Inspection on 27/07/06 for Belamacanda

This inspection was carried out on 27th July 2006.

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 21/11/05

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 Kathryn Moss Key Unannounced Inspection 27th July 2006 09:30 Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 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.V306272.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 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.V306272.R01.S.doc Version 5.2 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 Category(ies) of Physical disability (22), Physical disability over registration, with number 65 years of age (22) of places Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 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 21st November 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 assisted bathing facilities, a smoking lounge, a sitting room and a dining area. There is a small, enclosed courtyard area, and a garden to the rear of the property contains three sheds that are used for storage. 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 (the home also has its own minibus). The data (pre-inspection questionnaire) submitted by the provider earlier in the year indicated that at that time (February 2006) the fees at the home ranged between £534.80 and £730 per week, with additional costs for personal items (hairdressing, toiletries, contribution towards some leisure activities, etc.). Information on the home is available to residents and prospective residents through the service user guide, a copy of which is available on request and is provided to all residents. Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place on the 27.7.06, lasting nine hours. The inspection process included: • • • • • Discussions with the manager and with one of the directors; Discussions with four staff (care and ancillary); Discussions with four residents, and brief chats with some other residents; an inspection of the premises, including the laundry; inspection of a sample of records; 27 Standards were covered, and 2 requirements and 5 recommendations have been made. On the day of this inspection, the home was maintained in a good condition. Residents were receiving good care and support, and those spoken to enjoyed living at Belamacanda and were positive about the staff team. What the service does well: What has improved since the last inspection? Since the last inspection, the home has progressed staff NVQ training: a good proportion of staff have now achieved at least NVQ level 2 in care, which ensures that residents are supported by competent and qualified staff. Some staff had also achieved or were working towards NVQ level 3. Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 6 The registered provider had recently implemented a new monthly audit form for the manager to use on a regular basis in the home. This enabled them to review how they were meeting various aspects of the National Minimum Standards, and should assist the home in developing their self-monitoring processes. This shows a proactive approach to monitoring and developing the home for the benefit of residents. 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.V306272.R01.S.doc Version 5.2 Page 7 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.V306272.R01.S.doc Version 5.2 Page 8 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): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has information available to enable prospective residents to make an informed choice about where to live. The home obtains sufficient information to ensure that it can meet a prospective resident’s needs. The home is able to meet the assessed needs of individuals admitted to the home. EVIDENCE: A copy of the home’s ‘statement of purpose’ had previously been provided to the CSCI and met regulatory requirements. The home also has a comprehensive ‘service user guide’ that was not reviewed as part of this inspection: despite the size of this document, the director confirmed that a copy of the service user guide would be made available to any interested party, and stated that a copy was provided in each bedroom. This would enable current and prospective residents to have access to information about the home. The home obtains a local authority care management assessment for each new resident. The manager also confirmed that the home visits prospective new residents to carry out their own pre-admission assessment prior to agreeing any admission, to ensure they can meet the person’s needs. The home Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 9 records this on a set form, with scope to record brief information on all key areas of need; an example of this was seen on one of the files inspected. The manager also stated that prospective residents are encouraged to visit the home, and can have an overnight stay, in order to check whether they feel the home has the facilities to meet their needs. The home provides facilities and staff training appropriate to the needs that the home aims to meet. Residents spoken to were satisfied that the home had the skills and resources to meet their needs. No new residents had been admitted to the home for some time: the relative of a person visiting the home for a respite stay felt that staff understood the person’s needs and provided appropriate care and support. Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 10 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, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs and goals were set out in personal plans. Residents were supported to make decisions about their lives, and to take appropriate risks. EVIDENCE: The home had service user plans for each resident, covering personal and health care needs, social/emotional and behavioural needs, and needs relating to financial management and restrictions of choice. In some instances details of the action required by staff to support a specific need was fairly brief, but this was supplemented by further information recorded on a risk assessment form. This covered a good range of relevant risks (including medication, falls, bedsides, pressure areas, scalding, diabetes, smoking, going out on one’s own, challenging behaviour, gender sensitivity and any areas of risk of abuse). In one case an additional separate care plan was seen with good guidance on addressing a person’s behavioural needs; in another instance it was good to see a care plan address short-term goals. The home does not currently have a detailed moving and handling risk assessment form: the director advised that Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 11 this was being developed, and in view of the moving and handling needs of current residents, this should be progressed and implemented as soon as possible. There was evidence that residents had been involved in the development of their care plans and risk assessments, and also that these were being regularly reviewed. From discussion with residents and staff, it was clear that residents were encouraged to be involved in decision-making about their lives, both on an individual level and as a group. Each resident could have a key worker, and those spoken to confirmed that they had had a choice as to who their key worker was. The manager stated that residents could also choose not to have a key worker, as one person had. From observations on the inspection, residents were making choices (e.g. how and where to spend their day, attending college courses, etc.) and were provided with information and support to make these. The manager stated that advocacy support would be obtained through social services if required: one resident currently had an advocate and chose when to contact them, and the home was in the process of arranging for an advocate for another resident and for a solicitor to provide support with their financial affairs. Risk assessments identified any risks relating to a person’s daily activities, including their ability to manage their finances, and care plans had space to record any limitations of choice. Residents’ meetings provided a forum for group decisions about outings, holidays, etc. The fact that the home had recently arranged for three groups of residents to go on holiday to Spain was a good example of the home supporting residents to take risks as part of an independent lifestyle: the home had completed risk assessment forms in relation to this, and residents spoken to had thoroughly enjoyed these holidays. The manager confirmed that the home had a missing person’s procedure; this was not viewed on this occasion. Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16, and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were supported to take part in appropriate activities, both within the home and in the wider community, and to maintain family and personal relationships. Daily routines promoted independence, choice and individual rights. Residents were offered a healthy diet. EVIDENCE: The home supports and enables residents to access a range of appropriate social, developmental and educational activities. Although no current residents engage in paid or voluntary work, three attend a workshop for people with disabilities, and several attend (or have attended) various classes including computing, cookery, arts and crafts (including some adult literacy/numeracy input), and a Stroke Club. The home liaises with local colleges to access appropriate courses. The home uses local community resources for leisure activities (e.g. meals out, bowling, beach, local circus and carnival, etc.), and obtains information about Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 13 local events. The home has its own transport (a minibus), as most residents required a wheelchair accessible vehicle. There was good evidence of a wide range of social and leisure activities taking place both inside and outside of the home: there were regular social events (e.g. barbecues, and a recent party to celebrate the home’s 21st birthday), some activities were brought into the home (e.g. fortnightly ‘keep fit’ session, and a recent visit by a Zoo Ranger, etc.), and a wide range of trips had taken place (e.g. local meals and bowling, day trips to London and France, and recent holidays to Spain). The home had helped one resident to obtain a large TV for their room, as they were unable to go on trips out for health reasons, but enjoyed watching films. The manager stated that most excursions were financially supported by the home, which is commended. Three small groups of residents had recently been on holidays to Spain, and those spoken to had very much enjoyed these. It was good to see care plans also reflecting short-term goals relating to individual interests and aspirations that the home aimed to support (e.g. one person aimed to attend an Ipswich City football match this year). The home encouraged contact with family and friends: residents reported that they could receive visitors at any time and a visitor stated that they felt welcome in the home. Relationships within the home were supported by staff, and one resident described the home as feeling like being in a ‘big family’. Daily routines appeared flexible, with residents seen to have the freedom to move around the home and grounds, and to choose how and where to spend their day. Although on the day of the inspection outside activities had been curtailed because the minibus had broken down, residents appeared content and relaxed, and were seen spending their time around the home engaged in their own interests (e.g. TV, jigsaws, spending time with others, etc.). Staff were observed to knock on residents’ bedroom doors before entering, and residents were able to have keys to their doors. Residents spoken to were very positive about staff, with one reporting that ‘the staff are lovely’. The cook stated that the timing of the main cooked meal (whether at midday or early evening) was flexible depending on the residents’ activities: menus reflected this, and also showed that meal times were flexible (e.g. showed ‘high tea’ as between 5.30 and 7pm). Menus showed that a choice of food was provided at each meal, and residents spoken to confirmed this and stated that they could also request an alternative. The cook showed good knowledge of individuals’ likes and dislikes and of how he met this (e.g. one person particularly liked rabbit, and the cook said that this was provided for them on a regular basis), and also showed an understanding of special dietary needs (e.g. vegetarian, diabetics, soft diets, etc.). The main meal on the day of the inspection looked appetising, and residents spoken to were positive about the meals. The cook reported that two vegetables were generally served with each meal, and that primarily fresh vegetables were used in the home. Menus showed that snacks were available in the evenings, and it was noted that hot and cold drinks were regularly available during the day, and that (where able) residents could serve themselves to these. Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 14 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, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health needs were well met within the home, and personal support was provided appropriately. The home’s medication policy protected service users: some aspects of the home’s recording procedures were not satisfactory at the time of this inspection but, based on past evidence, the CSCI is confidant that the provider will take action to manage the improvements required. EVIDENCE: Residents spoken to were happy with the way staff supported them in their personal care, and care plans/risk assessments reflected key information on how this should be done (reference standard 6). Residents spoken to said that they had been involved in choosing their key worker, and risk assessments identified any sensitive gender issues or needs. Residents’ appearance reflected their personal choices of clothing, and times for getting up and going to bed appeared to be flexible and a matter of individual choice. The home had appropriate equipment available to support independence (e.g. most rooms were equipped with overhead hoists, special crockery was available, there were facilities for recharging electric wheelchairs, etc.) and where residents were at risk of pressure sores, pressure relief mattresses or cushions Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 15 were in situ (and the manager maintained a clear record of all pressure relief equipment in use). Healthcare needs were identified and supported by the home, and records were maintained of contact with healthcare professionals. Where residents suffered with diabetes, staff assisted in the monitoring and treatment of this condition and there was evidence that healthcare services had provided staff with comprehensive training in this, and had assessed their competency to provide the assistance needed. A senior member of staff spoken to showed a good understanding of the support required with one resident’s diabetes, and clear records of this were maintained. The home recorded all accidents and incidents, and there were systems in place to monitor these, to ensure that any patterns could be addressed. Arrangements for routine healthcare appointments and checks were not discussed on this occasion; nutrition records were not inspected. The home had a medicines policy that described the procedure for receipt, storage, administration, and disposal of medicines (including any controlled drugs), and promoted self-administration where appropriate. Secure medication storage facilities were available, and stocks viewed were stored in an orderly manner and a sample inspected were in-date; not all bottles of liquid medication had been dated on opening, and this was recommended. The home was monitoring the temperature of the storage area, and a medicines fridge was available if required. Most medication was dispensed to the home in a monitored dosage system, and the pharmacist supplied medication administration records (MAR) that were pre-printed with the medication name, dosage and administration instructions. Staff recorded the date and quantity medication received by the home onto this form. There were some occasions when additional medication details had been entered by hand by staff: these records showed several instances where staff had not fully entered the administration details (dose and frequency) and/or the quantity of medication received or carried over from a previous month, and had not signed or dated the entry. This needed to be addressed. The MAR sheets viewed had only recently been started: from the records available on these, staff appeared to consistently record when administration took place, and also the reasons for any non-administration. Systems were in place to record medication returned to the pharmacist. Medication administration practices were not observed on this occasion. Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 16 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ views and concerns were listened to and acted on, and the home’s practices and procedures protected residents. EVIDENCE: The home had an appropriate complaints policy and procedure, which encouraged complaints and aimed to treat them seriously and respond to them efficiently. Residents spoken to felt able to raise concerns, and were clear that they would speak to the manager if they had any complaints. The home maintained records of complaints received: these records showed that any complaints had been responded to. One resident had complained about the ironing of clean laundry, and felt that this had now improved. The provision of the complaints procedure in alternative formats was not discussed on this visit. Staff training records showed that all staff had attended training in abuse awareness over the last two years; the manager also reported that four staff had attended a Protection of Vulnerable Adults (POVA) workshop in June 2006, and a further four were booked on a workshop in August. The director had recently obtained a POVA training pack (DVD and workbook) produced by Essex County Council, and planned to use this to update staff training. The home had a policy relating to the protection of service users, which included a statement on the protection of service users’ monies, referred to the home’s Whistle Blowing policy, and clearly identified social services as the lead agency to which any concerns would be referred. A concern raised last year had been appropriately investigated, and it was confirmed on this inspection that no further concerns had been raised. Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 17 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): 24, 26, and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is homely, clean and safe. Individual rooms were personalised and promoted their independence. EVIDENCE: The premises are in keeping with the local community. On the day of this inspection the home was clean and tidy, and any odours dealt with promptly, showing effective cleaning processes. Rooms viewed were in a satisfactory state of decoration, contained sufficient furnishings and fittings, and were homely and well personalised. It was good to see the wide range of personal items in people’s rooms, including equipment to pursue individual interests (e.g. watching TV/films, music, jigsaws, etc.). The organisation had recently installed additional electric sockets in a couple of rooms, to ensure that the residents had sufficient sockets to run all their equipment, and it was noted that one person had their own telephone. The home has two communal lounge areas (one which could be used for smoking in), and a separate dining area. There was a small internal courtyard Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 18 area with seating facilities and a fishpond, which the manager reported was well used. The home has a maintenance person and additional assistance in the garden area; systems for identifying, planning and recording routine maintenance and decoration were not discussed on this visit. The premises were accessible throughout, and most rooms were fitted with overhead ceilingtrack hoists. The home has two bathrooms (both with assisted baths) and two shower rooms: a shower room noted at the last inspection to be in need of some decoration had since been refurbished. The home had a laundry that was sited away from areas where food was stored or prepared. It was equipped with a sink that was used for hand washing of linen and also as a hand washbasin, and there were supplies of liquid soap, paper towels, and disposable protective gloves. The laundry contained two heavy-duty washing machines and two drying machines: the manager described appropriate practices for dealing with any soiled linen, but also confirmed that the home has little soiled linen as most body waste was contained and disposed of via disposable products (e.g. incontinence sheets and pads, cleaning wipes, etc.). Appropriate arrangements were in place for the disposal of clinical waste. Infection control policies and procedures were not specifically inspected on this occasion; training records provided showed that all apart from one carer had attended infection control training over the last two years. Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 19 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): 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided staff who were appropriately trained and qualified, in sufficient numbers to meet residents’ needs. Recruitment practices did not fully meet regulatory requirements set out to protect residents: however, based on past evidence, the CSCI is confidant that the provider will take action to manage the improvements required. EVIDENCE: The staff rota for the week of the inspection was viewed and showed four staff per daytime shift, and two waking night staff. Copies of rotas from previous weeks provided following the inspection showed that these staffing levels were usually maintained, although there were some occasions when a shift was one person short due to last minute sickness. On a few occasions when staff had volunteered to cover last minute absences, this had resulted in staff working an afternoon shift followed by a night shift: the manager should monitor this closely and avoid it wherever possible due to the length of the hours involved. Feedback during the inspection suggested that the current level of staffing met residents’ needs, and that staff time could be provided flexibly if required. The staff team reflected the gender composition of the residents. The home has Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 20 regular staff meetings (minutes not inspected on this occasion), and it was good to hear that a resident representative attended these meetings. The manager confirmed that of the fifteen care staff currently employed at the home, nine had completed NVQ level 2 or 3; a further three staff had started level 2, and two of those with level 2 had started level 3. This is a good level of qualification amongst the staff team. Residents spoken to were positive about the staff, finding both staff and manager approachable, and stating that they felt staff had the skills to meet their needs. The home maintained a clear database showing training completed by staff: this showed that the majority of staff had attended all core training, and also that a good range of training in additional specialist subjects had been attended by many staff (e.g. in specific medical conditions). The home therefore provided appropriate training to ensure that staff had the knowledge and skills to meet residents’ needs. The home had recently accessed a one-day induction course through the local college, which they had been advised met the Skills for Care induction requirements (i.e. covered the Common Induction Standards). Although this appeared to be a useful course, it was discussed with the manager and director in relation to whether it enabled the home to assess and evidence that a new carer has the knowledge and skills (i.e. competence) to meet the needs of residents (as covered by the Common Induction Standards). It was noted that the home also had its own induction checklist that was completed with new staff over a period of time: although this covered a range of relevant issues, these were not specifically linked to the Skills for Care Common Induction Standards, and it is recommended that this could be revised to evidence these. Recruitment documentation inspected for one staff member included an application form, employment history, a criminal record declaration, evidence of identity and a photo, two written references, and a CRB and a POVAfirst check. The home had made appropriate efforts to obtain a last employer reference and the manager said they had also obtained a verbal reference, although had not recorded this. There had been delays in obtaining a CRB check, and so the carer had started work on the basis of a POVAfirst check: however, it was noted that the POVAfirst had not been received until a week after the person started work, and the manager was reminded that staff must not start work, even under supervision, without a POVAfirst check having been received. The manager and director demonstrated a considered and responsible approach to recruitment issues discussed, and had recently taken prompt and appropriate action when alerted to a recruitment concern. This reflected a recruitment practice that aimed to protect service users. Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 21 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): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from a well-run home. Systems were in place to ensure that residents’ views formed part of the monitoring and review of the home. Health and safety practices promoted the health, safety and welfare of residents. EVIDENCE: The home has a registered manager who is suitably experienced to run the home, and was currently undertaking the Registered Managers’ Award (NVQ level 4 in management). He demonstrated good knowledge and understanding of the service and of care and management practices, and training records showed that he regularly attended training to update his skills and knowledge. Residents and staff spoken to reported that the manager was supportive and approachable, and it was noted that he spent a lot of time working alongside staff in the home, and therefore provided a good level of support and was able to monitor practices. Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 22 The home had a quality assurance policy statement that promoted a positive approach to reviewing the quality of service. Quality assurance processes included an annual development plan (covering premises, staff training, and with reference to items identified from the service user survey), a monthly audit done by the manager reviewing how the home meets the national Minimum Standards, reports of monthly monitoring visits carried out by the registered provider, minutes of service user meetings, and a service user survey using a feedback questionnaire (carried out twice yearly, with the responses summarised). Action taken by the home in relation to responses from the last service user survey was not specifically discussed on this occasion. The manager stated that most of the current residents are able to indicate their views, and that staff assist with completing the questionnaire if help is required. It was suggested that this could compromise the objectivity of responses, and it is recommended that the home explore ways of providing assistance by someone who is not involved in the resident’s day-to-day care. It was noted that the home had a range of appropriate policies and procedures, which had been reviewed June 2006 and which included 17 core policies that staff had to sign to confirm they have read them (evidence seen). The home had systems in place to maintain the health and safety of the home, and a clear policy statement of the arrangements to maintain health and safety in the home, including employer and employee responsibilities. Staff training records showed that staff had received training in relevant health and safety topics, including the moving and handling of people. The home maintained records to show that equipment and utilities were regularly serviced, and that appropriate internal checks were carried out (e.g. routine testing of fire alarms and emergency lighting, fire drills, checking of bath and shower hot tap temperatures, checks on central hot water temperatures re risk of legionella, etc.). The home had a range of risk assessments on safe working practices, including fire risk assessments and the use/storage of chemicals (with hazard sheets available for the chemicals used). Belamacanda DS0000017766.V306272.R01.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 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 Standard No Score 1 3 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Belamacanda DS0000017766.V306272.R01.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 YA20 Regulation 13 Requirement The registered person must ensure that any details of medication entered onto the MAR sheet by staff include:• Full administration details (i.e. dose and frequency/ times); • the quantity of medication received or carried over from a previous month; • the date of the entry and the signature of the person making the record. 2 YA34 19 The registered person must ensure that a CRB and POVA check are obtained before new staff start working in the home. In exceptional circumstances someone may start on the basis of a POVAfirst check, but this must be obtained before the person starts work in the home. 14/08/06 Timescale for action 14/08/06 Belamacanda DS0000017766.V306272.R01.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 YA6 Good Practice Recommendations The home does not currently have a detailed moving and handling risk assessment form: the director advised that this was being developed, and it is recommended that this is progressed and implemented as soon as possible. (Reference also Standards 2, 9 and 42). It is recommended that staff ensure that care plans contain sufficient detail of the action required by staff to support each person’s assessed needs. It is recommended that bottles of liquid medication are dated on opening. It is recommended that any verbal references taken up are clearly recorded. It is recommended that the registered person ensures that records evidence that staff complete a structured induction process that meets the Sector Skills Council (i.e. Skills for Care Common Induction Standards) specification. 2 3 4 5 YA6 YA20 YA34 YA35 Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Belamacanda DS0000017766.V306272.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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