Inspection on 20/02/07 for Bellsgrove

This inspection was carried out on 20th February 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bellsgrove 14/01/09

Bellsgrove 16/07/08

Bellsgrove 02/08/07

Bellsgrove 22/06/06

Bellsgrove 05/01/06

Bellsgrove 15/09/05

Bellsgrove 10/12/04

Bellsgrove 15/10/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Bellsgrove Bellsgrove 250 Cobham Road Fetcham Surrey KT22 9JF Lead Inspector Lisa Johnson Unannounced Inspection 09:00 20 February 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bellsgrove DS0000013568.V325453.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. Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bellsgrove Address Bellsgrove 250 Cobham Road Fetcham Surrey KT22 9JF 01372 379596 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 Somasundaram Logathas Mrs Shyamala Logathas Mr James Iswurdut Sobun Care Home 14 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (5), Learning disability (1), Mental Disorder, of places excluding learning disability or dementia - over 65 years of age (5), Old age, not falling within any other category (14), Sensory impairment (1) Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Categories DE, LD and SI apply to a named service user only. 5 service users may fall within categories DE(E) or MD(E). For up to 5 additional places for day care within categories OP, DE(E) or MD(E). 22nd June 2006 Date of last inspection Brief Description of the Service: Bellsgrove is a family run care home registered to accommodate up to fourteen older people. Up to five residents who may have dementia and up to five residents who may have mental disorder can be accommodated. The home is also registered to provide day care for up to five people. The home is a large detached property situated in the village of Fetcham, with a range of local shops nearby. The accommodation is set over two floors, with a passenger lift serving both floors. There are fourteen single bedrooms, a spacious lounge/dining room and a large conservatory. An enclosed garden is provided to the rear of the property and limited car parking is available to the front. The fees at this service range from £460.00 to £560.00. Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a second key inspection. The visit was unannounced and took place over eight hours commencing at nine o’clock and finishing at five pm. Mrs. L Johnson Regulation Inspector carried out the visit. Mr. J Sobun registered manager represented the establishment for part of this visit. The inspector spoke to four residents and one relative to gain their views on the care provided. A full tour of the premises took place. Information was examined which was provided by the manager with the pre- inspection questionnaire. Staff training records, and policies and procedures were sampled. The inspector spoke to two members of staff. The inspector would like to thank the staff and residents for their time, assistance and hospitality during this inspection. What the service does well: The home provided a warm and friendly atmosphere. Good relationships were seen between staff and residents. Positive comments were received from residents and a relative including, “I am very contented and the staff are kind””; “Its lovely”; “I am very well looked after and the staff respect me as an older person”. One relative said “Its home from home and it is friendly”. Residents are provided with well-presented meals and one individual’s preference to have a glass of wine with her meal was respected. Residents spoken to were satisfied with the meals provided. The home provides a pleasant, accessible garden, which residents can use during the summer months, and a bright conservatory, which overlooks the garden. During this visit resident’s bedrooms were viewed as comfortable and residents are provided with the opportunity to bring their own furniture and possessions in to the home Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The care planning process requires improvement to ensure that the changing needs of residents are reflected in their individual care plans. Appropriate health care professionals must also be consulted regarding residents changing needs where required. Residents and or their relatives must be consulted and agree to their care plans. It is recommended that each identified care objective be recorded in more detail to reflect all of the identified care plan objectives. Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 7 One resident has a floor pad, which is used to alert staff that this individual is out of bed and may require assistance. The risk assessment for this individual did not include the need for this equipment. This matter was identified at the previous visit and has not been completed to date. An item of out of date medication stored in the cupboard must be returned to the pharmacy to ensure residents are protected by the hoes medication procedures. The home should consider maintaining a complaints record, which should be regularly reviewed. The outcomes of the quality assurance questionnaires should be analyzed and the outcome fed back to residents and their relatives. The manager is advised to record the allocated duties of staff are recorded on the duty rota including the hours worked in the home by the registered manager. It is recommended that staff training schedules be updated. A portable heater was observed in one resident’s bedroom and a risk assessment had not been completed to ensure the safety and wellbeing of the individual. The home needs to ensure that all events requiring notification are reported to the commission without dela, including the death of any resident. It was also recommended that copies of full accident records should be made available with resident’s file for easier access. 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. Bellsgrove DS0000013568.V325453.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 Bellsgrove DS0000013568.V325453.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, 3 & 6 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that sufficient information is provided to ensure that prospective residents are able to make an informed choice about the suitability of the home as a place to live. Pre- admission assessments are completed prior to admission to the home. The home does not support people with intermediate care. EVIDENCE: The home provides a statement of purpose and service user guide and the inspector was informed that these are provided to prospective residents and or their representatives. Since the previous site visit two residents have been admitted to the service. One relative spoken with stated that they had received this information. Pre- admission assessments were sampled that Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 10 indicated that full needs assessment is completed prior to admission to the home, which includes the cultural and diversity needs of residents. The service does not provide intermediate care and therefore standard six was not assessed. Bellsgrove DS0000013568.V325453.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each resident is provided with an individual care plan, which details how the individual’s health, personal, emotional and social needs are met. Residents are protected by the homes medication policy and procedures and are treated with respect and their right to privacy is respected. EVIDENCE: A sample of three care plans was examined. Each plan showed evidence of monthly reviews although it was recommended that each care objective should be reviewed in more detail as opposed to one paragraph reflecting all objectives. There was no evidence of consultation with residents and or their representatives in three care plans sampled. It was required that care plans must be brought to the attention of residents and or their representatives to ensure they are fully consulted and agree to their care plan. One relative spoken with said that staff consult and keep her informed of her relatives care needs. During discussion with staff the care needs for one individual have Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 12 increased which was not reflected in the care plan and did not include an identified health issue. The mobility needs of this individual have also deteriorated and this was also not reflected in the care plan. It was required that the registered person must ensure that the residents care plan is reviewed and amended to reflect the changes in need. A referral must be made for this individual to an appropriate health care professional to ensure that the needs of this individual are fully met. During discussion with staff it was clear that residents are mainly supported by health care professionals including a General Practitioner, district nurse and chiropodist. A record sheet was in place to detail visits from health care professionals but these had not been regularly completed. The identified risks for residents were recorded and incorporated in to the care plan including mobility, although risk assessments must be updated to reflect the change for one individual to ensure their health, welfare and safety. At the previous visit floor pads were used to alert staff that residents are out of bed and may require assistance and assessments had not been completed for the identified residents. During this visit these pads were still seen to be in use and risk assessments had still not yet been completed to ensure their safety and wellbeing. Staff were observed to talk with residents in a friendly manner, treating them with respect. The inspector spoke with one relative who said, “Staff always interact with residents”. Staff spoken with said that residents have to access to a telephone should they wish to use this. Both the resident and staff groups are of mixed gender. The cultural background of the resident group is of white British origin. The cultural background of the staff group is of Asian origin and one resident spoken with was complimentary about the staff group by stating, “that he felt respected by the staff”. The home has a medication policy in place. Photographs were available with resident’s medication administration records and a list was maintained for all staff that are trained and authorized to administer medication. All medication administered was signed for and medication was stored appropriately. However it was required that a bottle of medicine in the cupboard which was discontinued must be returned to the pharmacy to ensure that residents are protected by the homes medication policies and procedures. Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to a range of recreational and leisure activities and maintain links with their family/friends and the local community. Residents are supported to make choices and individual preferences are respected. Residents receive well-presented and balanced meals. EVIDENCE: Since the previous visit the inspector was informed that the hours of the activities organiser works in the home has increased from two to three days. There is an activities programme in place, which includes activities such as music, physical exercise group discussion, art and crafts and board games. The activities organiser was not available during this visit to speak with and the inspector was informed that care staff carries out this role on the days the activity organiser does not attend. During this visit some residents were watching television, reading newspapers and playing cards and some residents were observed to be unoccupied. The inspector was informed that one member of staff is completing a course on activities in the care setting. The Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 14 registered manager could consider booking all care staff on this training as this would provide staff with the appropriate skills to support residents with dementia by offering them a range of meaningful activities. The inspector was informed that ministers of religion visit the home and conduct services, which meets their religious and cultural needs. One resident spoken with stated that he was satisfied with the activities on offer. “I like to read the papers and do crosswords and I am assisted to go to the town occasionally and attend a club for lunch”. The inspector spoke with one relative who stated, “The home holds a Christmas party, summer barbecue and there is a trip to the seaside”. One relative stated that she is made to feel welcome when she visits and has the opportunity to spend time in the conservatory with her loved one or goes out for walks. One resident spoken with said that his family visit him and another resident was observed to be receiving a visitor. Residents are provided with the opportunity to bring in their own furniture and possessions in to the home, which were seen on display. Residents were observed to be supported to make choices with one resident having a glass of wine with her meal, which meets her preference. During this visit the inspector was supplied with a copy of a four-week menu, which looked varied and well balanced. At the previous visit a recommendation was made that the menu should be reviewed with a dietician. The inspector was informed that the menu was based on nutritional guidance. As there is no chef employed in the home a further recommendation was made that the menu should be discussed with the appropriate professional to ensure that the menu fully meets the nutritional needs of residents. During the visit the lunchtime meal was observed to be well presented and balanced with fresh vegetables provided. One resident spoken with said, “the meals are good and a choice is available”. One relative said that she was satisfied with the meals and that there are always fresh vegetables. Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 15 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives have access to an effective complaints procedure and their views are listened to and acted upon. Policies and procedures are in place, which protects residents from abuse. EVIDENCE: A complaints procedure was seen on display in the lounge. The registered manager stated that no complaints have been received since the previous visit. A recommendation was made at the previous visit that a record is maintained which should be regularly reviewed, dated and signed to indicate whether any or no complaints have been received. This recommendation has not been responded to and the home is advised to consider a system of monitoring the complaints procedure in the home. One relative spoken with stated that the staff are approachable and was happy with the care provided. One resident said the home is “lovely”. The local authority updated safeguarding adults procedure was in place. Staff training records were examined which indicated that staff have received appropriate training which was confirmed by two members of staff spoken with, although one member of staffs training schedule needs updating and a member of staff spoken with was clear in her responses to as to the action she would take if she ever witnessed any abuse taking place. Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 16 There has been limited notifications to the commission regarding events that affect the welfare of residents. One matter, which had been referred under the local authority safeguarding adult procedures, had not been notified to the Commission as required. The manager should ensure that he is fully up to date regarding the nature and type of events that require notification. Information is available on the commission website regarding such matters. Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents in the main live in a well-maintained, homely and clean environment with one matter identified needing attention. EVIDENCE: Since the previous visit a number of environmental improvements have taken place including the replacement of some vanity units in bedrooms and improvements in the bathrooms. During a tour of the home some minor redecoration work was identified upstairs and the inspector was informed that a redecoration programme is being arranged. The home provides a large sitting / dining room and extra space is available with the provision of a pleasant conservatory, which overlooks the garden. The garden was accessible, well maintained and contained garden furniture for residents to use Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 18 in the summer months. A lift is available and grab rails were provided throughout the home to meet the needs of residents with mobility difficulties. During this visit the home was clean and hygienic. Separate laundry facilities were available and soap and towels were provided in all bathrooms and toilets. One bedroom had a strong pervading odour and staff stated despite cleaning this had little affect. Therefore a requirement was made that the carpet must be replaced with suitable floor covering to ensure that residents have comfortable and pleasant bedrooms to live in. Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty were adequate to meet the needs of residents. Residents were protected by the homes recruitment policies and procedures and were in the safe hands of the staff that were competent and trained to do their jobs. EVIDENCE: At the time of this visit there were three members of staff on duty. The duty rota was examined which concluded that there are three members of staff working in the morning and two staff on the afternoon shift. The inspector was informed that these levels are sometimes higher as on occasions the manager works from ten am until six pm. The hours worked by the manager were not recorded. The home employs a member of staff who carries out cleaning from six to eight pm. The Inspector was informed that some cleaning is carried out in the morning with the major cleaning being carried out in the evening. Staff also carry out cooking and provide activities on the days the activity coordinator is not working. While there was no evidence to suggest that outcomes for residents were not being met by the staffing arrangements in place the manager is advised to record the allocated duties of staff on the Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 20 rota. This is particularly important in view of the varied roles and tasks that the staff are required to complete. The registered manager informed the inspector that a number of staff have completed or are completing National Vocational Qualifications. The deputy manager has completed National Vocational Qualification (Level 4) and one member of staff spoken with stated that she had completed National Vocational Qualification (level2). Training records were sampled for three members of staff which recorded that staff have received training in fire safety, safeguarding adults, food hygiene and first aid and that this training has been updated over the last year. It was recommended that all training completed be accurately recorded on the staff training schedule. The manager informed the inspector that applications have been made for all staff to attend dementia awareness training. The staff personal files were examined for three members of staff and photographs were available and all of the required information was in place including police checks. At the previous visit it was observed that the original Criminal Record Bureau disclosures had been retained in the home. During this visit it was observed that these records were still maintained. The manager is advised to consult the Criminal Records Bureau regarding the retention and disposal of certificates in order that they are complying with correct guidance and legislation. Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 21 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, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is able to demonstrate that he has the appropriate qualifications and experience to manage the home and is run in the best interest of residents. The financial interests of residents are protected. The health, welfare and safety of residents are mainly protected with two issues identified needing attention. EVIDENCE: The manager has been in post for a number of years and is qualified general and mental health nurse. The manager was available for part of this visit. One member of staff spoken with said that regular staff meetings take place and that there is good teamwork. The inspector was informed that the registered providers are closely involved in the home and cover the home in the manager’s absence. Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 22 Quality assurance questionnaires had been updated by residents and their representatives. These were sampled during this visit. The registered manager should consider analyzing the outcomes of the questionnaires to residents and their representatives. Pre-inspection information provided by the registered manager indicates that there are policies and procedures in place some of which were sampled during this visit. The supervision records for staff were examined for individuals, which indicated that supervision sessions are being carried out regularly and documented The home does not handle any financial affairs or maintain monies on the behalf of residents. Any extra expenditure incurred such as chiropody is invoiced to resident’s representatives. During this visit all cleaning materials were locked away. Records were available to suggest that monthly health and safety audits are conducted in the home. The home maintains water temperature records but these had not been recorded for weeks. During this visit the manager immediately attended to this matter. During a tour of the premises it was observed that a portable heater was in place in one bedroom and no risk assessment had been completed. An immediate requirement was made that this matter must be attended to ensure the safety and wellbeing of residents. Accident records were maintained by the home and there was evidence to that suggest that accident records were completed. The deputy manager was unable to locate the full accident reports and it was recommended that these should be made available with resident’s individual files for access. During discussion with the manager it came to the attention of the inspector that a service user had passed away and a written notification had not been made to the Commission for Social Care Inspection. A requirement was made that written notifications must be made without delay to the commission regarding all events affecting the welfare of residents including notifications of death. The fire officer has recently attended the home to carry out training with staff and to carry out a fire drill and will be attending again in six months time. Records sampled indicated that fire alarms had been checked two months ago Pre-inspection information received indicated that regular routine maintenance and servicing is taking place. The water company has visited and the home is currently awaiting a certificate. Confirmation that gas servicing has taken place was available for inspection. The home has received a visit from environmental health and work was seen in progress to rectify problems with the water connections in the kitchen. Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 15 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 X 3 3 X 2 Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(2)(ad)&13(4)( c) 13 (4) (c) Requirement Residents and their representatives must be consulted regarding the individual care plans a) A referral must be made to a health care professional to assess the mobility needs for one individual and the current care plan and risk assessment must be reviewed. Timescale for action 20/03/07 2. OP7 23/02/07 3 OP9 13(2) 4 OP26 23 (2)(d) 5. OP38 13 (4) (a) 37 b) Risk assessments must be completed regarding the use of floor alarm pads for individuals. The registered person shall make 06/03/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medications in the home The registered person must 20/03/07 ensure that the flooring is replaced in one residents bedroom ensuring that residents have clean and pleasant bedrooms to live in. (a) The registered person must 20/02/07 ensure that all parts of the home to which residents have access DS0000013568.V325453.R01.S.doc Version 5.2 Page 25 Bellsgrove are so far as reasonably practicable free from hazards to their safety. Specifically ensuring that a risk assessment is completed in respect of the portable heater placed in one bedroom. (b) The registered person must ensure that the commission is informed without delay of the death of any resident 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 Refer to Standard OP7 OP12 OP15 OP33 OP27 OP38 Good Practice Recommendations It is recommended that the care plan monthly reviews should be more detailed as opposed to one pagraph to reflect all care objectives. The registered person should consider booking all staff on the activities in the care setting training course. It is recommended that the menu and dietary needs of residents be reviewed with the involvement of a dietician. The registered person should consider analyzing the outcomes of the quality assurance questionnaires and to provide feedback to residents and their representatives. The registered person should consider recording the allocated duties of staff on the duty rota It is recommended that copies of accident records are maintained with the residents personal file Bellsgrove DS0000013568.V325453.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Bellsgrove DS0000013568.V325453.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. 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