Inspection on 09/01/07 for Belgrave House

This inspection was carried out on 9th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Belgrave House 23/01/09

Belgrave House 01/12/05

Belgrave House 19/07/05

Belgrave House 01/03/05

Belgrave House 06/12/04

Belgrave House 16/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Belgrave House School Road Terrington St John Wisbech Norfolk PE14 7SE Lead Inspector Mrs Lella Andrews Unannounced Inspection 9th January 2007 10:00 Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belgrave House Address School Road Terrington St John Wisbech Norfolk PE14 7SE 01945 880087 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) Mr Mukesh Bouri Mr Mukesh Bouri Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (3) of places Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate up to three people aged over 65 within its registered numbers. The total number accommodated not to exceed 12. 1st December 2005 Date of last inspection Brief Description of the Service: Belgrave House is a care home currently providing care for ten adults with learning disabilities. The home is owned by Mr. Mukesh Bouri and was first registered in August 1984. Belgrave House is located in the village of Terrington St John and is within walking distance of local shops and community facilities. The home has transport to enable access to larger local towns. The Home currently has eleven single bedrooms with a twelfth almost finished. Some bedrooms have ensuite bathrooms whilst others have handbasins within the room. There are three lounges, dining room, kitchen, toilet and bathrooms. The laundry is situated on the first floor. The proprietor has recently completed the development of a hydrotherapy pool and sauna. Within the grounds of Belgrave House is a day care building which service users attend on a daily basis. This facility is solely for the use of people who live at Belgrave House. The grounds of Belgrave House are well maintained and have been landscaped to provide space for leisure and relaxation. Its situation offers pleasant views over the fenland landscape. Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit to the Home was carried out on the 9th January 2007 between 10am and 4.45pm as part of the Inspection process. CSCI are trying to improve the way we engage with people who use services so we gain a real understanding of their views and experiences of social care services. We are currently testing a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care service. The term ‘experts by experience’ used in this report describes people whose knowledge about social care services comes directly from using them. The Inspector was joined for part of the visit to the Home by an expert by experience and their support worker. The Inspector would like to thank the Proprietor and the staff team for their support during the Inspection . This report contains information about the Home that has been gathered since the last Inspection. This includes the receipt of comment cards from residents (10, assisted by staff), relatives (7) and visiting professionals (1). During the visit the Inspector and the expert by experience spent some time talking to residents, staff and the Proprietor, looked at records as well as observing staff supporting clients. There are currently ten residents living at the Home. The fees are variable dependent on individual needs and assessment. Currently the fees range from £600 - £850, inclusive of day care costs, per week and are current at the time of the visit. Queries about fees should be made directly to the Proprietor. What the service does well: The Home provides an excellent standard of accommodation for the residents The residents like living at the Home and feel well cared for Relatives are happy with the care that their relatives receive The Home is well managed The staff are enthusiastic about their work and receive appropriate training and support The Proprietor and staff have worked particularly hard to provide support to one of the residents who has recently been in hospital. This includes the Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 6 purchase of a chair lift so that the resident can return to their bedroom on the first floor. 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. Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The Home has information about the services provided but this needs to be made clearer to ensure prospective residents and their relatives have adequate information on which to base decisions. Assessments are carried out prior to residents moving to the Home so that staff have information about how to meet their needs. EVIDENCE: The Home has a Statement of Purpose, a Service User Guide and a Statement of Terms and Conditions, all of which provide information to prospective residents, relatives and placing authorities. However, additional information needs to be included in these documents to ensure that they meet the Regulations and Standards. See requirements. The Service User Guide includes symbols as well as words but some of these are not accurate and so may actually cause more confusion than clarity to those people who rely on them for communication. It is recommended that Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 9 the symbol version of the Service User Guide is reviewed and updated to make it more clear. It is also recommended that the Statement of Terms and Conditions is available to each resident in a format which they will find easier to understand. Two residents have moved to the Home since the last inspection. Both residents moved on an emergency basis which meant that the Proprietor did not have much time to carry out assessments prior to them moving. However, staff said that the information that they had to refer to was accurate and gave them sufficient guidance to be able to meet the residents needs. The care plans are currently being put together for the two residents. Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans are detailed but there is a need to ensure that they are updated as needed. Risks are assessed with guidance in place for staff about how to manage them Residents are encouraged to make their own choices in a range of daily living situations. EVIDENCE: Two of the care plans were seen. These are detailed documents containing assessments, risk assessments and plans for care. The staff also complete daily notes relating to each resident. One of the care plans was for one of the residents who has only recently moved into the Home. This contains Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 11 information from the previous place that they lived with additional information being added during the few weeks that they have lived at this Home. The risk assessment policy provides clear guidance for staff about the role of risk taking with regard to learning opportunities and the staffs responsibilities with regard to assessing and planning for risk taking. The other care plan seen was for one of the residents who has recently had a health problem. The care plan had not been updated to reflect the change in their personal and health care needs, nor had an updated moving and handling risk assessment been carried out although the staff were aware of the changes in the needs of the resident. Requirements are made about this. The Home has a key worker system in place with staff taking on particular responsibilities for individual residents, including updating care plans. The care plans show that regular reviews are carried out, however, when discussed with the Proprietor it was clear that whilst the care plan indicated that it had been reviewed and remained the same the situation had actually changed some time ago. The Proprietor said that he will discuss this with all staff to ensure that reviews are carried out appropriately. The Inspector and the expert by experience were given examples by residents and staff of how residents are able to make their own choices. Residents said that they are able to choose what food and drinks they have and what activities they do in the day centre. They said that staff remind them of times to go to bed and get up but that if they wish to stay up to watch something on television they are able to. Staff gave a range of examples of how the residents are encouraged to make their own choices in different situations. Currently there are no advocates involved with any of the residents and none of the residents are involved with citizen advocacy groups. However, the Proprietor said that one of the clients will be supported to attend a new group that is being organised in Kings Lynn. The Proprietor said that the financial arrangements for the two residents who have only recently moved to the Home are still in the process of being altered to reflect their new living arrangements but that all of the other residents have their own bank/building society accounts. The Proprietor is appointee for all of the residents. A petty cash system is in place so that staff only have to have access to one source of money and then the records and residents accounts are charged accordingly. One of the members of care staff is responsible for ensuring that this is carried out. The records relating to daily expenditure was checked against one of the residents cash held and this was found to be correct. The residents individual benefits are currently paid into the Proprietors trading account and then the Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 12 personal allowance component transferred to the residents accounts. It is required that the residents benefits are paid directly to the residents themselves. It is recommended that the care plans contain a detailed financial care plan for each resident which shows their monthly income and outgoings, such as the component that they pay towards their fees and describes the processes in place for managing their money. Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents are provided with a range of activities to take part in at the Home and at the day service provided on site. However, the opportunities for residents to take part in activities within the community are more limited. Staff recognise the residents rights and responsibilities within their daily lives at the Home. The residents are involved with the planning of menus, shopping and cooking. Relatives are satisfied with the care provided and feel that they are kept informed about their relatives care. EVIDENCE: Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 14 The two residents who have recently moved to the Home attend a day service in Kings Lynn and the other residents all spend each day at the day service which is located in the grounds of the Home and is staffed by the Homes staff. The residents take part in a range of activities at the day service which includes basic numeracy and literacy as well as craft activities. The Home also has a hydrotherapy pool, sauna, steamroom and treadmill which residents are encouraged to use. Some of the residents are becoming more frail as they become older and the staff are aware of the effects this has on activities within the day service. One of the residents is supported by staff to carry out food shopping each day using local shop. Residents spoke about enjoying the Christmas party and the Christmas meal at a local restaurant. Residents have also been to the cinema and to the pantomime in recent weeks. Staff support residents to go shopping in the local towns. One of the residents has work experience at a local supermarket for two half days per week. Residents and staff said that residents usually spend the weekends at the Home. The residents do not access many community facilities and when this does take place it often takes place as a large group. The residents comment cards all state that they have lots of things to do. Whilst the residents are given a choice about how they spend their time this is mainly within the Home and day service. The care plans do not provide evidence of residents being supported to try a range of leisure activities although staff and the Proprietor describe a various activities that residents take part in within the local community. It is recommended that the issue of community involvement is discussed as part of the residents care plan reviews to see if there are other activities that residents might like to take part in. All of the relatives completed comment cards state that they are made to feel welcome and that they are kept informed of issues affecting their relative. They all state that they are satisfied with the overall care provided. The residents comment cards state that they are able to have visitors. The care plans contain details of the arrangements in place for enabling residents to maintain contact with relatives. The residents said that they have a choice at mealtimes and this was seen to take place during the lunchtime of the day of the visit. Residents are involved in planning menus, shopping and cooking. One of the residents is vegetarian and their needs are catered for. One of the monthly audits carried out by the staff is a nutritional audit which the Proprietor said is carried out by looking at the menus and talking to residents about the meals provided. Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 15 The staff recognise the rights and responsibilities of the residents within their daily lives. Staff were seen to knock on doors prior to entering rooms and risk assessments are carried out with regard to whether residents have keys to their bedrooms. Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The residents health and personal care needs are met with additional support provided to residents at times of ill health. Some improvements need to be made to the medication system to reduce risks of errors occurring. EVIDENCE: The care plans contain details about how to provide personal care to the residents in the way that they prefer. These also contain evidence of residents having regular dentist, chiropody and optician appointments. The residents are registered with the local GP practice. The residents comment cards state that they feel well cared for. Staff have a good knowledge of the individual needs of the residents. Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 17 Although the recruitment practices are non disciminatory the only male staff working at the Home is the Proprietor and so the male residents do not have much choice about the gender of the staff who support them. As previously mentioned in this report, one of the residents has recently had some health problems which meant that they spent some time in hospital. Staff and the Proprietor ensured that the resident received regular visitors and provided additional support at this time. The Proprietor ensured that the resident could come home at the earliest opportunity and has made temporary alterations to the residents accommodation until a new chair lift can be fitted to the staircase. This additional support is to be commended. The comment card received from a social care professional states that the are satisfied with the overall care provided to the residents and that they have not had to make any complaints about the service. The medication system was inspected. The medication is now kept in one of the new rooms in the Home which is much more accessible for the staff. A monitored dosage system is in use and the staff receive appropriate training prior to being able to administer medication. None of the residents look after their own medication and so all medication is kept locked securely and administered by staff. There are some good practices in place such as having photographs of the residents in the MAR charts as well as a record of staff signatures and initials. Some requirements are made to ensure that the system is as safe as possible: It is required that – the medication procedure includes information about homely and herbal remedies that creams and liquids are dated when opened that a record is kept of all medication received at the Home that guidance is available to staff in situations when medication is prescribed in variable doses. Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Homes complaints procedure needs to be more widely available to ensure that residents/relatives have access to it. The staff receive appropriate training with regard to protecting the residents and are confident that any concerns will be dealt with appropriately. Clarification is needed within the relevant policies and procedures. EVIDENCE: The Home has a complaints procedure which is available in symbol format. It is recommended that this is displayed in the Home. The residents comment cards state that they would speak to the staff if they were not happy about something. The Proprietor said that residents meetings take place. The Home has a “suggestions” policy displayed in symbol format with slips available for residents/staff/relatives to make suggestions on for consideration. Two of the relatives comment cards state that they are unaware of the complaints procedure and so it is recommended that the Proprietor ensure that all relatives have a copy of this. Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 19 The requirement for the Safeguarding Adults (Protection of Vulnerable Adults) procedure to have been updated was not met until the time of the visit. There is still a need for clarification of this procedure so that the local contact details are included for the adult protection team and social services. A requirement is made about this. The Proprietor made some changes to the Whistle blowing policy on the day of the visit to make it clearer. It is recommended that these changes are brought to the attention of staff. Staff said that they have recently attended relevant training with regard to safeguarding adults and that they are aware of the whistle blowing policy. However, the domestic staff do not attend this training and it is recommended that ALL staff attend Safeguarding Adults training. The staff said that they have confidence in the Proprietor of dealing with any allegations appropriately. Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The Home provides a very high standard of accommodation which meets the needs of the residents. EVIDENCE: The Home is maintained to a high standard and provides homely and comfortable accommodation for the residents. There are three lounges although one is currently being used as a bedroom on a temporary basis. There is a large dining room as well as a table in the kitchen which can also be used at mealtimes. The Home has extensive gardens which are well maintained and can be used for walking, playing sports and for sitting out in nice weather. The Home Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 21 employs a gardener/maintenance member of staff and so any maintenance issues are dealt with straight away. Since the last Inspection the Proprietor has altered the remaining shared bedrooms so that all bedrooms are now single with either a hand basin in the room or an en-suite toilet or bathroom. There are currently eleven single bedrooms in the Home and the Proprietor has plans to convert another room into the twelfth single bedroom. Due to the recent health problems of one of the residents the Proprietor said that he has ordered a chair lift to be fitted to one of the staircases to make it easier for the resident to get to their room on the first floor. The Home employs domestic staff for four hours every day of the week, including weekends. The domestic staff are responsible for cleaning all areas of the Home except for the kitchen and for undertaking all of the laundry. The Home is exceptionally clean and tidy throughout with no unpleasant odours. Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents like the staff and feel well cared for. Staff receive the appropriate training and support to carry out their roles effectively. Appropriate recruitment checks are carried out prior to staff starting work at the Home. EVIDENCE: The staff who spoke to the inspection team were enthusiastic about their roles and seem to enjoy working with the residents. Staff have a good understanding of the needs of the residents, even those staff who have not worked at the Home for very long. The residents comment cards all state that the staff treat them well and listen to them. Communication between Proprietor, staff and residents was relaxed and friendly. Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 23 The Proprietor has a commitment to ensuring that staff receive good induction and training. He has reviewed the induction standards in response to the new standards from Skills for Care. He said that 75 of the care staff have completed NVQ Level 2 with some having completed NVQ Level 3. Training is provided through a mix of external and internal training. For example, the Proprietor said that the Environmental Health Officer is satisfied with the training that he provides to the staff with regard to Food Hygiene. Staff have all recently attended moving and handling training provided by an external trainer. The usual staffing arrangements are for there to be three staff on duty between early morning and approximately 4.30 pm with two staff on duty from then until 9.30pm. There is one waking night staff on duty with the Proprietor, or a member of staff, providing additional support if needed as they live close by. The Proprietor regularly spends time working in the Home and supporting residents. A look at records show that appropriate recruitment procedures are followed with the necessary checks on the suitability of prospective care staff being carried out. Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Home is well managed by the Proprietor There are systems in place to continually monitor the quality of the service provided. Health and safety issues are given a high priority EVIDENCE: Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 25 The Proprietor has owned and managed the Home for twenty years. He knows the residents very well and works with them on a daily basis. He has completed the Registered Managers Award and keeps his knowledge updated. The Proprietor has systems in place which constantly monitor the quality of the service provided. These include questionnaires for relatives and visiting professionals. The results of these were seen and only included positive responses. The Proprietor plans to produce the annual quality assurance report following on from the previous twelve months plan and will send the Commission a copy of this shortly. Records show that regular health and safety checks are undertaken, for example, vehicles, hot water, fire safety equipment. Accident records are kept and notifications are sent to the Commission as appropriate. Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 2 X 3 X 3 X X 3 X Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 27 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4 Requirement It is required that the Statement of Purpose includes the information listed in Schedule One of the Care Homes Regulations and that a copy of the revised document is provided to the Commission It is required that the Service User Guide contains the information listed in Regulation 5 of the Care Homes Regulations and that a copy of the revised document is provided to the Commission It is required that the care plans and risk assessments are reviewed effectively and kept up to date It is required that a moving and handling risk assessment is carried out for the resident who has recently been in hospital It is required that the residents benefits are paid into their own named accounts It is required that the medication procedure contains information about homely remedies and herbal remedies It is required that the creams DS0000027386.V326811.R01.S.doc Timescale for action 31/03/07 2 YA1 5 31/03/07 3 YA6 YA9 15 09/02/07 4 YA9 13 (5) 09/01/07 5 6 YA7 YA20 20 13 (2) 28/02/07 31/01/07 7 YA20 13 (2) 09/01/07 Page 28 Belgrave House Version 5.2 8 YA20 13 (2) 9 10 YA20 YA23 13 (2) 13 (6) and liquid medications are dated when opened It is required that written guidance is available for those medications which have a variable dose It is required that a record is kept of medication received at the Home It is required that the Safeguarding Adults procedure is updated to reflect the local protocol and includes the necessary contact numbers 16/01/07 16/01/07 31/01/07 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 5 6 7 8 Refer to Standard YA1 YA5 YA7 YA14 YA22 YA22 YA23 YA23 Good Practice Recommendations It is recommended that the Service User Guide is available in a simpler format which residents will be able to understand more easily It is recommended that the Statement of Terms and Conditions is provided in a simpler format which enables the residents to better able to understand it. It is recommended that the residents have a financial care plan which details the arrangements in place for the payment of their income and expenditure It is recommended that the issue of community involvement is discussed with residents It is recommended that the complaints procedure is displayed in the Home It is recommended that the Proprietor ensures that all relatives have a copy of the complaints procedure It is recommended that the revised whistle blowing policy is discussed with staff It is recommended that ALL staff working at the Home attend Safeguarding Adults training. Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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. Extracts may not be used or reproduced without the express permission of CSCI Belgrave House DS0000027386.V326811.R01.S.doc Version 5.2 Page 30 - 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!