Inspection on 29/04/08 for Belamie Gables

This inspection was carried out on 29th April 2008.

CSCI found this care home to be providing an Adequate 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

Belamie Gables 10/10/07

Belamie Gables 14/02/07

Belamie Gables 02/02/06

Belamie Gables 19/07/05

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 Amanda Longman Unannounced Inspection 29th April 2008 08:20 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 Belamie Gables DS0000011398.V361091.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. Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belamie Gables Address 210 Hyde End Road Spencers Wood Reading Berkshire RG7 1DG 0118 988 3417 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) belamiegables@hotmail.co.uk Mr J Parry Mr D L White Belinda Vickery Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th October 2007 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 people. The home is not registered to provide nursing care nor care for people whose primary diagnosis on admission includes dementia. It is situated in a quiet residential area to the south 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. The fees for this home range from £430.00 - £452.00 per week. Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection of the service was an unannounced ‘Key Inspection’. It was a thorough look at how well the service is doing. We (the commission) received detailed information from the service in the form of an annual quality assurance assessment (AQAA). This provided details of current care provided, as well as plans for the future, details of staff and resident numbers, qualifications and training of staff, and information about the health and safety of the home. A site visit was undertaken on 29 April 2008. During this site visit we toured the home, observed care practices. spoke with residents and staff. We examined care records and staff records. A large number of requirements (14) had been made following the last inspection in October 2007 and we spent a lot of time during this inspection talking with the manager and reviewing evidence to establish that these requirements had been met. The service has in place policies and procedures relating to equality and diversity and there was evidence that they could meet a range of different needs and choices. What the service does well: Belamie Gables currently maintain detailed care plans which contribute to positive outcomes for residents. The home supports people’s healthcare and medication needs appropriately. The home strives to meet individual’s cultural and religious needs. Contact with family and friends is supported and encouraged. Meals are of good quality and residents enjoy meal times. The home is run by an appropriately qualified manager, who is developing suitable quality assurance procedures. The recruitment procedures protect residents. Some staff are well qualified. Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 4. Quality in this outcome area is adequate. Service users needs are fully assessed before they are offered a place at Belamie Gables. The home is confident it can meet the needs of those people to whom it offers a place. However, the home needs to be confident it has the skills to meet all of those needs without it impacting on the support offered to other residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose and service user guide are both appropriate and up to date. We spoke with two people who confirmed they, or their family representative had had enough information about the home, and a chance to visit it, to enable them to decide whether or not they wished to move in. The manager confirmed that all admissions are subject to a six week trial period on both sides. A new assessment form has been developed since the last inspection. All prospective residents have a pre admission assessment and those planning to permanently move in to Belamie Gables will have an opportunity to visit the home first. We looked at the pre admission assessment for one person who has recently moved in. It was very detailed. It contained all of the local authority’s assessment details, reports from the hospital and Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 9 the rehabilitation unit, a summary of the person’s life history and significant social networks and medical history. People who come to stay at the home for a short period of respite arranged at short notice by the social services department may not have an opportunity to visit the home first but will still have a pre admission assessment. The previous requirement that “All residents should be fully assessed by the home before admission to ensure that the home will be able to effectively meet their needs”, is thus met. However, one person living at the home was admitted with a primary diagnosis of dementia. A pre-admission assessment had been undertaken and the manager confirmed that they were currently able to meet this person’s needs. The person is supported by the social services department, who asked the home to admit them. However, the home is not registered to provide care for people with dementia. It does not have specialist resources, although some staff have received specialist training in dementia. We discussed this with the manager who will discuss it further with social services and will not offer a place to someone with a primary diagnosis of dementia in the future. Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. Accurate, detailed care plans contribute to positive outcomes for residents and the home supports people’s healthcare and medication needs appropriately. People are generally treated with dignity and respect but further training is required to ensure staff always support individuals’ wishes and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A new system of care plans has been introduced since last inspection. The manager explained that she draws up the care plan and then goes through them with each resident who signs them if they are happy with them. They are monitored monthly, and updated as required by key workers and carers. All service users have an annual review meeting with family and social services as relevant. We looked at the care plans for three residents. They detailed identified needs, expected outcomes and care staff instructions. They contain detailed personal choices such as rising and retiring. For example, one resident likes to be woken particularly early. This is recorded in her care plan and this is accommodated. The care plans were signed by the relevant resident and had Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 11 been reviewed monthly. Care plans also include significant things for the key workers to assist with, for example, a note is made of relatives’ birthdays. Risk assessments were in place, including for example nutritional risk assessments, falls, escorting, bathing, pressure ulcers and manual handling. Where risks are identified, plans were seen to include managing a reduction in risk. For example a resident was identified as at risk because they were having problems eating and their weight was beginning to fall. The person agreed to try having their food pureed to make it easier to eat. The manager has plans to further develop the procedures relating to risk assessments. Healthcare needs were identified in care plans, records of doctors and other appointments are maintained and there is a medication sheet detailing what medication the person is taking. Since the last inspection new medication procedures and training have been put in place. We checked the medication records for three service users and these were all accurate. Some files contained information about whether or not residents wished to be resuscitated. The manager will seek legal advise about how residents wishes in this area should be recorded and handled. We spoke with two service users about how they are treated by staff within the home. Both spoke highly of the care they received and confirmed they make there own choices about, for example what time to get up or go to bed, what they wore or whether or not to have a bath. They also confirmed that staff use manual handling equipment such as hoists, to assist them with bathing. The three surveys we received back also stated that staff listen to them and act on what they say and that they “always” receive the medical support they need. We observed people being supported in a friendly and respectful way. However, during the course of our observations we noted that on two occasions resident’s wishes or requests were not responded to appropriately. One instance regarded a resident requesting a cup of tea who was told tea would be served in a little while a second incident involved a resident who appeared to be saying she would like to have a rest who was discouraged from this and assisted in to a chair instead. In both instances staff were polite and spoke kindly and courteously but they were examples of where individual freedom and choice were curtailed. By contrast at another point in the day a carer was seen to respond to an individual request for a cup of tea. We discussed these instances with the manager who agreed to raise these issues in staff meetings, supervision sessions and training sessions to ensure sure all staff fully understood how to encourage and respond to individual requests and choices. All resident’s clothes are now labelled and they all have their own clean laundry baskets. Visual notices in service users bedrooms remind care workers to respect their residents’ clothes and wardrobes. Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 12 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 and 15. Quality in this outcome area is adequate. The home provides a limited range of activities but does strive to meet individual’s cultural and religious needs. Contact with family and friends is supported and encouraged. Residents are supported to exercise some choice and control over their daily lives but this needs to be improved in terms of the daily routine of the home. Meals are of good quality and residents enjoy meal times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the previous inspection it was noted, “residents have very limited opportunities to participate in activities”. The manager stated in the AQAA that a range of activities are now provided and of the three surveys we received from residents prior to the site visit two said there were “always “ activities they could take part in, but one said there were “never” activities they could take part in. At the site visit we noted a timetable of activities was on display on the wall. There was one activity a day, Monday to Friday, which included arts and crafts, Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 13 shopping, keep fit and bingo. Activities are not formally arranged at weekends. The manager said this was because a lot of visitors come to the home at weekends. This was confirmed by people we spoke with who also said visitors were always made welcome at the home. Outings are also sometimes organised. The day after the site visit a number of residents were going out to a Chinese restaurant for lunch and the manager was finalising numbers for this. She also confirmed to residents that next month they would go out to a carvery for lunch. The home does not currently have any transport and outing take place using cars or taxis. The mobile library visits monthly. As does the Free Church. Holy communion has been arranged in the past but is not currently required by any service users. However there is still scope to expand the choice and range of activities on offer. The manager was confident that they would be able to meet a range of diverse religious or cultural needs in line with prospective resident’s wishes and that to do this, where necessary they would seek advice from the resident, their family or relevant organisations. For example, the home recently had a prospective resident who wished to have Halal food. The manager explained she undertook the necessary research and advise to put this in place. However, the person’s circumstances changed and they did not come to stay at the home. The manager also confirmed that any specific wishes relating to death is discussed with the resident and their family, usually at the six week review and we saw evidence on resident’s files where such wishes or religious requirements were noted. We observed lunch being served and sampled the food. The food was hot, tasty and well presented. Pureed meals were served with the different elements of the meal being pureed separately. There was a choice of two main courses and where people had changed their mind about what they had ordered, this was accommodated with no fuss. Staff supported those residents who needed assistance with eating in a respectful and appropriate way. There was a relaxed friendly atmosphere in the dining room and residents chatted easily with each other and with staff. There was a homemade pudding or a choice of yogurt and fruit. Seconds were offered and served to those who wanted it. Two people chose to eat in their room, and this choice was respected, and one person retired to her room without eating lunch. Staff confirmed they would prepare something fresh for her later. The dining room was bright with comfortable chairs and new table cloths. After lunch staff supported residents to return to the sitting room. Although staff were polite and friendly in their interactions with residents not all requests were acknowledged or catered for. For example a request for a cup of tea was met with a response about tea coming round a bit later and a request to go to their room for a rest was not taken seriously. Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 14 We spoke with the manager about this and she agreed that these responses, although well intentioned, did not support the wishes or choices of residents and stated she would address this with the staff concerned. We spoke with two residents who said the care they received was very good and that staff were kind and polite and answered their call bells promptly. They said they had the freedom to get up and go to bed when they liked and to spend time in the lounge or in their own room if they wished. One said the home “has a happy and friendly atmosphere”. In the afternoon we observed that staff organised a game of bingo, which several residents enjoyed. This was the only activity of the day. Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. Residents know their complaints will be listened to and acted upon. Mechanisms are in place to protect residents from abuse but staff need training in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: After the last inspection a requirement was made to update the complaints procedure and ensure it was accesible. In the AQAA the manager stated that they had reviewed and revised the complaints policy and procedure and had ensured that all residents, families and staff had received a copy the new procedure. Of the three surveys we received from residents prior to the site visit one said they “usually” knew who to speak to if they were not happy and one said they “sometimes” new who to speak to. The third said they had “no problems”. At the site visit we spoke in detail with two residents who confirmed they knew who to speak to if they were not happy about something. We reviewed the new procedure and log during the site visit and it was being used appropriately. In the AQAA the manager stated that a new Protection of Vulnerable Adults (POVA) Training Pack had been purchased. The home has an appropriate safeguarding procedure in place. Training for staff in POVA has been planned but not yet delivered. No information about complaints or safeguarding issues have been received by us since the last inspection. Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 16 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 and 26. Quality in this outcome area is adequate. Residents enjoy a safe and reasonably well maintained environment. The home is reasonably clean. Improvements need to be made to the front of the property to make it an attractive place to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: After the last inspection a requirement was made to ensure that the home is kept clean and hygienic and that proper infection control measures are taken at all times. The AQAA we received prior to the site visit stated that all staff are trained in, and understand, the importance of Infection Control. Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 17 The AQAA also contained evidence that it is regularly maintained and all relevant maintenace checks are undertaken on gas, electrical and other equipment, in line with manufacturers recommendations. It also stated that in the last 12 months bedrooms have started to be refurnished and refurbished, that all water outlets within the home are thermostatically controlled and that new furniture has been purchased for the garden. Furthermore, all rooms have paper towel and soap dispensers. Of the three surveys we received from residents prior to the site visit all stated that the home is “always” fresh and clean. During the site visit we toured the home and saw that it was mostly clean, tidy and hygienic. Soap and paper towels are provided. Some light pull cords were grubby. We raised this with the manager because of its implications for infection control. The manager agreed to ensure these were cleaned or replaced immediately. Belamie Gables is a converted house and some of the rooms are small. Some of the furniture in bedrooms has been replaced, in line with what was stated in the AQAA, but in one of the vacant rooms we saw some tatty furniture, which still needs to be replaced. Residents we spoke with confirmed they are able to personalise their room and bring small pieces of furniture if they wish. Belamie Gables has a parking area to the front and a garden to the rear. The front of the house appears mismatched and shabby. There are different types of windows and doors and windows have an assortment of style and shapes of net curtains. There is no formal layout to the front. However a new slope to the front door has been built to improve access. Work has commenced on the back garden. This is now accessible for residents. On the day of the site visit tree debris was being tidied and taken away. The home had a recent fire inspection and the manager is in the process of confirming all the requirements have been met. Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is adequate. The number of staff on duty has been increased to try to meet the needs of residents. Some staff are well qualified. Recruitment procedures protect residents and the manager is aware that there are some gaps in the training programme and plans to deal with this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Following the last inspection a requirement was made to ensure that at all times residents have sufficient numbers of appropriately trained staff on duty to meet their needs. The AQAA we received prior to the site visit stated that all appropriate recruitment checks are now undertaken and that staffing levels had been increased to meet the needs of residents. It also stated that 75 of care staff had achieved NVQ level two or above. Of the three survey responses we received from residents prior to the site visit two said staff were “always” available when needed and one said staff were “sometimes” available. During the site visit we established that three care workers are on duty in two shifts from 7.30am until 7.30pm. In addition the manager and/or the deputy Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 19 manager are on duty everyday (including weekends). This has been an increase in staff as previously there were only two care workers from 3.30pm until 7.30 pm. There are two waking night staff. The home also employs a housekeeper. The home now has a full compliment of staff and has not used any agency staff since March. Some staff do choose to work additional hours (up to 44 per week), but no staff any longer work a double shift. We checked the recruitment records for the two most recently recruited members of staff. All appropriate recruitment checks had been completed including full employment history, two references and a report from the criminal records bureau. The manager has constructed a training database for all mandatory training and all staff have now received training or arrangements are being made for them to do so. For example on the day of the site visit the manager met with a manual handling trainer who was arranging a course for staff who needed this training for the following week. All new care workers now receive an induction training book which is in line with the common induction standards. One member of staff is qualified to NVQ level three and one member of staff commenced level three in February. Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 20 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 and 38. Quality in this outcome area is adequate. The home is run by an appropriately qualified manager, who is developing suitable quality assurance procedures. Residents’ financial interests are protected and improvements have been made to the infection control procedures within the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The last inspection highlighted poor Health and safety systems which were not sufficiently robust to protect residents from harm. These referred specifically to infection control procedures. There were also concerns that a quality assurance procedure needed to be developed which sought the views of residents, and that residents money deposited for safekeeping was properly accounted for and records of all transactions were correctly receipted. Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 21 In the AQAA the manager stated that higher staffing levels have allowed the manager to concentrate more on putting new procedures and systems in place. The home is run by a suitably qualified manager who is registered with the commission. She has been in place for a number of years and stated at the site visit that she is very keen to improve the home. Since the last inspection the number of administrative hours provided in the home has increased to support the manager in her development of manager systems. Several improvements have been made to the quality assurance processes since the previous inspection. A new quality assurance form has been developed to cover all the weekly health and safety checks undertaken in the home and a new questionnaire for residents has been devised. The manager has also obtained information on self auditing of processes which she had evidently begun to explore having assigned certain processes to be audited in certain months. We discussed with the manager how she might consider the process of quality assurance in terms of reviewing the homes performance against its aims and objectives, as stated in the statement of purpose, and thereby producing a development plan. Residents meetings are now held every two months and minutes are kept of these. Staff meetings are held monthly, and again a minuted record of these meetings is kept. Small amounts of pocket money are held securely in the office on behalf of residents. We looked at the records and money for two residents. Records were accurate to the cash held. Withdrawals are signed and countersigned and expenditure receipts are numbered for easy correspondence with individual records. The records are audited by the manager. We recommended that they also be periodically audited by another person. Only the manager or the deputy have access to residents’ monies Health and safety policies are in place, as are appropriate health and safety risk assessments. Some staff have received infection control training and the manager plans to carry this through to all staff but there are no definite arrangements in place. All staff have access to the kitchen. We discussed with the manager the possibility of limiting access to assist with infection control and the manager will look in to how this could be managed. The home has a suitably equipped laundry and all clean laundry is put in to labelled baskets for returning to the correct resident. Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 22 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 3 X 3 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 2 X 2 Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 23 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 OP4 Regulation 14 (1) (d) Requirement The home must only admit people whose needs it can meet, as documented in its Statement of Purpose. The home must ensure that external areas are appropriately maintained, to ensure the safety and welfare of residents. Timescale for action 29/05/08 2. OP19 23 (2) (o) 29/07/08 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 2 Refer to Standard OP12 OP19 Good Practice Recommendations It is recommended that the home further improves the range and type of activities on offer to further promote positive outcomes for residents. In order to meet requirement number 2 above, it is recommended that the front appearance of the house and the front gardens are tidied and refurbished to a reasonable standard. To ensure the protection of residents, it is recommended DS0000011398.V361091.R01.S.doc Version 5.2 Page 24 3 OP35 Belamie Gables that residents’ accounts be independently audited on a regular basis. Belamie Gables DS0000011398.V361091.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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