Inspection on 12/02/08 for Belle Vue Country House

This inspection was carried out on 12th February 2008.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Belle Vue Country House 07/11/06

Belle Vue Country House 15/02/06

Belle Vue Country House 15/06/05

Belle Vue Country House 13/01/05

Belle Vue Country House 27/08/04

Belle Vue Country House 30/07/02

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

The Laurels

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

CARE HOMES FOR OLDER PEOPLE Belle Vue Country House Warninglid Lane Warninglid West Sussex RH17 5TQ Lead Inspector Ann Peace Unannounced Inspection 12th February 2008 09:00 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 Vue Country House DS0000024117.V356763.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 Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belle Vue Country House Address Warninglid Lane Warninglid West Sussex RH17 5TQ 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) 01444 461207 01444 461077 Newcare Homes Ltd Mrs Irma Lew Kum Hoi Care Home 41 Category(ies) of Dementia - over 65 years of age (41), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (41) Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That up to 3 persons under the age of 65 may be accommodated in the home. Date of last inspection Brief Description of the Service: Belle Vue Country House is a Care Home registered to provide 41 places in the category of Elderly Mental Disorder and Dementia (including 3 places for 50 ). Belle Vue is an adapted and extended two-storey house, standing its own extensive grounds near the village of Warninglid. The home is situated within a rural location in reach of the A23 and there is a bus service that stops near the home. Accommodation is provided on two floors with a lift connecting the two floors. The home currently has 29 single rooms and 6-shared rooms. The home has an extensive garden around the home and an enclosed patio area. There are plans to extend the home in the near future. Fees range between £600.00 and £800.00. Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. A visit to the home was carried out on the 12th February 2008 by Ann Peace Inspector and lasted five hours and this was the first visit since November 2006. Prior to the site visit the Annual Quality Assurance Assessment (AQAA) was returned to The Commission for Social Care Inspection (CSCI), which provided us with information and data about how the service meets the needs of the people who use the service, and what improvements the service has identified it could make. Have Your Say surveys had been sent to people using the service, staff and health professionals prior to the inspection and everybody returning surveys made positive comments about the management of the home and the delivery of care. Due to the mental frailty of the majority of the residents we were not able to engage in meaningful conversation with many during the visit. However those that could offer an opinion said they were well looked after and the staff were very good to them. We observed that residents were relaxed and content in the home and had good relationships with the staff who care for residents in a caring, friendly and professional manner. Some comments were: “Staff have the right skills and respond to differing needs”. “The home meets needs and respects individual privacy and dignity”. “ They do well to maintain persons dignity”. “We feel confident that our mother is in safe hands at this stage of her life”. “My mother is well looked after and we have been impressed by the high standard of care shown to her by all of the staff”. “Staff were always welcoming, sensitive and caring and that they give the right care and support, listen to what residents and relatives say and are always available”. “The leadership of the manager ensures the staff’s approach to care and respect, in turn creates a home from home atmosphere which is evident at Belle Vue and is condusive to the stability and security essential for dementia sufferers. A requirement made at the last inspection has been complied with. Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Work should continue to adapt signage and other aids to make them specific to residents suffering from Dementia. Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 7 Some internal decoration is needed as parts of the home are beginning to look tired; although we are aware there is a programme for re decoration throughout the home. The organisation had identified improvements, which it could make in the Annual Quality assurance Assessment (AQAA) that it returned to us. These included: • To provide a ten bed extension with additional communal space. • Replace some of the bedroom furniture. • Improve the activity provision for residents with varying levels of Cognitive impairment. • Provide more specific training for staff in clinical procedures and new legislation. 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. Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose and service users guide has been updated and contains the views of residents, staff and people who visit the home. People have an accurate assessment of their needs carried out before admission. Once admitted a further in depth assessment is undertaken and risk assessments compiled. Staff have training specific to the needs of the residents. Residents all have a contract which sets out clearly the fees and any extras that will be charged. Intermediate care is not offered at Belle Vue. EVIDENCE: The statement of purpose and service users guide has been updated and contains the views of residents, staff and people who visit the home. People Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 10 have an accurate assessment of their needs carried out before admission, this is because they or people close to them have been able to visit the home and have been given good information about the service the home provides. Once admitted a further in depth assessment is undertaken and risk assessments compiled. Staff have training specific to the needs of the residents. Residents all have a contract which sets out clearly the fees and any extras that will be charged. Intermediate care is not offered at Belle Vue. Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Resident’s health and personal needs are met to a very high standard. All residents have a person centred plan of care and risk assessments that they or people close to them have been involved in making. The home operates safe procedures for the storage and administration of medicines and staff care for residents with privacy and dignity. EVIDENCE: There is a key worker system in operation in the home whereby a qualified nurse is in charge of the day-to-day care of a group of residents; this provides accountability of care given. Residents were seen to be encouraged by staff in a friendly and supportive manner to make decisions about what they wanted to do. Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 12 Records showed that all residents have an up to date person centred care plan generated from a full assessment. The care plan sets out in detail the action which needs to be taken by care staff to ensure all aspects of the health personal and social care needs of residents are met. Risk assessments are comprehensive and when tracked to individual residents were appropriate to their needs. Nutritional assessments are in place along with a nutritional screening care plan. Where necessary a nutritional monitoring system is in place and when tracked these had been completed as stated in the care plan. A case tracking exercise was carried out to check whether the care identified as being needed from assessments was being followed up by staff. In all the cases checked, residents were receiving the care and support they needed to a very good standard from a caring, well-trained and supportive staff team. Records and observation showed that clinical guidelines and safe infection control procedures are being followed in the home. Specialist equipment necessary for the promotion of tissue viability and the treatment of pressures sores is provided. We are told and records showed, that residents receive care and support from other health care professionals such as doctors, dentists, opticians and chiropodists on a regular basis. We are told and we observed that residents are treated with respect and dignity at all times by a professional, caring and excellent staff team. The home operates a Gold Standard Framework for palliative care and when first admitted residents will have an advanced care plan compiled with the help of relatives and friend if necessary. This will ensure that when they are approaching the end of their life they and their close ones will be reassured that their death will be handled with sensitivity, dignity and respect and will take into account their spiritual and cultural wishes. Records of these were seen and where possible signatures of agreement had been obtained. One resident who was poorly and being nursed in bed looked clean and comfortable, staff were noted to be following the instructions in the care plan in respect on turning the resident regularly and ensuring food and fluids were given. Policies and procedures are in place for the safe administration of medication. No residents presently at the home are self-medicating and qualified nurses always administer all medication. Records and observation of part of the medication administration round showed that medicine is being administered as prescribed and records completed appropriately. Medication training for staff is provided on a regular basis. Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 13 Surveys says residents receive the care and support they need, relatives say they are kept up to date and a health professional said the home seeks advice to manage and improve the health care needs of residents. Comments included: “Staff have the right skills and respond to differing needs”. “The home meets needs and respects individual privacy and dignity”. “They do well to maintain persons dignity”. “Staff are caring, sensitive, attentive and respectful”. “We feel confident that our mother is in safe hands at this stage of her life”. “My mother is well looked after and we have been impressed by the high standard of care shown to her by all of the staff”. Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident is treated as an individual and the care home is responsive to their diverse needs. The home supports personal interests and activities, residents are encouraged and supported to be as independent as they can be within their mental capabilities. Residents are able to keep in touch with their family friends and representatives and the local community is involved with the home. Residents have good well-balanced home cooked food and can have drinks and snacks at any time. EVIDENCE: We observed, and are told that the routines within the home and the activities provided are flexible and that that relatives and friends are always made very welcome by managers and staff. People told us that they are encouraged to take part in the running of the home and that residents are encouraged and supported to make decisions and choices about their day to day life. Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 15 Residents are able to bring personal possessions into the home to make their rooms more homely. There are three lounges available, two downstairs and one upstairs, these had recently been decorated in a Valentines Day theme and were bright and cheerful. Although some residents prefer to go to a particular lounge, others can wander safely at will around the home. Staff are in attendance in all lounges to ensure the safety and welfare of residents. There is an enclosed patio garden with a well-stocked aviary and residents who like to smoke can go out or be taken out to this area. Some residents were outside smoking during the visit. There is a raised vegetable plot in the garden and residents are encouraged to tend to the plants by watering, weeding and harvesting them. The home is in a beautiful area of woodland and countryside and the wildlife is a regular feature around the home. The providers have recently completed a sensory garden with a large water feature across the car park to the front of the home. Residents were involved in the planting stage of the garden as photographs in the home showed. There are pathways suitable for wheelchairs and adequate seating for residents and visitors. Although this is not readily accessible to the majority of the residents who need assistance and supervision we are told that staff will take those residents who need help to access it. We are told that relatives and friends who visit the home do use the garden with the residents they are visiting. Photographs of the official opening party were available and the residents looked as if they were enjoying themselves. There are plans to extend further into an open area to create a secret garden where people can wander safely around. People told us that suitable activities are provided for residents, these consist of individual activities, small group and large group activities and outings. Photographs were available of a recent outing and Mrs Lew Kum Hoi told us that often staff also take residents out on an individual basis, records confirmed this. Clergy visit the home to provide spiritual care and two residents go out to services in the community. The home has links with the community and a May Day celebration is planned with the help of a local primary school. Comments included: “We are encouraged to visit at any time”. Staff are always helpful and always appear happy welcoming visitors with a cup of tea”. Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 16 The home is presently in the process of recruiting a full time chef. At present a suitably qualified cook is preparing and cooking the meals. The menus were displayed and showed that a good range of home cooked food was available. We are told that drinks and snacks are available 24 hours a day. People told us that the meals at the home are very good and that residents enjoy them. This was noted on the day of the visit when the main meal was sausage and bacon roll with mixed vegetables and mashed potatoes, followed by jam roly-poly. Staff were on hand to help discreetly when necessary and residents seemed to enjoy their lunch. One resident asked for egg and tomatoes on toast and this was cooked for them. Residents are able to eat in the dining room, the lounges or their rooms as they wish. We sampled the main meal and it was very tasty and well balanced. A visitor who is a regular at the home told us that staff are always friendly and helpful and refreshments always offered. The staff always make an occasion of birthdays and other celebrations with cakes and decorations. Photographs were seen of the parties which included residents, staff, managers, friends and relatives. We are told and did observe that staff do respect the privacy and dignity of residents by knocking on doors and waiting before going into rooms and giving relatives and friends privacy when they visit. Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. If people have concerns about their care they or people close to them know how to complain. Any concern is looked into and action taken to put things right. Policies and procedures are in place to protect resident’s legal rights and advocates are accessed when needed. The home safeguards people from abuse and neglect and takes action to follow up allegations. EVIDENCE: CSCI has not received any complaints or allegations related to the home since the last visit. The complaint procedure is clearly displayed in the foyer of the home and people told us that they knew who to complaint to if they had a problem. There are no outstanding complaints in the home’s records. Staff training records and induction records showed that staff are trained and are aware of their roles in protecting residents from abuse. Staff have had training in the Mental Capacity Act and further training is planned to ensure that residents who lack capacity are protected. Information Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 18 on advocacy services are available in the home and staff aware of how to access advocates if necessary. All surveys indicated that relatives and close ones knew who to complain to and they knew there was a procedure. Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, comfortable, clean environment and have the specialist equipment they need to meet their needs. EVIDENCE: The home is situated in a beautiful rural area in Warninglid in West Sussex. Large well-kept gardens surround the home and there is an enclosed patio area in which residents can safely wander at will. There is a well-stocked aviary in the patio area. Since the last inspection a sensory garden with a water feature had been created which has improved the outside environment for residents and further work is planned. Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 20 The home is adequately maintained and provides aids and equipment to meet the needs of the residents presently accommodated, the home has recently purchased 3 new hoists and 2 new hi lo beds. The home is well lit, comfortable and homely. The communal areas are pleasant, furnished in a homely fashion with high back comfortable chairs. There are television and music centres in the lounges. Some of the internal decoration is in need of attention although there is a decoration programme in place. People who completed the surveys told us that the home is always clean and fresh. Resident’s rooms have been personalised with their belongings to make them more homely and where rooms are shared, screens are provided for privacy. One bedroom is in need of redecoration and when this was bought to the attention of Mrs Lew Kum Hoi we were told that the arrangements for this were already in place and they were going to ask the resident to move to another room while the re decoration was in progress. In some rooms some furniture is in need of replacing and we were told that this is already planned for. There are plans to extend the home in the near future and with this some more internal decoration will take place. Records indicated that equipment and services in the home are regularly maintained. A number of bedrooms have had locks provided following a risk assessment, the call bell system does have cords which could be a risk, however and these are covered by the resident’s individual risk assessments and would be removed if the risk of accident were high. Bedroom doors are individualised with different nameplates and there are various stimulating signs around the home, however this could be improved and the environment could have more signage and pointers appropriate for residents with dementia. Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents living at Belle Vue Country House are protected by the recruitment procedures and staff receive good training so they can meet the needs of the people living at the home. The staff team work well together to deliver a very high standard of care. EVIDENCE: The service has a well-developed recruitment procedure, which puts the residents at the centre of the process. The service is highly selective with the recruitment of the right people more important than filling the vacancy. The records of two new staff were seen during this visit they included the necessary records and checks required to ensure their fitness and suitability to work with vulnerable residents. Duty rotas showed that a good number and skill mix of staff is employed over a 24-hour period to meet the needs of the residents in an individualised and person centred way. The home has a stable staff team who work well together to the benefit of residents. The staff were noted to be well organised and able to respond to the needs of residents living at the home. Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 22 In addition to the registered manager, qualified nurses and care staff there are cleaning staff, maintenance staff, kitchen staff and an administrator. Residents and people close to them were full of praise for all of the staff team and told us that the care and support given was first class. They said, “Staff were always welcoming, sensitive and caring and that they give the right care and support, listen to what residents and relatives say and are always available”. Over 50 of the staff have NVQ level 2 or above and other are working towards it. A staff-training programme is in place and includes mandatory training in health and safety and specific training related to the identified needs and illnesses of residents. A supervision and appraisal system is operated in the home. Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents benefit from a very well run home which concentrates on providing excellent outcomes for the residents and are safeguarded by the homes policies procedures and systems. EVIDENCE: Mrs Lew Kum Hoi the registered manager is highly competent to run the home and meet its stated aims and objectives. Mrs Lew Kum Hoi has eight years management experience in care settings and is near completion of the Registered Managers Award. She is also a Registered Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 24 Mental Health nurse. The Annual Quality Assurance Assessment was completed and returned to CSCI in good time for it to inform the visit. This showed that the home continues to develop in all areas to improve the daily lives of the residents. Mrs Lew Kum Hoi has a sound knowledge of both strategic and financial planning and how the operational/business plan for the home fits into the overall picture. There is a clear vision for the home based on the home’s values. Mrs Lew Kum Hoi provides an excellent role model for staff and demonstrates a clear sense of direction and application of best practice systems to the benefit of the residents and staff. Equality and diversity issues are managed effectively, the inspector was told confidentially about a recent example of how an equality and diversity issue had been dealt with to a positive conclusion. Mrs Lew Kum Hoi is able to demonstrate through her professional qualifications and experience the ability to manage to home to a very high standard. People told us that the home is managed to a high standard and is run in the best interest of the residents. They also told us that Mrs Lew Kum Hoi maintains a high profile in the home and is always available if people wish to see her. Some comments were: “The leadership of the manager ensures the staff’s approach to care and respect, in turn creates a home from home atmosphere which is evident at Belle Vue and is condusive to the stability and security essential for dementia sufferers. “The managers and nurses are always available”. “Belle Vue is a well run regulated home and I don’t think they can improve”. Mrs Lew Kum Hoi ensures that staff follow the policies and procedures of the home and monitors this through the supervision and appraisal system. Record keeping is of a high standard and records are kept securely, staff are aware of the requirements of the Data Protection Act. The home does not manage the finances of any of the residents but in the event of there not being any relatives, will access an advocate when the need arises. Working practices in the home are safe and staff are trained to a high standard in mandatory and selective areas. There is a comprehensive range of policies and procedures to promote and protect resident’s and employee’s health and safety. Staff are trained, understand and follow these. There is full and clear written recording of all safety checks and accidents, accidents records are analysed to ensure that any trends would be identified. Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 25 Quality assurance is taken seriously and the results of two recent audits were available along with any action that was required. Spot checks and quality monitoring systems provide management evidence that practices reflects the home’s and organisation’s policies and procedures. At the last inspection a requirement was made under Regulation 26 that the Provider carries out monthly checks at the home and writes a report on the conduct of the home. These are available in the home for inspection so the requirement is met. Belle Vue Country House DS0000024117.V356763.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 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 3 4 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 3 3 3 4 3 Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone, Kent ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Belle Vue Country House DS0000024117.V356763.R01.S.doc Version 5.2 Page 29 - 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. 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