inclusive and person centred in the delivery of care and approach to record keeping. Meetings with staff and people living at the home are held and quality assessment by questionnaires has been undertaken. At the last key inspection in September it was reported that: Quality monitoring systems and policies were in place, and the home has actively sought views from residents and other stakeholders on the conduct of the home in April 2007. The home sought the help of an independent advocate to support people living at the home to complete the survey. This is very positive. Records were seen to be safely managed and stored. Access to records is appropriately restricted. Records for fire safety and maintenance were examined, these included: Patient hoists, serviced in 10.07 Passenger Lift service 9.1.08 Gas safety check, 02.08 Syringe driver service 04.07 Nurse Call 01/02 2008 Fire safety; Fire risk assessment was completed in January 2007, no change for 2008. Fire alarm weekly tests were carried out with the zones varied. Emergency lighting 02.08. Fire equipment is service under contract. The manager confirmed that all staff have received fire training and that fire drills are undertaken for staff and all staff have received food hygiene training. Comment cards indicated that: People and relatives would approach the management if they had any concerns. One person commented that they would ‘go to the office and talk it through’. In response to the question how do you think the care home can improve? One person said ‘what they have here is ample, to continue to do the job they are best at’; another person said ‘I have no complaints on how the care home is run, always an open and welcoming door to myself and relatives’. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 28 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 2 9 2 10 3 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 3 X X X X X X 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 3 3 3 X 3 X X 3 Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 29 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 (2) Requirement Medication that is used on when required basis must be more carefully monitored and fully recorded. The implementation of person centred care planning must be continued. Care planning must include the details for specialist interventions and treatments in line with best practice. Timescale for action 25/04/08 2. OP8 15(1) 25/04/08 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. Refer to Standard OP9 Good Practice Recommendations It is recommended that the registered person ensure that two staff sign any hand transcribed entries, which are made on the Medication Administration Record. Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Belmont Villa Nursing & Residential Home DS0000003242.V359561.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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