Inspection on 19/07/05 for Belamie Gables

This inspection was carried out on 19th July 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 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

Belamie Gables 29/04/08

Belamie Gables 10/10/07

Belamie Gables 14/02/07

Belamie Gables 02/02/06

Belamie Gables 05/01/05

Belamie Gables 25/10/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE BELAMIE GABLES 210 Hyde End Road Spencers Wood Reading Berkshire, RG7 1DG Lead Inspector Stewart Mynott Unannouced 19 July 2005 @10.30am 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 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. BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Belamie Gables Address 210 Hyde End Road, Spencers Wood, Reading, Berkshire, RG7 1DG. Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0118 9883417 Mr J Parry and Mr D white Mrs Belinda Vickery Care home only (PC) 20 Category(ies) of Old age, not falling within any other cateogry registration, with number (OP) of places BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5th January 2005 Brief Description of the Service: Belamie Gables is a privately owned care home. The service is registered to provide personal care and accommodation for up to 20 persons who are over the age of 65. It is situated in a quiet residential area to the West of Reading. The property is a large detached house set back from the main road. There are large front and rear gardens with car parking spaces at the front of the property. There is a passenger lift in the building and accommodation is provided on two floors. BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection made in the day, which lasted for 5½ hours. During this time the Assistant Manager gave a tour of the building and spent time in discussion with the inspector. Time was spent talking to nine service users, one relative and staff on duty during which daily life was observed at the home. Both the homes and care records were also inspected to confirm observations made during the day. 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. BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards 1-6 were not assessed during this inspection. EVIDENCE: BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Care practises ensure privacy and dignity for service users. Service users care is appropriately planned and reviewed regularly and includes personal, social and health needs. The homes medication system meets the needs of service users. EVIDENCE: Three service users care documentation records were examined. Each service user had a 24-hour care plan detailing preferred routines and personal care required. A further plan of care details health and social needs. Additional detailed information including likes and dislikes are also held. All records seen were clear and up to date with any recent change highlighted for staff to view. All care documents are reviewed monthly and a record shows where changes have occurred. All care records seen were up to date. There is consultation with service users and evidence clearly showed invitations to attend reviews and in one case the care plan was read to a service user who is unable to read. Care records and discussion with three service users indicated that there is access to their GP when needed and local NHS facilities are accessed. Service users are risk assessed for preventing the development of pressure sores; those at higher risk have access to specialist equipment and support. BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 9 During the inspection staff were observed to be professional, treating service users with respect and dignity in a kind manner. Service users spoken to confirmed they receive personal care in a private and respectful manner and were complimentary about the management and staff team. One service user was observed to have their own telephone in their room and was able to confirm his key worker assists with some of his personal care needs. A relative spoken to also confirmed that their relative was well cared for and the staff team were excellent. The medication policy was examined and the system for ordering, administration, recording and disposal were explained by the assistant manager and were seen to be satisfactory. The home has recently changed to a monitored dose system provided by the local pharmacy. Hand written medication administration records are currently being used which are neat however there could be a potential for copying errors, as original prescriptions are not available to refer to. Printed administration records are available only in weekly format and the use of these is currently being considered by the home. BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards 12-15 were not assessed during this inspection. EVIDENCE: BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Service users are fully aware of the complaints policy and their views are acted upon. The homes policies protect service users from abuse. EVIDENCE: There is a comprehensive complaint policy both within the home and in the statement of purpose, which is clear and straightforward for service users and their relatives to access. Four service users spoken to were very clear about this policy and fully understood who to complain to and that any compliant would be recorded in a complaints register should the need arise. One relative spoken to also was clear in relation to this policy. There are two complaints books, which are located in the main hallway. One is for service users and the other for staff. On examination there were two minor recorded complaints from service users since the last inspection. These were both acted upon and resolved immediately by the staff team. Their documentation also demonstrates a positive open culture towards listening to service users views. Five policies were sampled in relation to protection of service users, which were clear, and ensured service users are safeguarded. All staffs spoken to were aware of protection issues and were clear about their responsibilities. Policies and practise described by care staff indicate a clear understanding of dealing with any more complex behaviour by service users in a protective manner. Training records show that staffs receive training in the protection of adults. BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 23, 24 and 26 Service users live in a clean, comfortable and homely environment. EVIDENCE: The assistant manager facilitated a tour of the premises, which included all areas of the home. The service users were seen to be using the lounge and dining room, which were clean and tidy providing enough space. A previous recommendation had been acted upon in that the downstairs bathroom had been fully refitted and bath relocated. Staff spoken to commented on the improved layout and access for service users. Service users bedrooms were clean and tidy and odour free. Most bedrooms were viewed and were personalised with individual belongings. Each room had an individual door lock although keys are not routinely held and this is recorded in care records. Following a review of one smaller shared room this is now only used by one occupant. One downstairs room is small however the assistant manager was able to demonstrate the needs of the occupant are being met and the potential to extend this room would be explored when vacant. BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 13 Outside there is a large garden. The assistant manager advised there has been no permanent maintenance person recently. It was noted that despite this the garden is well maintained. Some redecoration of the outside of the building had occurred including painting of window frames and the fire escape stairs. The laundry facilities were adequate with segregation of dirty and clean laundry. Procedures for control of infection and disposal of clinical waste were observed. BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 There is a stable and committed staff team, present in sufficient numbers to support service users needs. All staff receives a varied training program. EVIDENCE: During the inspection there were three care staff in addition to the assistant manager on duty. Observation determined that service users needs were being met during the day. The staff rota for the last 4 weeks was sampled and indicated sufficient staff on duty over a 24-hour period. The assistant manager confirmed that no agency was being used and staff turnover was low. Three staffs spoken to confirm that they were multi-skilled which clearly contributed to the overall efficiency of the staff team. Three staff were spoken to and confirmed that they had received full and varied training and were encouraged and supported by management to undertake this. The training records for these staffs were observed and indicated comprehensive training including more specialist training such as dementia. Although the training records required updating for this year, certificates were available on personnel files. The home also has a good induction program and completed records for one staff on duty was inspected which is presented in a booklet format devised by the management. This fully meets NTO guidelines. It was also confirmed by the assistant manager that 75 of care staff have completed NVQ level 2. The assistant manager confirmed that after induction all staffs are encouraged onto the NVQ program. Staff spoken to and records confirmed this is occurring. This BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 15 approach to induction and NVQ clearly has contributed to a good training program being available to the care team. Three staff’s personnel files were examined. These contained information required under regulation and schedule and included appropriate CRB checks. BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards 31 to 38 were not assessed during this inspection. EVIDENCE: BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x 3 x 3 3 x 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x x BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 18 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 Regulation Requirement Timescale for action 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 OP23 Good Practice Recommendations It is recommended that the use of bedroom 4 which is only 8.15sq metres, be reviewed when vacated by the current service user, as the room provides very little personal space for the occupant. BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Address 4 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 BELAMIE GABLES H52-H01 S11398 Belamie Gables V226517 190705 Stage 4.doc Version 1.30 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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