Inspection on 21/11/05 for Belamacanda

This inspection was carried out on 21st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Belamacanda 27/07/06

Belamacanda 13/07/05

Belamacanda 14/02/05

Belamacanda 10/06/04

Similar services:

Claremont House

Sun Court Nursing Home

Bramley Avenue (73)

15 Bramble Close

Dolphin Court

Fen Road

Wakes Hall

165 Putnoe Lane

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

CARE HOME ADULTS 18-65 Belamacanda 172/174 The Street Little Clacton Clacton-on-sea Essex CO16 9LX Lead Inspector Jane Greaves Unannounced Inspection 21st November 2005 10:30 Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 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 Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 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 Adults 18-65. 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. Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Belamacanda Address 172/174 The Street Little Clacton Clacton-on-sea Essex CO16 9LX 01255 862238 01255 861837 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) Black Swan International Limited Michael Ralph Melton Care Home 22 Physical disability (22), Physical disability over Category(ies) of registration, with number 65 years of age (22) of places Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, under the age of 65 years, who require care by reason of a physical disability (not to exceed 22 persons) Persons of either sex, aged 65 years and over, who require care by reason of a physical disability (not to exceed 22 persons) The total number of service users accommodated in the home must not exceed 22 persons 13th July 2005 Date of last inspection Brief Description of the Service: Belamacanda is a large detached property in Little Clacton in the County of Essex. The home offers accommodation to 22 service users of either sex who have physical disabilities. There are 20 bedrooms on the ground floor of the property with 2 further bedrooms on the first floor accessed by means of a stair lift. The communal areas on the ground floor include a smoking lounge and a sitting room. There is a garden to the rear of the property, which contains three sheds. One is a wheelchair storage/charging facility, one is an incontinence pad storage facility and one contains garden equipment. There is ample parking to the front of Belamacanda and there is a bus stop right outside the home enabling access to the local community. Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place 21st November 2005 over 4 ½ hours. 16 of the 43 National Minimum Standards were assessed and 14 were met. During the inspection process the inspector gathered views and opinions from 7 residents and three staff members. A tour of the premises was undertaken and documents were scrutinised. The registered manager was not on duty the day of the inspection, the inspector appreciated the assistance and co-operation received from residents, the deputy manager and staff team during the inspection process. Overall the care and support offered to the people living at Belamacanda on the day of the inspection was good. What the service does well: 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. Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 and 4 Prospective residents could be confident their individual needs and aspirations would be assessed before being admitted to the home. There were opportunities to visit and ‘test drive’ the home before making the decision to move in permanently confident in the knowledge that the home chosen would meet their needs and aspirations. EVIDENCE: On admission to the home a senior member of staff made an initial assessment of the resident’s needs and aspirations using the Social Services COMM 5 and involving the resident, their families/representatives. This assessment was comprehensive covering all areas of the resident’s life within Belamacanda. The deputy manager and residents confirmed that prospective residents were offered the opportunity to visit the home for meals, overnight stays and weekends before making the decision to move in permanently. The prospective residents were able to integrate with staff and the established residents and to make an informed decision to whether the home could meet their individual needs and goals. Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 Residents could be confident that their individual plans of care reflected their assessed changing needs and personal goals. Residents were supported to take responsible risks within the context of the home’s risk assessment and risk management strategies. EVIDENCE: The residents’ individual care plans evolved from the initial admission assessments made by the home and covered all aspects of personal and social support together with healthcare needs. Residents and their families were included in the formulation of the care plan along with healthcare professionals where a need was identified. All residents at Belamacanda were offered the services of dedicated key workers; two residents had chosen not to have a key worker. Care plans contained evidence that 6 monthly reviews took place and that a monthly update was done to compare individual’s activity records against their aims and aspirations ensuring each resident was given the support and opportunities to achieve their personal goals. Risks to the residents’ health safety and well being were identified and assessed during the pre admission process and reviewed regularly thereafter. Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 Page 9 Actions were taken to minimize identified risks and these were fully explained to the individual as observed during this inspection. Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Residents were fully supported to enjoy appropriate family and personal relationships. EVIDENCE: Information regarding residents’ families’ birthdays was present in the care plans. Key workers supported residents to shop for cards and presents for significant family events. Residents’ Christmas shopping trips were planned with their key workers. Residents and staff members reported that friends and family were welcome to visit at any time and were always made welcome. Residents were supported to join activities where they met with people in the community such as bowling, dining out and going to the pub. Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 20 and 21 Residents received personal support in the way that protected their privacy and dignity. Residents were protected by the home’s policies and procedures for dealing with medicines. The registered manager and staff members deal with the ageing illness and death of a resident with sensitivity and respect. EVIDENCE: Discussions with residents and observation of care practice on the day of the inspection confirmed the ethos within the home is that of respect and dignity for the people living there. The medication procedures followed at Belamacanda were that two members of staff administered all medication. One staff member checked the Medicine Administration Record sheets (MAR) and the other dispensed the medication meaning that each dose was double checked before being administered to the resident. There was no procedure in place for the second person to sign for giving out the medication. 8 care staff members had received external competency assessed training for the safer handling and administration of medicines and the remainder had completed a 12-week distance-learning course. Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 Page 12 The deputy manager reported that residents and their families were consulted on admission to the home about their wishes regarding illness and dying. This was confirmed in residents’ files sampled at this inspection. Some members of the staff team had attended a ‘Loss and bereavement’ course. Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Residents could be confident their views were listened to and acted upon. EVIDENCE: There had been no complaints received by the home or the Commission for Social Care Inspection since the last inspection. The home’s complaints policy and procedures were regularly updated and contained all information required by this standard. All residents spoken with confirmed that they were confident that any of the staff team would take a complaint seriously and that they would be listened to. One resident had an on going complaint regarding the laundry service provided at Belamacanda. The registered manager had employed a person to do the laundry however the resident reported that the situation had not improved. The resident was happy that the registered manager had taken the necessary steps to deal with this complaint and was confident that it would be resolved. Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25,26,27 and 28 Residents’ bedrooms were appropriate for their needs and lifestyles while promoting their independence. The majority of toilets and bathrooms were suitable to meet the needs of the residents. Safe and accessible shared space was provided to complement and supplement residents’ individual rooms. EVIDENCE: Residents’ bedrooms viewed at this inspection were personalised and homely. Residents were enabled to ring personal items of furniture into the home, where this option had not exercised the home provided furnishings of an appropriate standard. Overhead tracking and hoists were installed to enable residents to maximise their independence and for the care staff to provide appropriate help and support where required. Most of the bathroom, shower and toilet facilities had been refurbished as part of an on going improvement programme. A toilet and shower room had recently had a power shower installed however the wall tiles were cracked and chipped and the flooring was stained and ‘tired’ giving the room a dirty Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 Page 15 appearance. The registered manager reported this room was included in the home’s redecoration and refurbishment plans. The residents’ lounge had been redecorated since the previous inspection and a replacement lounge suite had been provided. The room appeared comfortable and inviting with the exception of an electric wheelchair stored at one end. There were wheelchair storage and charging facilities provided in the garden however it was the resident’s wish that their chair remained in the lounge. Discussions took place at this inspection regarding the wishes of other people using the communal lounge. The deputy manager reported that carpeting in the communal hallways was due to be replaced by the end of this year. Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 and 32 Residents benefited from the clarity of staff roles and responsibilities. Competent experienced staff provided support for residents. EVIDENCE: Clearly defined job descriptions were present on staff files sampled at this inspection. Observation of care practices, discussions with staff members and residents confirmed that the staff team had a clear understanding of the aims and ethos of the home. Staff members demonstrated good knowledge of individual’s needs and goals and had developed friendly and respectful relationships with the residents. According to the training matrix observed at this inspection some areas of mandatory training such as safer people moving and handling and Protection of Vulnerable Adults from abuse (PoVA) were overdue for annual refresher training. The deputy manager reported that a PoVA course had been booked for later this month. Four members of the care staff team of 20 had achieved NVQ level 2 or above by the date of this inspection, two further members of staff were due to complete their course by March 2006 and four due to enrol. Four staff members were working towards their NVQ 3 with 2 more due to enrol. This will not meet with the desired target of 50 of care staff having achieved NVQ level 2 or above by 31st December 2005. Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 41 The health, safety and welfare of residents were protected and promoted. EVIDENCE: Training in areas such as moving and handling, fire awareness, first aid, food hygiene and infection control had been provided for the care staffing team in order to protect the health and safety of the residents at Belamacanda. Some of this mandatory training was due to be refreshed at the point of this inspection. The registered manager ensured the health and safety of residents and staff by organising regular servicing of boilers and central heating systems, regular checks on electrical systems and equipment and undertaking regular environmental risk assessments. Any incidents affecting the health, safety or well being of residents was recorded and had been reported to the Commission for Social Care Inspection. Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 3 X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X 3 3 2 3 X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Belamacanda Score 3 X 3 3 Standard No 37 38 39 40 41 42 43 Score X X X X X 3 X DS0000017766.V267402.R01.S.doc Version 5.0 Page 19 NO Are there any outstanding requirements from the last inspection? 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 YA32 Regulation 18(1)(a) Requirement The registered manager must ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. This specifically refers to the provision of moving and handling refresher training and PoVA refresher training. The registered person must ensure that all parts of the care home are kept clean and reasonably decorated. This specifically refers to the toilet/shower room. Timescale for action 31/12/05 2 YA27 23(2)(d) 31/12/05 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 YA32 Good Practice Recommendations It is a recommendation of good practice that the registered manager ensures the continuation of the NVQ training DS0000017766.V267402.R01.S.doc Version 5.0 Page 20 Belamacanda programme in the home. Belamacanda DS0000017766.V267402.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 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. 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