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Inspection on 15/05/06 for Belgarth Nursing Home

Also see our care home review for Belgarth Nursing Home for more information

This inspection was carried out on 15th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home ensured that residents were admitted only when detailed assessments had been completed and when the home was clear they could be looked after. The home had confirmed, in writing, that following an assessment they could care for people properly. Care plans were developed from the assessments and contained information about how staff would meet the resident`s needs. Staff had been given appropriate training to help them to meet the resident`s needs and staff had a good understanding of residents needs. Training in relation to privacy and dignity had been provided and staff were seen responding to residents and visitors in a friendly but respectful manner. A range of activities had been arranged that met the needs and interests of the majority of residents. A new activities co-ordinator was due to start this month to improve this area. Residents were able to choose whether they joined in or not. The dining areas were bright, airy and nicely decorated and lunchtime was unhurried. The meals looked tasty and nutritious and residents confirmed they were offered a choice. Mealtimes were staggered to ensure everyone was supported. One visitor said `the food must be good as mums appetite has improved`, a resident said `it is good food and you can have a choice of something else`. Comment card information and discussions with visitors clearly supported that visitors were made to feel welcome when visiting the home. The home was fully staffed and provided staff with a range of skills and qualifications to meet resident`s needs. One visitor said staff `are a good bunch` and `they work hard`; another said `staff are a friendly bunch and know what they are doing`. One resident said `staff listen to you they help you if they can`. Comment card information from relatives indicated that they were satisfied with the care provided. Residents and their relatives were confident that if they raised a concern or made a complaint they would be listened to and action taken to resolve the problem. The home continued to seek the views of people who used the service to determine whether the home was meeting people`s needs.

What has improved since the last inspection?

What the care home could do better:

The care plans for residents did not clearly show what staff needed to do to meet resident`s needs. Risks had been assessed but there was not enough information about how what action staff would need to take to reduce or remove the risks.As noted the medication policies and procedures had been improved however from looking at medication charts and talking to staff it was clear that the procedures had not been followed in all aspects and this could put residents at risk. The home had clear policies and procedures regarding abuse and staff had received appropriate training to help them to protect residents from harm; however concerns were raised that procedures had not always been followed and this could put residents at risk. The registered manager needs to ensure that records are available for inspection at all times.

CARE HOMES FOR OLDER PEOPLE Belgarth Nursing Home Wheatley Lane Road Barrowford Nelson Lancashire BB9 6QP Lead Inspector Mrs Marie Matthews Unannounced Inspection 09:30 15 & 23rd May 2006 th 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 Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 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. Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Belgarth Nursing Home Address Wheatley Lane Road Barrowford Nelson Lancashire BB9 6QP 01282 699077 01282 619030 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) Bellgarth Care Home Limited Mrs Lynne Margaret Markham Care Home 47 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number disorder, excluding learning disability or of places dementia (2), Mental Disorder, excluding learning disability or dementia - over 65 years of age (22), Old age, not falling within any other category (44) Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Within the overall registration of 47, a maximum of 37 service users requiring nursing care who fall into the categories of either OP,DE(E), or MD(E) may be accommodated. Staffing must comply with the letter to the registered provider dated 11th February 2004. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The variation for the two younger service users with a mental disorder (MD) should apply only whilst accommodated in the home and under the age of 65 years. 21st November 2005 2. 3. 4. Date of last inspection Brief Description of the Service: Belgarth is a detached older building situated on the outskirts of Barrowford, near Nelson. The home is close to the local park, churches and shops. The building has been extended over the years and is registered to provide both nursing care and personal care for up to forty seven older people. There is a passenger lift to access the first floor. The home has garden and patio areas for service users to sit out in and provides a parking area for visitors and staff. The home has a separate unit for people who are elderly and have dementia or a mental disorder. Information about the services that the home offers is provided in the form of a service user guide and is available to existing and prospective residents and their relatives. A summary of the most recent inspection report is available within the service user guide. The fees from April 2006 range from £355.50 to £496.12. Additional charges are made for hairdressing, toiletries and newspapers. The home also makes an additional charge if a carer is needed to accompany a resident on any appointments. Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted at Belgarth on 15th & 23rd May 2006. The inspection was conducted over two days as on the initial visit the inspector did not have access to records required by regulation. This was discussed with the registered manager on return from leave. The inspection involved looking at records, talking to staff, three visitors and six residents, a tour of the premises and generally looking at what was happening in the home. Information was also obtained from survey forms received from ten relatives and one General Practitioner. This inspection looked at things that should have been done since the last visit and a number of areas that affect resident’s lives. There were forty-two people living in the home on the day of the inspection. What the service does well: The home ensured that residents were admitted only when detailed assessments had been completed and when the home was clear they could be looked after. The home had confirmed, in writing, that following an assessment they could care for people properly. Care plans were developed from the assessments and contained information about how staff would meet the resident’s needs. Staff had been given appropriate training to help them to meet the resident’s needs and staff had a good understanding of residents needs. Training in relation to privacy and dignity had been provided and staff were seen responding to residents and visitors in a friendly but respectful manner. A range of activities had been arranged that met the needs and interests of the majority of residents. A new activities co-ordinator was due to start this month to improve this area. Residents were able to choose whether they joined in or not. The dining areas were bright, airy and nicely decorated and lunchtime was unhurried. The meals looked tasty and nutritious and residents confirmed they were offered a choice. Mealtimes were staggered to ensure everyone was supported. One visitor said ‘the food must be good as mums appetite has improved’, a resident said ‘it is good food and you can have a choice of something else’. Comment card information and discussions with visitors clearly supported that visitors were made to feel welcome when visiting the home. The home was fully staffed and provided staff with a range of skills and qualifications to meet resident’s needs. One visitor said staff ‘are a good Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 6 bunch’ and ‘they work hard’; another said ‘staff are a friendly bunch and know what they are doing’. One resident said ‘staff listen to you they help you if they can’. Comment card information from relatives indicated that they were satisfied with the care provided. Residents and their relatives were confident that if they raised a concern or made a complaint they would be listened to and action taken to resolve the problem. The home continued to seek the views of people who used the service to determine whether the home was meeting people’s needs. What has improved since the last inspection? What they could do better: The care plans for residents did not clearly show what staff needed to do to meet resident’s needs. Risks had been assessed but there was not enough information about how what action staff would need to take to reduce or remove the risks. Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 7 As noted the medication policies and procedures had been improved however from looking at medication charts and talking to staff it was clear that the procedures had not been followed in all aspects and this could put residents at risk. The home had clear policies and procedures regarding abuse and staff had received appropriate training to help them to protect residents from harm; however concerns were raised that procedures had not always been followed and this could put residents at risk. The registered manager needs to ensure that records are available for inspection at all times. 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. Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home provided current and future residents and their representatives with information that enabled them to make an informed choice about admission to the home. Resident’s needs had been assessed and the home confirmed, in writing, that they were able to meet their needs before admission. EVIDENCE: Information about the home was clear and detailed the services on offer and was given to residents and their families. Staff said that the information would be available in large print or other formats if requested. Assessments of needs had been done before new residents were admitted to the home. The home confirmed, in writing, they could meet people’s needs. Staff showed they had a good understanding of residents needs and the home had provided staff with specialised dementia training to help them to care for the residents in the home. Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The residents care plans did not clearly detail the action to be taken by staff to meet resident’s needs but some residents and their relatives had been involved in care planning. Medication policies and procedures were clear and detailed but staff needed to adhere to them to ensure that residents were not put at risk. Staff treated residents with respect and maintained peoples rights to privacy and dignity. EVIDENCE: Three care plans were looked at in detail. One plan contained detailed information about likes and dislikes and preferences but this was not the case in all the plans. All plans contained risk assessments including a falls risk assessment; however staff had not always detailed action to be taken by staff to reduce or eliminate any identified risks to residents. Two of the care plans showed that residents or their relatives had been consulted about the care plan and staff said they were trying to get more people involved in this process. Eight out of eleven relatives said they were involved in decisions about care Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 11 and consulted about any changes affecting their relative. One relative said ‘they keep us up to date with what is going on’. Care plans had been reviewed every month by staff and there was evidence that the plans had been updated to reflect current needs. One GP said that staff had a clear understanding of residents needs and they were satisfied with the overall care provided. The medication policies and procedures had been reviewed and gave clear guidance for staff to ensure the safety of residents. However the policies and procedures needed minor additions to reflect that prescriptions were seen by the home prior to dispensing and this practice needed to be followed to ensure residents were receiving the correct medication. From looking at medication charts and talking to staff it was clear that the procedures had not been followed in all aspects, in particular using appropriate codings for medication not given, medication given covertly, the dosage of medication given when an option of one or two tablets was directed and protocols for medication to be given ‘when needed’. These practices could put residents at risk. Some concerns were raised from the comment cards with regard to the privacy and dignity of residents. One visitor said that her relative was dressed in inappropriate clothing that was creased another said they were unable to visit in private as the bedroom doors were locked. On the day of the inspection residents were seen to be appropriately dressed and clothing was tidy and ironed. One visitor said ‘ mum is always well dressed in her own clothes’, a resident said ‘staff look after my clothes there is always something in the wardrobe to wear’. Some doors were locked on the first floor but these were empty rooms waiting cleaning and decorating. Residents were seen walking freely around each unit. There were a number of residents in the upstairs lounge area, which was cramped; this was discussed with the registered manager and alternative arrangements were suggested. Staff had received training in relation to maintaining privacy and dignity of residents. Staff were seen to respond to residents and visitors in a positive way. Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Activities and entertainments were appropriate and met the expectations and needs of some residents in the home and improvements were planned. Visitors were welcomed. The home provided a varied menu and the residents were able to exercise choice about what they ate. EVIDENCE: Residents said they were given choices about how to spend their day. One resident said she didn’t like mixing and this was respected. Some residents were sitting alone others in groups or with a friend. Staff were seen sitting with residents on the dementia unit. Photos on activity board showed visits to the theatre, park, heritage centre, visits by the movement to music and music man. Residents said it was ‘a bit quiet’ sometimes. There were no activities on the day of the inspection. A new activities person was due to start in the home this month. It was recommended that the staff involved residents and relatives in providing ‘life history’ information that would assist with the planning of activities. Comment card information and discussions with visitors clearly supported that visitors were made to feel welcome when visiting the home. Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 13 The dining areas were bright, airy and nicely decorated; lunch was unhurried. Mealtimes were staggered to ensure everyone was supported and residents could eat in their rooms. Residents said they were offered a choice of meal. One visitor said ‘the food must be good as mums appetite has improved’, a resident said ‘it is good food and you can have a choice of something else’. The home needed to provide a clear record of meals that had been served to each resident to evidence that they had been given a choice at all times. Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home had a good complaints system and people knew how to complain and were happy the situation would be dealt with appropriately. The home had clear policies and procedures regarding abuse but procedures had not always been followed and this could put residents at risk. EVIDENCE: There was a clear record maintained of complaints or concerns that had been raised. Two relatives spoken to were aware of the procedure, as they had been given a service user guide. Two residents knew how to complain. Survey info indicated that one out of ten relatives was unaware of the procedure and another had used the procedure and the situation had been resolved. Some staff had recently had training in relation to responding to abuse and this would help them to maintain the safety of residents in the home. Concerns were raised as it was clear that following identification of a suspicion of abuse an investigation had taken place but the appropriate adult protection procedures had not been followed. This was discussed with the registered manager who was made aware that the procedure must be followed at all times to ensure that residents were protected at all times. Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 19, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The standard of décor in many areas of the home had improved and provided a safe, homely and comfortable place for residents. There was a documented programme of planned maintenance and renewal to support future improvement. EVIDENCE: From a tour of the home it was clear that improvements to the standard of the environment had been made since the last inspection. Redecoration and refurbishment of the home was ongoing and there was a planned programme of maintenance and renewal to evidence further improvements to be made. It was noted that some rooms would benefit from redecoration and refurbishment but the staff said this was being done as rooms became empty. Rooms were generally comfortable, bright and nicely decorated; not all rooms were furnished to the minimum standard but residents were happy with their rooms and had brought in personal items to make them feel more homely. One resident said ‘my room is lovely’. Lockable storage keys and keys to rooms Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 16 were not provided for all residents which impacted on the privacy of residents; the reasons for this had not been included in their care plan. The home was free from offensive odours and clean and tidy. Failed double-glazing units had been replaced and radiator covers were in place to ensure residents safety. Water temperatures were tested randomly and were found to be safe. There was an attractive patio area and gardens to the rear of the home which were accessed by a ramp. Residents had said they had enjoyed the gardens on the warmer days. Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staff received appropriate training to ensure they had the skills to meet the needs of residents in their care. The home had improved the way it recruited new staff and this ensured residents were safe. EVIDENCE: Staffing rotas were clear and showed that the home was fully staffed with a good skill mix of permanent staff. Three out of eleven relatives commented that there was not enough staff around however residents were seen getting prompt attention, as they needed during the course of the inspection. Information from records and discussions with staff showed that staff were appropriately trained. Staff were able to confirm that they had received induction and update training to help them to meet the needs of the residents who lived in the home. A training plan was available to support the need for training and further development of staff. The way the home recruited new staff had improved and all checks had been completed prior to employment. This made sure that residents were safe and that staff were suitable to care for them. One visitor said staff ‘are a good bunch’ and ‘they work hard’; another said ‘staff are a friendly bunch and know what they are doing’. One resident said Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 18 ‘staff listen to you they help you if they can’. Comment card information from relatives indicated that they were satisfied with the care provided. Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The systems for consultation with residents, visitors and staff are good with evidence that the home had responded to any issues raised. Staff were supervised in their work to ensure they were able to meet the residents needs. Records required by regulation and for the protection of residents were maintained. EVIDENCE: Mrs Lynne Markham is the registered manager of Belgarth. She is a registered nurse with many years experience in care and management and has completed the registered managers award. Mrs Markham is also the NVQ assessor, moving and handling trainer, fire marshal and person with responsibilities for health and safety. Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 20 Staff said regular staff meetings, for staff to air their views, had taken place. Minutes were recorded. Memos were also used to keep staff informed of any changes prior to meetings taking place. The senior nurse said meetings had been arranged for residents and their visitors and had been poorly attended; an evening meeting was due to take place. Surveys had been completed in June 2005 and questionnaires for this year were to be collated this month. The findings would be made available to residents, their relatives and other interested people. The home had achieved Investors In People award; this is a quality assurance award accredited by an outside body and demonstrates a commitment to staff training and development. The records of one to one staff supervision were seen. Staff were supervised to ensure they could meet residents needs. The home kept clear records of resident’s finances. This made sure that people’s finances were safe. The registered provider visited the home regularly to monitor the day to day running of the home and a record of visits had been made. The registered manager had notified the Commission of any incidents under Regulation 37. On the day of the inspection the registered manager was on leave and records needed to conduct the inspection were unavailable. The registered manager was advised that records must be available for inspection at all times to enable the inspector to be sure that the home was being well managed and that residents were being looked after. Information provided by the registered manager indicated that certificates to evidence servicing of systems were up to date and that people’s health, safety and welfare was maintained. Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 21 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 2 3 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 3 X 3 X 3 3 2 3 Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 22 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 OP7 Regulation 15 Requirement The registered person must ensure that the resident’s plan of care sets out in detail the action to be taken to ensure all needs are met. Once a risk has been identified the care plan must show what action staff need to take to reduce or eliminate the risk. Prescriptions must be seen by the home prior to dispensing and the policies and procedures must reflect this safe practice. Covert administration of medicines must be supported by written evidence and the procedure followed. Medication must not be omitted without clarification of the reason. A record of meals served must be maintained. The registered provider must ensure that allegations of abuse are responded to appropriately in accordance with written policies. The registered provider must ensure that care home records detailed in schedule 3 & 4 are at DS0000022470.V287741.R01.S.doc Timescale for action 10/07/06 2. OP8 13 10/07/06 3. OP9 13 10/07/06 4. OP9 13 10/07/06 5. 6. OP15 OP18 16 13 10/07/06 01/06/06 7. OP37 17 01/06/06 Belgarth Nursing Home Version 5.1 Page 23 all times available for inspection by any person authorised by the Commission to enter and inspect the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The criteria for PRN medication should be clearly defined and recorded. The MAR should clearly indicate whether one or two tablets have been taken. Transcribing should be witnessed on the MAR sheet. Medication trolleys must be secured when not in use. The registered person should ensure that each room is audited for contents against standard 24 and this is discussed with the resident and their representative, to ascertain their wishes. These wishes regarding furnishing should then be recorded as part of their care plan. The registered person should ensure that residents are provided with keys to their lockable space and to their rooms unless a risk assessment determines otherwise. 2. 3. 4. OP9 OP9 OP24 5. OP24 Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Belgarth Nursing Home DS0000022470.V287741.R01.S.doc Version 5.1 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!