Inspection on 05/01/06 for Bellsgrove

This inspection was carried out on 5th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 20/02/07

Bellsgrove 22/06/06

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 Sandra Holland Unannounced Inspection 5th January 2006 12:30 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.V277192.R01.S.doc Version 5.1 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.V277192.R01.S.doc Version 5.1 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.V277192.R01.S.doc Version 5.1 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). 15th September 2005 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. Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the second to be carried out in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. As the inspection was unannounced, the staff and the residents were unaware that it was to take place. Mrs Sandra Holland, Lead Inspector for the service carried out the inspection, over a period of five hours. Mr Somasundaram Logathas and Mrs Shyamala Logathas, Registered Providers were present representing the service. Mr James Sobun, Registered Manager was present from 2.10.p.m. A tour of the premises was carried out and a number of records and documents were examined, including staff files, the complaints procedure, care plans and assessments of risks. Seven residents and three members of staff were spoken with. The inspector wishes to thank the residents and staff for their hospitality, time and assistance. The people living at Bellsgrove prefer to be known as residents and that is the term that will be used throughout the report. What the service does well: What has improved since the last inspection? Contracts to be supplied to residents now contain the required information. Staff have received training in the protection of vulnerable adults. Improvements have been made to the standard of presentation and odour control in resident’s bedrooms. Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 Page 6 What they could do better: Assessments of residents must be carried out before they are admitted to the home. The resident’s plans of their care and support needs must be checked and updated as required, and residents must be involved in drawing up the plans. Assessments must be carried out of any risks to residents. Medication must be stored in a locked provision. Residents must be consulted about the activities programme. The complaints procedure must be made available to residents and in a format to suit their needs. Radiators and heated towel rails must be guarded or be of a specific low surface temperature variety. A review of the numbers of staff and the hours that they work must be carried out. Staff must not be employed or allowed to work in the home, without the necessary checks being carried out, or the required records and documents being obtained. The home must be managed in a more robust and effective way. Reviews of the quality of the service provided must be carried out and should be circulated to all those involved in the support of residents. Staff must receive formal supervision. The records that are required to be kept in the care home, must be maintained. Hazards to the safety of residents remain in the home. Residents must be safeguarded and substances hazardous to health must be stored in a locked provision. Please contact the provider for advice of actions taken in response to this Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 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.V277192.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. Contracts now contain the required information. Pre-admission assessments have not been carried out. EVIDENCE: The provider stated that the contracts that are provided to residents have been revised to contain the required information and an example was seen. This will be supplied to any future residents, the provider advised. A requirement was made at the unannounced inspection carried out on 15th September 2005, that the registered person must not provide accommodation to a resident at the care home unless, so far as it is practicable to do so, the needs of the resident have been assessed by a suitably qualified or suitably trained person. The registered person must obtain a copy of the assessment and there must have been appropriate consultation regarding the assessment with the resident or their representative. It was noted at this inspection that the needs assessment of the most recently admitted resident, was carried out two days after admission in December Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 Page 10 2005. The provider stated that the resident had visited the home prior to admission for an assessment, but no record was available to confirm this. The provider stated that intermediate care is not provided. A requirement has been made. Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9. The residents’ individual plans of care have not been updated to reflect changes in needs. Medication is still not being stored in a locked provision. EVIDENCE: A requirement was made at the unannounced inspection carried out on 15th September 2005, that the registered person must make the resident’s plan available to the resident and keep the plan under review. In addition, where appropriate, unless it is impractical to do so, the resident’s plan must be revised, after consultation with the resident or their representative and the resident is to be informed of any such revision. A timescale of 14th October 2005 was given for this to be carried out, but it remains unmet. It was noted at this inspection that although reviews of the care plans have been recorded, the care plans have not been updated and do not reflect changes in residents’ needs. The care plan for one resident states that no medication has been prescribed and the sheet for recording medication is blank. A record elsewhere states that this resident does take prescribed medication. Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 Page 12 Assessments of known risks to residents have not been carried out or have not been updated. For the most recently admitted resident, a risk assessment record sheet had been named and was dated two days after admission. The assessment had not been carried out and the sheet was blank where risks and preventative measures should be listed. The provider stated that he was aware of risks to the mobility of this resident. No photograph was available of this resident, although admission had taken place in December 2005 and the assessment of the resident stated that the garden gate should be kept locked to ensure the resident does not wander off. An immediate requirement was made at the inspection on 15th September 2005, that the registered person must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. At today’s inspection, medication was again stored in an unlocked cupboard in the kitchen. A package of medication stated to belong to a member of the provider’s family was stored in a second unlocked kitchen cupboard. The package was removed by the provider. (Also referred to at Standard 38 which refers to the health and safety of residents). An immediate and other requirements have been made. Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10, 12, 14 and 15. Residents’ privacy and dignity are respected. Activities are carried out but need to take residents wishes and abilities into account. Meals served looked appetising and were enjoyed by residents. EVIDENCE: Staff were observed to speak to residents in a friendly but appropriate way using the resident’s preferred name. Personal care was seen to be given in a discreet and sensitive manner that respected the resident’s privacy and dignity. The activities co-ordinator was spoken with as she finished a craft session with residents and she stated that residents had been making decorative cards, some of which are sold in the home. The activities programme displayed did not show this to be the planned activity for the day, but the co-ordinator stated that this is changed from time to time to suit resident preferences or to carry out a seasonal activity. The range of activities on offer and being carried out, must take the specific wishes and needs of residents into account. The hours worked by the activities co-ordinator and other staff should be reviewed to ensure that enough staff are provided to carry out the activities planned. Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 Page 14 During the tour of the home, it was noted, that no residents were spending time in their bedrooms. Some residents were observed reading the papers and watching television in the lounge, but other residents were not being occupied or stimulated. The provider stated that residents handle their own affairs if they are able, or are supported by their families. He advised that residents are able to bring their personal possessions into the home, and some of these were seen on the tour of the home. It is recommended that details of a local advocacy service are displayed to enable residents and their representatives to contact them if necessary. The lunch time meal was being served during the inspection, which was well balanced and looked and smelt appetising. The residents were seated at two dining tables, one in the dining area of the lounge and another in the conservatory. The tables were attractively set with colourful tablecloths and tablemats. Residents spoken to said that they enjoy the meals served, the portions were good and that a choice was available. A requirement and a recommendation has been made. Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. A complaints procedure is in place, but is not available to residents. EVIDENCE: The provider stated that the complaints policy and procedure is provided to residents when they are admitted, but did not have a record to confirm this. The contract that is supplied to residents states that a copy of the complaints procedure is displayed, but it is not. As the complaints record is retained in the office, there is no provision freely available for residents or their representatives to make a complaint, which they may prefer to make anonymously. In line with the home’s categories of registration, the majority of residents at the home may have dementia or mental health problems. It is required that the complaints procedure is made available in a format that suits the specific needs of all residents and this must be made available. In the event that residents are unable to understand the complaints procedure, it is recommended that it is explained to the resident and recorded as such in their individual plan. Alternatively, it can be provided to the resident’s representative on their behalf, and this should also be recorded in their care plan. A requirement and a recommendation have been made. Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 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): 24 and 25. Improvements have been made to some bedrooms, but more are required. Radiators in two bathrooms are not guarded and do not protect residents. EVIDENCE: A requirement was made at the unannounced inspection carried out on 15th September 2005, that the registered person must ensure that the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally. Equipment provided at the care home for use by residents or persons who work at the care home must be maintained in good working order and all parts of the care home are to be kept clean and reasonably decorated. A timescale of 14th October 2005 was given for this to be met and this has been partially met. It was pleasing that some of the shortfalls noted at the last inspection have been addressed, but others still need to be attended to. Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 Page 17 A lamp positioned on a bedside table in a resident’s bedroom, was fitted with an electric bulb that was too large and the bulb fitting was loose, a bedroom carpet was marked with cigarette burns which the provider stated were caused approximately two years ago, and radiators in two bathrooms have not been covered to prevent residents from burning. (These shortfalls are also referred to at Standard 38 which refers to the health and safety of service users). A requirement has been made. Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 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 and 29. A review of the numbers of staff still needs to be carried out, to ensure that the needs of residents can be met. The poor standard of recruitment practices continue to place residents at risk. EVIDENCE: From looking at the rota and speaking to staff, it was clear that a very small staff team are employed to meet the needs of the residents. Both of the registered providers are involved in the day to day running of the home, there is a registered manager in post and two full time and two part time staff are employed. The rota did not appear to accurately reflect the staffing of the home. The registered providers are listed on the rota to be in the home every day, but as both names are listed on one line, it is not possible to know who would be working. Mr. Logathas is also listed on the rota to be carrying out three waking nights shifts, within the same week when he may be in the home every day. The line on the rota for the sleeping in member of staff, has the name of Mrs. Logathas and another member of staff alongside it, so is not possible to know who is on duty. Mrs. Logathas is listed elsewhere on the rota to work four other day shifts. It was noted that a full time member of staff was listed on the rota to work every day of one week, including a double shift on one of the days. Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 Page 19 It is a requirement that enough staff are working in the home to meet the needs of the residents and it is also required that the rota is an accurate record of what shifts are actually worked and by whom. A requirement was made at previous inspections carried out on 15th October 2004 and 10th December 2004 that the registered person must ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of residents. A timescale of 31st March 2005 was given for this to be met. These had been carried forward as the timescales had not elapsed. At the unannounced inspection carried out on 15th September 2005, this was found to be unmet and a further requirement to the same effect was made. A timescale of 14th October 2005 was given for this to be met, but this remains unmet. The manager stated that a number of staff have undertaken National Vocational Qualifications (NVQ’s) in care at differing levels. Four members of staff have achieved NVQ level 2, 1 has achieved level 3 and two others are currently working towards level 3. Mr. Logathas has completed NVQ Level 4 and the Registered Manager’s Award (RMA). Requirements were made at previous inspections carried out on 15th October 2004 and 10th December 2004 that the registered person must not employ a person to work at the care home unless the person is fit to work at the care home and he had obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2. A timescale of 31st December 2004 was given for this to be met. At the unannounced inspection carried out on 15th September 2005, this requirement was found to be unmet and remains unmet at this inspection. It is of serious concern that no personnel details are held for two members of staff working at the home and for other staff, shortfalls in the required records and documents were noted. Criminal Record Bureau disclosures have not been obtained for a number of members of staff and for some staff only one or no references have been obtained. An immediate and other requirements have been made. Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 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, 33, 36, 37 and 38. The home continues to need much stronger and effective management to safeguard the residents. A quality review system is in place, but needs to be carried out. Staff must be formally supervised with a record maintained. The standards of record keeping and shortfalls in aspects of health and safety, place residents at risk. EVIDENCE: It was very disappointing to find that ten of the sixteen requirements made at the last inspection on 15th September 2005, have not been met, even though the timescales for these have passed. It is of serious concern that three immediate requirements made at the last inspection on 15th September 2005, have not been met. An immediate requirement was made that the registered person must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. At today’s inspection, medication was Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 Page 21 stored in an unlocked cupboard in the kitchen. A package of medication stated to belong to a member of the provider’s family was stored in a second unlocked kitchen cupboard. The package was removed by the provider. (Also referred to at Standard 9 which refers to the administration of medication). An immediate requirement was made at the inspection on 15th September 2005 that the registered person must not employ a person to work at the care home unless the person is fit to work at the care home and he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2. At the inspection today, once again, none of the required records or documents were available for two members of staff. Of three other members of staff, no references were available for two, and only one reference was held for the other. No Criminal Record Bureau (CRB) disclosures were available for four members of staff and no photographs of staff were available. (Also referred to at Standard 29 which refers to recruitment). A further immediate requirement was made at the inspection on 15th September 2005 that the registered person must ensure that all parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety. At the inspection carried out today, products hazardous to health were still not stored in a locked provision in two bathrooms, the bedside lamp with the loose fitting and oversized electric bulb was still in the service user’s bedroom, on the table. The radiator in the downstairs bathroom and the towel rail in the upstairs bathroom were still not covered to protect service users from burning themselves. The provider and manager were advised that these serious failings would be referred to a Regulation Manager, as to further action to be taken. It was stated by the manager, that the home carries out yearly reviews of the quality of the service provided, and that the last review was carried out in December 2004. From the documents available, it appeared that the last quality review had been carried out in March 2003. This review asked the views of residents only. It is recommended that any review is widened and offered to resident’s families, friends and others involved in the support of the residents, such as community nurses and G.P.’s. The provider stated that the home maintains two visitors books, one for “official” visitors, which the inspector was asked to sign during the inspection and one for all other visitors. The visitors book for other visitors was not available during the inspection and the provider stated that it could not be found. A requirement was made at the inspection on 15th September 2005 that the registered person must maintain in the care home the records specified in Schedule 4, which specifies a record of all visitors to the care home, including the names of visitors. A timescale for this to be met by 14th October 2005 has not been met. Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 Page 22 A requirement has been made at the last two inspections, on 10th December 2004 and 15th September 2005, that the registered person must ensure that persons working at the care home are appropriately supervised. A timescale of 14th October 2005 was given for the last requirement to be met, but this remains unmet. The provider stated that supervision of staff is not taking place . Requirements and a recommendation have been made. Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 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 x 3 1 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 x x x x x x 2 2 x STAFFING Standard No Score 27 1 28 3 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 2 x x 1 1 1 Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 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 OP3 Regulation 14 (1) (a-c) Requirement Timescale for action 03/02/06 2 OP7 15(2)(ad)&13 (4)(c) 3 OP7 13 (4) (c) The registered person must not provide accommodation to a resident at the care home unless, so far as it is practicable to do so: (a) The needs of the resident have been assessed by a suitably qualified or suitably trained person (b) the registered person has obtained a copy of the assessment and (c) there has been appropriate consultation regarding the assessment with the resident or a representative of the resident. 03/02/06 The registered person must: (a) make the resident’s plan available to the resident (b) keep the resident’s plan under review (c) where appropriate and, unless it is impractical to carry out such consultation, after consultation with the resident or a representative of a resident, revise the resident’s plan and (d) notify the resident of any such revision. Unnecessary risks to the health 03/02/06 or safety of residents must be identified and so far as possible eliminated. DS0000013568.V277192.R01.S.doc Version 5.1 Bellsgrove Page 25 4 OP9 13 (2) 5 OP12 16 (2) (m & n) 6 OP16 22(1 & 2) & (5) The registered person must 05/01/06 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person must, 03/02/06 having regard to the size of the care home and the number and needs of residents, consult with residents about their social interests, and make arrangements to enable them to engage in local, social and community activities and to visit. Additionally residents must be consulted about the programme of activities arranged by or on behalf of the care home and provide facilities for recreation. 03/02/06 (1) The registered person must establish a procedure (the complaints procedure) for considering complaints made to the registered person by a service user or person acting on the service users behalf. (2) The complaints procedure must be appropriate to the needs of service users. (5) The registered person must supply a written copy of the complaints procedure to every service user and to any person acting on behalf of a service user if that person so requests. The registered person must ensure that all parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety. The registered person must ensure that at all times suitably qualified, competent and experienced persons are working DS0000013568.V277192.R01.S.doc 7 OP25 13 (4) (a) 05/01/06 8 OP27 18 (1) (a) 03/02/06 Bellsgrove Version 5.1 Page 26 9 OP29 19(1) (a&b) Sched 2 10 OP31 10 (1) at the care home in such numbers as are appropriate for the health and welfare of residents. UNMET FROM 31/03/05 and 14/10/05 The registered person must not 05/01/06 employ a person to work at the care home unless: (a) the person is fit to work at the care home and (b) he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2. UNMET FROM 31/12/04 and 15/09/05 The registered provider and the 03/02/06 registered manager must, having regard to the size of the care home, the statement of purpose, and the number and needs of the service users, carry on or manage the care home (as the case may be) with sufficient care, competence and skill. (1) The registered person must establish and maintain a system for reviewing at appropriate intervals and improving, the quality of care provided at the care home, including the quality of nursing where nursing is provided at the care home. (2) The registered person shall supply to the Commission a report in respect of any review conducted by him for the purposes of paragraph (1), and make a copy of the report available to service users. (3) The system referred to in paragraph (1) shall provide for consultation with service users and their representatives. 03/03/06 11 OP33 24 (1-3) Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 Page 27 12 OP36 18 (2) (a) 13 14 OP37 OP38 17 (2) Schedule 4 13 (4) (a) The registered person must ensure that persons working at the care home are appropriately supervised. UNMET FROM 28/02/05 and 14/10/05. The registered person must maintain in the care home the records specified in Schedule 4. The registered person must ensure that all parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety. 03/02/06 03/02/06 05/01/06 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 Refer to Standard OP14 OP16 Good Practice Recommendations It is recommended that contact details of local advocacy services are displayed in the home. It is good practice to explain the complaints procedure to those residents who are not able to access it in other ways and for the explanation to be recorded in the resident’s individual plan. When a review of the service provided is carried out, it is good practice to include external stakeholders. 3 OP33 Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Bellsgrove DS0000013568.V277192.R01.S.doc Version 5.1 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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