Inspection on 21/06/05 for Belgarth Nursing Home

This inspection was carried out on 21st June 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Belgarth Nursing Home 20/07/09

Belgarth Nursing Home 26/06/07

Belgarth Nursing Home 15/05/06

Belgarth Nursing Home 21/11/05

Belgarth Nursing Home 08/03/05

Belgarth Nursing Home 26/07/04

Belgarth Nursing Home 03/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Sunny Bank (P.R.S.) Ltd

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

Langrigg House

Parkside

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

CARE HOMES FOR OLDER PEOPLE Belgarth Nursing Home Wheatley Lane Barrowford Nelson BB9 6QP Lead Inspector Marie Matthews Announced 21 June 2005 9.30 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. Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Belgarth Nursing Home Address Wheatley Lane Road Barrowford Nelson Lancs BB9 6QP 01282 699077 01282 619030 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) Bellgarth Care Home Ltd Mrs Lynne Margaret Markham Care Home 47 22 24 44 2 Category(ies) of MD(E) registration, with number DE(E) of places OP MD Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 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 2. Staffing must comply with the letter to the registered provider dated 11th February 2004 3. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 4. 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. Date of last inspection 9/03/05 Brief Description of the Service: Belgarth is a detached older building situated on the outskirts of Barrowford, near Nelson. The building has been extended over the years and is registered to provide both nursing care and personal care for older people. The home has garden and patio areas for service users to sit out in and provides a small parking area for visitors and staff. The home has a unit for people who are elderly and have dementia or a mental disorder. Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection was conducted at Belgarth on 21st June 2005. The inspection involved looking at records, talking to management, three staff, nine residents and three visitors, a tour of the home and generally looking at what was happening in the home. Information was also taken from comment cards filled in by three residents and twelve visitors. This inspection looked at things that should have been done since the last visit and a number of areas that affect resident’s lives. Serious concerns about the standard of staff recruitment procedures and safe access to the gardens were raised in a separate letter to the registered provider. There were forty-five people living in the home on the day of the visit. Residents and visitors were in the main content with the care provided. Residents commented that they were ‘treated kindly’ and that staff were ‘patient’ and ‘caring’. Since the last inspection the ownership of the home has changed. The registered provider is now Mr Saeed Ahmad. Mr Ahmad owns a number of care homes in the area. 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 their needs could be met. Care plans were developed from the assessments and generally indicated how staff would meet the resident’s needs. Some areas of the home had been refurbished last year and residents in those rooms were content with their bedrooms. One resident said ‘ I am very happy with my room’ and had brought in personal items to ‘make it feel more like home’. Residents and visitors made positive comments about the cleanliness of the home. A resident said ‘it is always clean and tidy’. Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 Page 6 The staff team communicated well and regular staff meetings were always well attended. A visitor confirmed they had been asked to complete a survey about the home and that management had responded promptly to any concerns they had raised. The home was very good at providing appropriate training to help staff to meet resident’s needs. Residents said staff were ‘friendly’ and that they were ‘treated kindly’. What has improved since the last inspection? What they could do better: The home could improve the standard of information available to residents and their relatives with regard to arrangements for living in the home. Residents and visitors had been involved in a survey about the home but had not seen the results of the survey. Meetings with residents and relatives had been poorly attended and the registered manager was aware that she needed Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 Page 7 to develop other means to make sure that residents and visitors could have their say about how the home was run. As noted above staff were provided with training to help them to understand residents needs but required specialised ‘dementia’ training to support them. Residents care plans needed to include all information about their health needs. Residents and their relatives needed to be involved in the development and review of the care plans. The management of medicines needed improving to ensure safe systems were in use and that residents were not placed at risk. Further work needed to be done to make the building and its surroundings pleasant, safe and comfortable for the people who lived there. The home needed a written development plan to support this. Serious concerns were raised again about the way the registered manager recruits new staff. This needed to be sorted out immediately to make sure that residents are not put at risk. Health and safety issues were discussed with the registered manager and requirements were made. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 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 standard(s) 1, 2, 3 and 4. (standard 6 is not applicable). The home did not provide current or future residents and their representatives with enough information to enable them to make an informed choice about admission to the home. Residents were admitted only when detailed assessments had been completed and when the home was clear their needs could be met. Staff had a clear understanding of residents needs but required specialised training to support them. EVIDENCE: The statement of purpose and service user guide had been changed following the last inspection but still did not contain the correct information. The registered manager said that service user guides were not issued to all residents. The registered manager needed to provide new and existing residents with appropriate information about the home. Contracts informing residents about their rights within the home were supplied and a copy was available on file. Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 Page 10 Resident’s needs had been assessed and the home confirmed, in writing, whether they were able to meet their needs before admission. The home’s assessment document had been reviewed but still needed some minor changes. Staff showed they had a good understanding of residents needs though they still lacked specialist dementia training. Staff training files confirmed this. Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 Page 11 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, 10 and 11. The residents care plans still needed to include all information to ensure staff had a good understanding of how to meet the resident’s health needs. Residents and relatives had not been involved in the development or review of their care plans. The medication system placed residents at risk. Staff treated residents with respect and care was offered in such a way to maintain the residents rights to privacy and dignity. EVIDENCE: All residents had care plans generated from an assessment. Three care plans were looked at. A new care planning system was being introduced and will be monitored at the next visit. The plans were generally detailed and contained some relevant information to enable carers to meet the resident’s needs. Risk assessments were included in the plan but there were no risk assessments relating to falls. There was no evidence to support residents or their relatives had been involved in the development or review of the care plans. Reviews by staff had taken place every other month but one care plan had not been updated to reflect a change in needs. All residents were assessed to identify Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 Page 12 whether they were at risk of developing pressure sores but interventions were not always recorded. Specialised mattresses were seen in use around the home. Nutritional screening was completed on admission but appropriate weighing equipment had still not been provided. One care plan evidenced use of ‘tippex’ to alter the records. The registered manager was advised this practice must cease. The registered manager said the medication system was under review. Policies and procedures still needed slight amendment to meet the standard. Records of medication orders were clearly maintained. Records of returns were not clear. The records of administration did not always indicate clear directions and this should be discussed with the GP or pharmacist. Transcribing had not always been witnessed. Controlled drugs were randomly checked and were correct. Two residents said they felt their privacy was respected only ‘sometimes’, two others said the staff did respect their right to privacy. One resident said she would see her GP in her own room. One visitor said his relative was ‘always dressed nicely’ and a resident said her clothes were ‘looked after’. Staff were seen knocking before entering rooms and treating residents in a friendly but respectful manner. One relative from a recently deceased resident commented ‘these people are angels’ and that staff had been ‘a constant support’ to the family and ‘wonderful to our beloved mum’. Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 Page 13 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) 12, 13 and 15. The home had improved the provision of a varied menu and the residents were able to exercise choice about what they ate. The home offered a range of suitable activities to meet the needs and interests of the residents. EVIDENCE: There was a range of planned activities displayed on the resident’s notice board. Residents said they could choose whether they wished to join in and confirmed that the activities provided were suitable. All visitors said they were welcomed into the home and could visit in private. Visitors commented that they were kept informed about important issues affecting their relatives. Some residents were able to go out with their relatives others said they relied on staff to take them out. One visitor said that staff took residents out in the warmer weather. Residents said they were able to move into other areas of the home and were given a choice in respect of bedtimes and rising. The menu was displayed and offered a choice of meal. Residents said they enjoyed the food and confirmed they were given a choice at mealtimes. Positive comments were made about the dining areas being ‘bright and tidy’. Staff were seen giving assistance to residents who needed. A ‘hot trolley’ had still not been provided Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 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 standard(s) 16 and 18. The home had a good complaints system and clear records had been maintained. Information about the complaints procedure was not easily accessible to residents and visitors. The home had clear policies and procedures to guide staff regarding abuse and suspicion of abuse. EVIDENCE: Records had been maintained of any complaints or concerns raised and any action taken. The procedure was displayed in the entrance of the home but not available to all residents in the service user guide. One visitor told the inspector he would be happy to discuss any concerns with staff and felt they would be resolved. Half of the relatives who completed the comment cards said they were not aware of the home’s complaint procedure. This problem would be resolved when residents and their relatives are provided with a service user guide. Residents said they would know who to talk to if they were unhappy with their care. Staff confirmed that the home had clear policies and procedures to guide them regarding how to respond to any suspicion of abuse. A training pack had been developed and training was due to commence. Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 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 standard(s) 19, 24, 25 and 26. The standard of décor in some of the bedrooms was poor and did not present a safe, homely and comfortable place for residents. There was no documented programme of planned maintenance and renewal to support future improvement. Access to the gardens was not well maintained or safe for residents. The home was clean and odour free. EVIDENCE: Redecoration of the home was ongoing although there was no planned programme of maintenance and renewal. During a tour of the home it was noted that some bedrooms would benefit from redecoration and refurbishment. Furnishings in some rooms were ‘shabby’ and not co-ordinated. A large number of double-glazing units had failed; the registered manager said new units were on order. Radiators were still uncovered; the registered manager said the covers were still waiting to be painted then would be fitted. Minimum furnishings were not provided in all rooms, the reasons for this had not been included in the care plan. Some rooms did not have lockable storage space Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 Page 16 whilst another room had three. Plugs were missing from some resident’s sinks; there were no risk assessments in place to support this. There was a hole in one of the floorboards in a resident’s room and this created a risk of trips and falls. One visitor had said that the bedrooms were ‘not up to the standard you would expect’. Some residents whose rooms had been refurbished last year were happy with their rooms and had personalised them. One resident said ‘ I am very happy with my room I have my own bits and pieces to try to make it feel more like home’. Another said ‘it was always clean and tidy’. The home was free from offensive odours. The rear patio and ramp to the gardens were in need of repair and presented a considerable risk to residents, staff and visitors. The gardens were not safely accessible. The registered manager said that this was due to be repaired and new garden furniture was available. Concerns regarding the environment were discussed with the registered manager and notified to the registered provider in writing following the inspection visit. Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 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 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. The registered manager did not operate safe and robust recruitment practices; appropriate checks had not been carried out which potentially left residents at risk. New and existing staff received appropriate training to ensure they had the skills to meet the needs of residents in their care. EVIDENCE: The staffing rota was clear and showed the home was compliant with the staffing levels required. Two of the twelve visitors felt there was not always sufficient staff on duty. There was evidence that the home had tried to cover staff shortages and had been generally successful in maintaining staffing levels. Three staff files were looked at; two of the staff had recently been employed. It was clear that a safe and robust recruitment procedure had not been followed despite serious concerns raised at the last inspection. Two staff did not have current Criminal Records Bureau and Protection of Vulnerable Adults checks in place; the third staff had received checks following employment. One file did not have a completed application form and it was not clear whether references were appropriate or not. One file had two appropriate references but one was undated and one was obtained following employment. Information to support that Criminal Records Bureau and Protection of Vulnerable Adults checks had been requested was not available. One staff did Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 Page 18 not have a contract of employment. It was again recommended that a complete audit of all employment files be undertaken to ensure compliance. These serious concerns were detailed in a separate letter to the registered provider and a response was required by a set date. There was documentation to support that staff had completed induction and foundation training. Two members of staff confirmed they had completed a basic induction when they commenced employment. The deputy manager said that almost half of care staff had obtained an NVQ in care and others were working towards the qualification. Other training had taken place and was planned for the future. A need for specialised ‘dementia’ training has been identified earlier in the report. Residents said that they were ‘treated kindly’ and that staff were ‘friendly’. From talking to residents and information sent in with the comment cards six residents said they felt they were well cared for and one resident said they ‘sometimes’ felt cared for. Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 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 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) 31, 32, 33, 36, 37 and 38. The systems for consultation with residents, visitors and staff are good with evidence that the home had responded to any issues raised. Records required by regulation and for the protection of residents were not consistently maintained. EVIDENCE: Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 Page 20 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. The registered manager had organised regular staff meetings that were well attended. Staff said they were confident to raise any concerns. Minutes were recorded. The registered manager said that meetings had been arranged for residents and their visitors but that no one had attended. Other methods of involving residents and their visitors were discussed. Resident surveys had been completed in June 2005, visitors confirmed they had been involved and action had been taken on issues raised but they had not seen the results. Re-assessment of the Investors In People quality award was due to take place in September 2005. The home did not have an annual development plan. The records of staff supervision could not be found, this would be reviewed at the next visit. The registered provider had not completed a record of his monthly visits under Regulation 26 and a further requirement was made. The registered manager was again reminded of her responsibilities of reporting incidents under Regulation 37. Records covering safe working practices were checked and generally up to date. Risk assessments were in place and accident records had been maintained. However it was noted that the electrical installation certificate was overdue and there was still not a qualified first aider on duty at all times. Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 1 3 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x 2 1 x STAFFING Standard No Score 27 2 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 3 3 2 x x 2 2 2 Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 Page 22 yes 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 1 Regulation 4&5 Requirement Timescale for action By 22/8/05 2. 4 18 3. 7 15 4. 7&8 13 The registered person must ensure that the statement of purpose and the service user guide meet the requirements of the regulation and the contents of the standard. On completion copies must be forwarded to the Commission and new and existing residents must be issued with a service user guide. Timescale of 2/5/05 not met. The registered person must By 8/8/05 ensure staff receive appropriate training to enable them to care for residents with a dementia. By 8/8/05 The registered person must ensure that the residents plan of care sets out in detail the action to be taken to ensure all aspects of health needs are met. The plan must be drawn up with the involvement of the resident or representative and reviewed by care staff at least once per month and updated to reflect changing needs. Timescale of 2/5/05 not met. The registered person must By 8/8/05 ensure that all risks to residents are identified and appropriate care to reduce those risks are Version 1.20 Page 23 Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc 5. 9 13 6. 9 13 7. 16 22 8. 19 23 9. 10. 19 25 23 13 11. 29 19 12. 37 26 13. 37 37 14. 38 13 recorded for all areas of care. Timescale of 2/5/05 not met. The registered person must ensure there are clear and accurate records of medicines for disposal. The registered person must review medication policies and procedures to include information regarding PRN medication and non prescribed medication. The registered person must provide all residents with information about the complaints procedure. The registered person must ensure there is a development plan to evidence a programme of replacement and renewals, with particular reference to residents bedrooms. The registered person must ensure the grounds are safe and accessible. The registered person must ensure the radiator covers are fitted and that risk assessments are available until they are in place. The registered person must operate a thorough recruitment procedure ensuring the protection of residents. Timescale of 11/4/05 not met. The registered provider must provide the Commission with a copy of the documentation to support Regulation 26 monthly visits. Timescale of 11/4/05 not met. The registered person must give notice to the Commission without delay of any occurrence as listed in Regulation 37. Timescale of 11/4/05 not met. The registered person must ensure the electrical intallation F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc By 8/8/05 By 22/8/05 By 8/8/05 By 22/8/05 By 18/7/05 By 18/7/05 By 18/7/05 By 8/8/05 By 8/8/05 By 18/7/05 Page 24 Belgarth Nursing Home Version 1.20 test certificate is up to date. 15. 16. 38 37 13 17 The registered person must ensure there is a qualified first aider on duty at all times. The registered person must ensure records are clear and accurate and that tippex is not used. By 8/8/05 By 18/7/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 3 8 15 24 Good Practice Recommendations The registered person should revise the assessment documentation to ensure that it contains all aspects as listed in standard 3.3. The registered person should review the type of weighing equipment available to ensure that the weight of all residents can be regularly recorded. The registered person should consider utilising the ‘hot trolley’ or serving meals directly from the kitchen to prevent food from going cold at breakfast time. 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 a lockable space unless their risk assessment determines otherwise. The registered person should ensure a minimum ratio of 50 care staff are qualified to NVQ level 2 or equivalent. The registered person should audit staff files to ensure they meet regulation. The registered person should ensure residents, visitors and other stakeholders have access to the resident survey results. The registered person should ensure that the formal supervision of staff follows the guidance of this standard. 5. 6. 7. 8. 9. 24 28 29 33 36 Belgarth Nursing Home F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 Page 25 Commission for Social Care Inspection Unit 4 Petre Road Clayton-le-Moors 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 F57 F57 S22470 Belgarth V221791 210605 Stage 4.doc Version 1.20 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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