Inspection on 19/05/06 for Belle House

This inspection was carried out on 19th 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.

Other inspections for this house

Belle House 19/08/08

Belle House 21/09/07

Belle House 18/10/05

Belle House 17/05/05

Belle House 25/10/04

Belle House 22/06/04

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

CARE HOMES FOR OLDER PEOPLE Belle House Belle Hill Old Town Bexhill-on-sea East Sussex TN40 2AP Lead Inspector Caroline Johnson Key Unannounced Inspection 19th May 2006 10:10 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 Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belle House Address Belle Hill Old Town Bexhill-on-sea East Sussex TN40 2AP 01424 221624 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) Britannia Care Homes Limited Mrs Gillian Parsons Care Home 16 Category(ies) of Dementia (16) registration, with number of places Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of residents to be accommodated is sixteen The people accommodated will be aged sixty five years or over on admission The people accommodated will have senile dementia type illness Date of last inspection 18th October 2005 Brief Description of the Service: Belle House is registered to accommodate up to sixteen older people with a dementia type illness. The building is an old converted property situated in the old town area of Bexhill on Sea, close to local amenities. The main town centre with its access to bus and rail routes is approximately half a mile away. Accommodation is provided on two floors and a stair lift is fitted to assist access to first floor accommodation. The registered providers are Britannia Care Homes Ltd who also own another three homes in the area. The home makes CSCI reports available to prospective residents and/or their relatives/representatives upon request. The fee charged as of April 2006 is £345 to £400 per week. Additional charges are made for chiropody and hairdressing. Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection an unannounced site visit was carried out on 19 May 2006. The site visit lasted from 10.10am until 17.50pm. Over the course of the day there was an opportunity to meet with the owner, the registered manager, with two care staff and briefly with the cook and the cleaner. The inspector observed residents over the lunch period and talked to the majority of residents during this time. There was also an opportunity to meet with two visiting professionals who were in the home during the inspection. Four care plans were examined in detail along with the preadmission documentation held in respect of one recently admitted resident. A wide range of record keeping was examined including, staff recruitment records, staff training, medication, health and safety, complaints and activities. A full tour of the building was undertaken. As part of the inspection process, survey cards were sent to the home, for completion by residents. However, due to the complex needs of the residents two relatives completed the forms on behalf of their relatives and another relative contacted the Commission to give feedback. In addition the inspector attempted to contact a number of relatives of residents but only managed to speak with one other relative. Relatives spoke very positively with comments like `staff are caring’ and `the home keep in touch if there are any problems’. One stated that `staff cope well despite the staff shortages’. In the surveys, one stated that they would have liked more information about activities provided prior to their relative moving into the home. Both surveys highlighted `usually’ in the comments about staff availability and cleanliness of the home rather than `always’. What the service does well: Record keeping held in relation to client forum meetings show that residents are encouraged to make choices and decisions. This was also observed on the day of the site visit when a resident chose not to have her main meal, two different alternatives were offered. Staff spoken with over the course of the inspection stated that the manager is `very supportive’. The manager regularly observes staff in their work and written records are kept of the observations and of any recommendations made to staff as a result. The home is well maintained and the ongoing programme for redecoration ensures that the quality of the environment remains good. Residents, or their relatives on their behalf, are encouraged to bring in small items of personal possessions so bedrooms look homely. Residents spoken with stated that they like spending time in the garden and that they enjoy the singing sessions that are provided in the home. Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 Quality in this outcome area is good. There is good information available for relatives to assist them in making a choice of home for their relative. The home carries out a detailed assessment of prospective residents’ needs prior to making a decision about whether they can meet the needs identified and offer accommodation. EVIDENCE: During the inspection it was noted that there were two different statements of purpose in place along with a service user’s guide. Prior to writing this report the owner had sent a copy of the revised statement of purpose to the Commission. Both the statement of purpose and the service user guide contain most of the information required by the Regulations. Feedback was given to the proprietors on the minor areas outstanding. A pre admission assessment was seen in relation to one resident recently admitted to the home. This was detailed including information about the resident’s individual needs and the action to be taken by staff to meet them. The home does not cater for intermediate care. Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 9 Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. Care plans need to be more of a working tool. Rather that having a daily records book for all residents, individual records should be kept. This will encourage staff to refer to individual care plans and to record action taken to meet identified needs. It will also make evaluating of care plans easier and will improve confidentiality. The home needs to enter on the MAR chart when medication is discontinued otherwise it looks as if medication that has been prescribed has not been administered. EVIDENCE: There were care plans in place for all residents in the home. Four of the care plans were examined in detail as part of this inspection. Information provided was detailed but on closer examination some of the points raised in the care plans were not followed in practice. Examples included, one care plan stated that a resident should have half hourly checks at night, but the night records show that they have two hourly checks. This resident’s care plan states that food should be liquidised but the resident’s food was not liquidised on the day of inspection. Cultural needs had not been assessed. In relation to another Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 11 resident, the care plan states that the resident is not aggressive. However, when speaking with staff and external professionals, and on examination of daily records, it was noted that this resident is often aggressive, requiring additional staffing at times so that personal care can be given. Day and night records books are kept highlighting the care given to residents. These books contain information about all the residents. Some staff write more detailed records than others but often the report will say `all care given, eaten well’. Monthly reports are also written and again some staff write detailed summaries and others write brief summaries. Some of the more detailed reports included reference to the care plans and to meeting the social and emotional needs of the residents. There is a policy and procedure in place on the administration of medication. In addition there is a homely remedies policy and a record is kept of all medication returned to the home’s pharmacy. It was noted that in relation to three residents there were a number of medications that had not been supplied that month. However, when this was checked with a staff member it was discovered that the medications had been discontinued. This should be marked on the MAR chart so as to avoid confusion. The manager advised that they are in the process of obtaining photos of all the residents for the MAR charts. Records showed that the residents have access to a wide range of healthcare appointments. During the inspection there was an opportunity to speak individually with two visiting professionals. Both are regular visitors to the home and they spoke positively of the staff on duty and the care provided by them. Both stated that the resident group can be challenging in terms of management of behaviour and stated that in order to provide treatment for residents during their visits, they require assistance from staff and one stated that she often requires assistance from two staff members. On the day of the site visit residents received treatment from the chiropodist. The treatment provided was in a section of the dining room with a screen used to provide privacy. However, the window was next to the front door and when the inspector arrived at the home the window cleaner was washing the window. Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. The home should keep individual records for each resident detailing the activities that they participate in and the level of participation. This will make evaluation of each individual’s social needs much easier. The home’s Client forum meetings work well and the frequency should be increased, as they are a good example of how the residents make choices and decisions. The home should provide a stool or other suitable seating for staff assisting residents with feeding. As well as making it a more social event it will also ensure greater dignity for the residents. EVIDENCE: There is a programme of activities in place for the residents and records are kept of the activities undertaken. From the records seen it was not possible to determine which residents participated in each activity and which activities work best. Activities available include sing-a longs, videos, puzzles, exercise sessions and an external entertainer who comes to play the keyboard. Another external company visits every two-four weeks to do a motivation and exercise class. In addition the local vicar provides a service in the home every two weeks. Staff stated that the majority of residents love sitting in the garden in the summer months and having tea or an ice cream. Residents spoken with confirmed that they like spending time in the garden and that, Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 13 they particularly enjoy the singing sessions. On the day of inspection an external entertained visited the home in the afternoon to provide musical entertainment. Client forum meetings are held occasionally and a record is kept of the outcome. Records showed that residents were exercising choices and making decisions. The minutes for the last meeting held in January 2006 showed that three residents requested more music and that one resident wanted to go out more. One of the residents used to write poetry and it was noted that one of her poems was on display in the home. Some of the residents have regular contact with families and friends and others have very limited contact. As required at the last inspection residents now have a more varied menu selection at breakfast time. Menus seen showed variety and were well balanced. The meal served on the day of inspection looked appetising and was received well by the residents. A number of the residents stated that the meal served was `lovely’. The home caters for those on special diets and at the time of inspection there were three residents that required a diabetic diet. All alternatives to the main meal served are recorded. One of the relatives spoken with stated that the food served is `always good’. There are two dining rooms and time was spent observing the lunchtime meal in the home. One resident had her lunchtime meal in her room and she required feeding. In the dining rooms one resident required total assistance with feeding and others required minimal support with feeding on occasions throughout the meal. Staff spoken with stated that the level of support required by residents varies from day to day. One resident chose not to eat her meal so a choice of complan drinks was offered. When this was given to the resident she then chose not to have the drink. A sandwich was then offered and the resident ate the sandwich given, independently. It was noted that whilst staff were feeding or assisting with feeding, they were either kneeling down beside residents or standing over residents. Belle House DS0000021048.V299611.R01.S.doc Version 5.2 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): Quality in this outcome area is adequate. The home keeps good records of the action they take in response to complaints. The new complaint record should capture the action taken to ensure that complainants are happy with the outcome. Newly recruited staff need to attend training on adult protection and prevention of abuse to ensure that they are aware of what constitutes abuse. The home’s policy on restraint needs to be expanded to provide and clearer and detailed advice to staff on the subject. EVIDENCE: There were six complaints recorded. Records showed that the home had investigated each complaint and that action was taken to address the issues raised. The home are in the process of introducing a new tool to record complaints and this will include a section to record if the complainant is happy with the action taken and the outcome. Since the last inspection of the home, the Commission has not dealt directly with any concerns or complaints made to them about the home. However, they were advised of a complaint made against the home and received correspondence that the complaint was resolved satisfactorily. The home has a policy and procedure in place on adult protection and prevention of abuse. Since the last inspection five staff attended training on adult protection and prevention of abuse. However, due to the staff turnover further staff training is required in this area. The home’s policy on restraint Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 15 was also seen. This policy is very brief and does not give clear guidance on how or when it is appropriate to restrain. Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The ongoing programme for the redecoration of the home continues and accommodation is generally of a good standard. In the interest of safety and dignity the home should ensure that footplates are always used on wheelchairs whilst transporting residents. EVIDENCE: All areas of the home (with the exception of one bedroom) were seen during the inspection. The home is continuing to upgrade the building and a number of areas in the home have benefited from redecoration since the last inspection. Work carried out has been to a good standard. Work has mainly been concentrated in the dining rooms and lounge. In one of the dining rooms it was noted that the seal covering one area of the carpet had come away leaving the risk of potential trip hazards. The doorframe in one of the corridors has been widened making the area more easily accessible for those in wheelchairs. In another section of the building a new roof has been fitted and another section of the roof will be replaced in the coming months. Residents’ families are encouraged to personalise bedrooms and some of the rooms seen contain lots of ornaments and family pictures. There is a screen provided in all Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 17 double bedrooms. In one of the bedrooms it was noted that the carpet was rucked in places. The manager confirmed that this had been highlighted in the maintenance book and would be dealt with. In another bedroom the chair provided was very low to the ground and the manager confirmed that a more appropriate chair could be provided. It was noted that whilst taking one of the residents from the dining room, a wheelchair was used that had no footplates. As a result the wheelchair was tilted back so that the resident’s feet didn’t drag on the floor. On the day of inspection the washing machine was broken but the manager confirmed that they hoped that it could be fixed that day or the next. In the interim they were using the facilities at one of the sister homes. Care staff confirmed that they do the laundry for the residents. The cleaner advised that she has set tasks to carry out on the days she works. The home was clean on the day of inspection and there were no unpleasant odours. Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. The turnover in the staff team has meant that additional staff training has to be provided to ensure that staff receive mandatory training. Staffing levels are at a minimum and need to be increased at peak times so that residents’ individual needs can be more easily met. Progress has been made in relation to record keeping in respect of staff recruitment and with some additional monitoring this could be improved even further. In order to improve the quality of staff induction, it should be spread out over a longer period and records should show more information about the topics covered and the dates training on each subject was provided. EVIDENCE: Staff confirmed that they have job descriptions detailing the tasks that they have responsibility for. One member of staff has additional responsibilities and she was unsure if she had a job description detailing the additional responsibilities. The rotas supplied for inspection showed that there are two care staff on duty throughout the waking day. In addition the manager works in the home Monday to Friday. However, when the manager is not in the home at weekends and on annual leave, staffing levels remain at two care staff. Care plans show that a number of the residents require two care staff at peak times of the day. Relatives’ survey cards highlighted a concern that staffing levels are low at times and visiting professionals also highlighted that they take care staff away from their duties to assist them when they visit the home. In addition to caring duties staff also attend to laundry tasks and serve and clear up after the evening meal. Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 19 Since the last inspection there has been a high turnover in the staff team. The reason for the staff turnover was beyond the control of the home and staff that have left the home have since been replaced. The home provides regular staff training on a variety of topics. However, due to the staff turnover further training is required for staff on dementia, safe use of medication, manual handling, infection control, food hygiene and first aid. The manager confirmed that five staff had received fire safety training this year and that another course is to be arranged. At the time of writing this report the owner had confirmed that training dates had been booked for courses on dementia, protection of vulnerable adults and manual handling, all to be held in June 2006. She also confirmed that training would be provided on pressure area care. Four staff have completed NVQ level three and one of the staff team has also completed the Assessor’s course. Arrangements are to be made for further staff to receive similar training. Recruitment records were seen in relation to three recently recruited staff members. In each case application forms had been completed and references obtained. In one case, one of the references supplied was poor and there was no written record to say that the home had followed this up with the referee or that they had taken account of this in the risk assessment carried out. In another case the dates of employment given in the application form did not tie up with the dates of employment provided in one of the references. Again there was no record that this had been followed up with the staff member. POVA first checks had been obtained and applications made for a full CRB check. Records showed that staff induction consists of a checklist of topics that must be covered with the manager. The manager advised that the induction package takes two weeks to complete and that the checklist is then signed at the end completion date by the manager and by the staff member. Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,38 Quality in this outcome area is adequate. The home needs to develop their quality assurance system so that they are continually evaluating how they perform and where necessary making changes to improve the quality of care in the home. Periodic fire drills will ensure that staff are tested on the home’s evacuation procedure in the event of fire. EVIDENCE: The manager has worked in the care industry for a number of years and has a wealth of experience in the care of people with a dementia type illness. She advised that it is her intention to commence NVQ level four in September 2006. As it is a few years since she attended a course on dementia she acknowledged that it would be appropriate to attend a refresher course. Staff spoken with over the course of the inspection stated that the manager is `very supportive’. They receive regular supervision and there were records in place confirming this. Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 21 The company have produced an annual development plan for the home. The plan is not very detailed. The manager confirmed that the home has sent quality assurance questionnaires to relatives but the response has been poor. The subject of quality assurance was discussed in detail and ideas were given of how to encourage relatives to take part in the system and of how to introduce difference types of audits to assist with judging and building upon the quality of the care provided in the home. As part of the inspection process survey cards were sent to the home for comments from residents. Due to the complex needs of the residents two relatives responded on behalf of residents and one relative contacted the inspector directly. In addition the inspector attempted to contact a number of relatives of residents but only managed to speak with one other relative. Relatives spoke very positively with comments like `staff are caring’ and `the home keep in touch if there are any problems’. One stated that `staff cope well despite the staff shortages’. In the surveys, one stated that they would have liked more information about activities provided prior to their relative moving into the home. Both surveys highlighted `usually’ in the comments about staff availability and cleanliness of the home rather than `always’. Staff are requested to record all maintenance issues noted in a maintenance book and this is ticked when the work is completed. Although the home has a house risk assessment, which is carried out annually, there is no monthly risk assessment in place. Records showed that portable appliances, the stair lift and the gas had all been serviced within the last year. A fire officer also visited in December 2005 and checked the home’s fire risk assessment. Emergency lights and alarms are all tested regularly in line with the home’s policy. Records showed that staff receive regular instructions in fire safety but fire drills are not generally carried out. Hot water temperatures were tested at two outlets during the inspection. One was within agreed safety limits. One outlet tested was 49°C. The manager confirmed that this would be adjusted. Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 2 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X X 3 X 2 Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 23 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. 2. Standard OP7 OP7 Regulation 12(4b) 15(2b) Requirement As part of the assessment process residents’ cultural needs must be assessed. In respect of two of the care plans seen the home must ensure that the needs identified in care plans are met. If the identified needs have changed then the care plan must be revised and updated. If medication has been changed or discontinued this must be recorded on the MAR chart. Record keeping in relation to daily activities held in the home must be more detailed. Records must show details of the activity, which residents participated and their level of involvement. (This could be linked in with the daily records) In relation to maintenance the following must be attended to: The seal over the carpet in the dining room must be mended or the carpet replaced, the rucks in the carpet in one bedroom must be addressed and the chair in one bedroom replaced. DS0000021048.V299611.R01.S.doc Timescale for action 31/07/06 31/07/06 2. 3. OP9 OP12 13(2) 16(2m,n) 31/07/06 15/09/06 4. OP19 13(4a,c) 31/07/06 Belle House Version 5.2 Page 24 5. 6. 7. OP22 OP27 13(4a,b, c) 18(1a) OP29 19(1c) 8. OP30 18(1c,i) 9. OP33 24(1) 10. OP38 23(4e) 11. OP38 13(4a,c) Footplates must be used on wheelchairs. There must be at least three care staff on duty at peak times of the day in the morning and evening. The home must be more vigilant in following up issues raised in staff references and recording the outcome and if necessary any action taken as a result. Arrangements must be made for the staff that have still to receive training in dementia, pova, first aid, food hygiene, manual handling and infection control. The home must continue to introduce an effective quality assurance system by expanding the annual development plan, collating information received from questionnaires and reporting the outcome to relatives and putting in place a number of audits to measure outcomes in the home. Fire drills must be held regularly to ensure that all staff know the procedure to be followed in case of fire. Records must be kept of the outcome and must include, the date, time and length of drill, a list of the staff in attendance and a detailed evaluation of the drill. The hot water at the outlet tested that was in excess of safety limits must be adjusted. 15/07/06 31/07/06 15/07/06 30/10/06 30/10/06 30/09/06 15/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 25 No. 1. 2. Refer to Standard OP7 OP10 Good Practice Recommendations Daily records should be kept separately for each individual resident so as to ensure confidentiality and make it easier to evaluate progress made with individual care plans. When chiropody or other treatment is being provided to residents in the dining room by the window, measures (such as a net curtain or screen and additional lighting) should be taken to promote privacy for residents. The frequency of the client forum meetings should be increased. A stool or other suitable seating should be provided for staff when assisting with the feeding of residents. The home’s policy on restraint should be expanded. Senior staff should have a job description detailing the additional tasks that they have responsibility for. The home should continue to work towards having 50 of staff trained to NVQ level two. The home must refer to Skills for Care in relation to induction and foundation training. Training must be spread out over a longer period. Details must be kept of the training provided to staff and the date the training was provided. The manager should commence training to NVQ level 4 in management and care. The home should draw up a checklist of areas to monitored on a monthly basis in relation to health and safety. Checklist to include areas such as rucks in carpets, monitoring of window restrictors and check for any trailing wires. 3. 4. 5. 6. 7. 8. OP14 OP15 OP18 OP27 OP28 OP30 9. 10. OP31 OP38 Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Belle House DS0000021048.V299611.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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