Inspection on 12/10/05 for Bellstone Residential Care Ltd

This inspection was carried out on 12th October 2005.

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

Bellstone Residential Care Ltd 05/03/09

Bellstone Residential Care Ltd 10/12/07

Bellstone Residential Care Ltd 13/12/06

Bellstone Residential Care Ltd 30/01/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Bellstone Residential Care Ltd 23-29 Beach Road West Felixstowe Suffolk IP11 2BL Lead Inspector Deborah Seddon Unannounced Inspection 12th October 2005 09:30 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 Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 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. Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bellstone Residential Care Ltd Address 23-29 Beach Road West Felixstowe Suffolk IP11 2BL 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) 01394 278480 01394 276597 Bellstone Residential Care Ltd Mrs Amanda Laine King Care Home 22 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (22) of places Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 The Home is registered for one named service user with dementia (DE E), as detailed in correspondence dated 27.12.04 7th March 2005 Date of last inspection Brief Description of the Service: Bellstone care home is situated close to the sea front in Felixstowe. The home is registered to provide care for a maximum of 22 older people. The home has a condition of registration to provide care for one named service user with Dementia. The home provides a television room at the front of the house with a sun lounge to the rear, through which the garden can be accessed. There are two dining rooms. The garden is small yet attractive with a lawn, seating and borders with plants and a water feature. There are sixteen single rooms and three shared rooms. Each room is furnished and centrally heated. There is a call bell system throughout the home. Access to the first floor is by two staircases, which have stair lifts, or by passenger lift. There is wheelchair access into and around the home. Service users are able to access hairdressing, chiropody, optician and dental services. The mobile library and church representatives regularly visit the home. Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 9.30am. It took place over seven hours during a weekday. Time was spent with the deputy manager and the company secretary and talking with three staff. A tour of the premises was made and a number of records were examined including those relating to the care of residents and a selection of policies and procedures. The inspector spent time talking with residents collectively and with nine residents individually, and with a relative of one resident who was visiting on the day of the inspection. What the service does well: What has improved since the last inspection? What they could do better: The home has undertaken pre admission assessments and has contracts in place between the home and the resident, however these are not signed and dated. Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 6 The home has a medication policy in place, however this does not include the keeping and administering of homely medicines or guidance to staff on the implications of administering these medicines alongside prescribed medication. Residents have access to their bedrooms on the first floor via the use of two stair lifts, however there are no risk assessments in place to ensure that residents safety has been assessed on their ability to use the stair lift unaided and free from the risk of falls and injury. The home must ensure the protection of residents at all times by making sure that all necessary checks are made before employing a new members of staff. A system for quality assurance and monitoring must to be implemented to obtain the views of residents and their relatives and other people connected with the home to ensure that they are continuously monitoring and improving the service. 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. Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 Residents can expect to have their health and personal needs fully assessed before moving into the home to ensure that there specific needs will be met, however they cannot expect that all documents will be signed and dated. EVIDENCE: The home has a detailed statement of purpose and service user guide, these documents are well presented and provide prospective residents with information about the home. Four residents files were inspected. Two residents that had recently moved to the home had completed needs assessments prior to their admission, however one was not signed and dated. Both had pre admission contracts, which had been signed by the residents however one had no date. The residents had recently moved to the home from hospital and they both had nursing and residential home transfer assessments, which outlined their previous medical background and current condition of health and needs. The needs assessments formed the basis of the residents care plan and covered all areas of their physical and emotional and social well-being and involvement in domestic tasks. Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9,10 Residents can expect to have their health and personal needs identified, and reviewed on a regular basis to ensure that their needs are met at all times. However, they cannot expect to be protected by the home’s policy for administering homely medicines. EVIDENCE: At the front of each plan was a care assessment sheet with the details of the resident’s next of kin and general practitioner (GP) and previous medical history and known medical conditions. The care plans were made up of different sections, which included issues around the resident’s social and health and personal care needs. Each of these headings was further explored in detail to form the care plan focusing on the resident’s assessed needs and evaluation of the support required. Staff kept detailed daily progress notes of the residents and evidence was seen that care plans and resident’s circumstances were being reviewed on a monthly basis. Monthly review sheets were discussed with the resident and signed and dated. The topics covered on the monthly review sheet were about their healthcare and any appointments and medication changes, their social activities and contacts and any changes to their diet or meal changes. Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 10 The inspector was shown a copy of the home’s medication policy, which included a covert policy. One resident had an agreed covert policy, which had been endorsed by their relative and general practitioner to agree that the resident’s medication could be mixed with food. This had been reviewed on the 15th September 2005. The inspector observed a member of staff administering medication in line with the home’s policy and all medication administration record (MAR) charts were completed with no gaps. A list of staff’s names and signatures designated with the responsibility to administer medication was held in the front of the MAR folder. There was also a list of medication review changes, which had been agreed by the residents GP. The home has homely remedies, which have a stock of paracetomol and gaviscon. These were being administered to service users. Two residents had been administered paracetomol for back pain and high temperature however there is no reference to this in the home’s policy on medication or a procedure for guidance to staff on the implications of administering medication alongside prescribed medicines. Evidence was seen on each of the care plans of detailed moving and handling assessments identifying the support required and equipment to be used. These included falls assessments and preventative action required. Evidence was seen that these risk assessments were being reviewed on a regular monthly basis. Residents are supported to have access to health services; one resident informed the inspector they were being escorted that afternoon to see a specialist about their constant headaches. Another resident told the inspector that they were able to go to the dentist locally but needed transport provided by the home to access the doctor. Two district nurses arrived during the inspection to visit two of the residents and were spoken with by the inspector. The senior district nurse referred to Bellstone “being a good home, one of the better ones” and stated that they were not called on very often and said, “They were always made welcome”. They informed the inspector that through their experience staff respected the privacy and dignity of residents. This was also confirmed when talking with residents and this was observed throughout the day. Staff informed the inspector that residents are supported to manage as much of their daily routines as they can to maintain their independence, however they did respect residents choices and gave an example where one resident whom normally is able to dress themselves requested and received help as they were not feeling well that morning, this information was observed being passed over to the afternoon shift at the change of meeting. Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Residents can expect to live in a home that supports a life style that matches their expectations. Residents can expect to receive a good standard of fresh and appealing food with a wide variety of choice as part of their daily diet. EVIDENCE: The residents and relatives notice board in the dining room displayed a range of services and activities on offer to the residents, which included a beauty therapist and reflexology, and naughty nails manicurist. The Spa pavilion was advertising a production of “The Crooners” on the 10th October and 13 residents had requested to go. A pantomime was scheduled also at the Spa on the 2nd January 2006 and a further 12 residents had requested tickets. There were also details for a local entertainer to visit the home on request. Other services that attended the home on a regular basis were a hairdresser and library, and taxies on request. The inspector joined residents sitting in the lounge and sun lounge at different times during the afternoon and was able to speak with residents about their experiences living in the home. Comments ranged from “this is a very good home, they look after us well” and “the food is good and plenty of it and it arrives on time” One resident commented that “everyone is very kind they couldn’t be better, we are not left wanting, I have a comfortable room and able to spend time on my own and the food and bed linen are good.” Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 12 Residents were observed having general conversations about things happening in the home and about their wartime experiences and the theatre. Another resident was reading a copy of a weekly magazine, which they have delivered to the home. One family relative was visiting on the day of the inspection, they were very happy with the way the home cared for their relative. They told the inspector “ they were always made to feel welcome and that the teapot was always on the go, when they arrived”. They described Bellstone as being “ just like home, warm and comfortable and the staff looked after their relative well”. They explained that their relative had celebrated their 103rd birthday at the home and the major had been organised to visit to share in their celebrations with food and drink for the occasion. The resident had had their photograph taken with the major. Other residents informed the inspector that their relatives visit regularly and one resident said “ that people that know me, pop in to see me” another resident spoke of “friends and neighbours visiting keeping them informed of the village gossip” and that they also attended a church group that visits the home twice a week. A member of staff informed the inspector that the relatives of one resident with dementia visits regularly to play cards and spend time reminiscing looking at photographs and through magazines and the resident’s life storybook to help keep them stimulated. Details seen in two residents care plans suggested that residents hold small amounts of money and that this is locked in a communal safe in the office and that the residents relatives were recorded as having power of attorney. There were no facilities in resident’s rooms that provided lockable storage for residents to have access to their own money. The home had leaflets on display for an advocacy service called Care Aware, “providing caring solutions for old age problems”, however the company secretary and deputy did not think that any of the residents and relatives were aware of this facility. Food seen was nicely presented and looked appealing and appetising. Residents had a choice of meal. The menu for the day of the inspection was a choice of roast chicken stuffing, roast potatoes and vegetables or a ham or egg salad. Discussion with residents and the record of meals showed that all the residents had chosen the roast chicken. The dessert was a choice of individual trifles or crème caramel. The teatime menu was seen and had a choice of tuna salad or soup or bread and butter and jam. The menu rotates on a four weekly basis; in addition to the two choices daily residents have a choice of boiled or jacket potatoes to accompany their meal. They are also served with a cold drink. Each resident has their own choices of breakfast; any changes to their preferred choice are written on the board in the kitchen for the cook and changed on their list. Specific diets were catered for; sugar free foods had been purchased for a resident who was diabetic. Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 13 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): 18 Residents can expect to be protected form abuse. EVIDENCE: The home has detailed policies and procedures in place for adult protection and whistle blowing. These were both reviewed by the home in July 2005. Each resident has a copy of the “No secrets” leaflet with the details of the Suffolk inter agency policy, customer first telephone number and a copy of the homes adult protection procedure in their room with the details of the Commission for Social Care Inspection (CSCI). Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 14 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): 19, 20, 21, 24, 25, 26 Residents can expect to live in a well-maintained and welcoming environment, which provides a good range of communal and personal accommodation, however the safety of the residents cannot be assured with regards to the risk of using the stair lifts unaided. EVIDENCE: Bellstone is situated close to the seafront and is in easy walking distance of the promenade and local shops and bus station and churches. The home has a homely feel and is nicely presented both inside and out; all areas of the home were nicely decorated and clean and tidy. The home is on two floors and has access by a passenger lift and two staircases each with a stair lift. The company secretary explained that there are ongoing problems with the passenger lift and that it was still out of action, which had been highlighted as an issue at the previous inspection in March 2005. The home has discussed the problems of the passenger lift with Stannah who provided and service the lift and have they two options to refurbish or replace it with a new and larger lift. The home is currently looking into the cost of replacing the lift. Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 15 Residents residing on the first floor have chair lifts on both staircases to access their rooms. These are serviced on a regular six monthly basis by Stannah and operate on a different circuit in the event of a power cut. However there are no risk assessments in place to assess the resident’s risk of using the equipment unaided and the risk of falling and injury. Communally there is a range of facilities available. A large television lounge is situated at the front of the house and a sun lounge leading out into the garden and patio area. There are two dining rooms adjacent to the sun lounge. All bedrooms seen were tastefully decorated and furnished with resident’s own belongings, with the exception of one resident who said that “they had not wanted any of their possessions and had sold them all when moving to the home”. One resident informed the inspector “they liked their room it was similar to their room at their own home”. Two residents rooms have cushion flooring rather than carpet. A requirement was made at the previous inspection in March 2005 for the registered person to demonstrate how the floor covering in both rooms meets the assessed needs of the residents who occupy the rooms. The inspector was informed on the day of the inspection that the resident that occupies one of the rooms chose to move into the room with the cushion flooring in place and the other resident spoken with informed the inspector that they were happy with this arrangement. To meet requirements set at the last inspection, the home has had all the radiators fitted with radiator guards and has changed their policy around the management of dealing with soiled laundry. A new washing machine with a sluice cycle has been installed and the home now operates using red dissolvable bags which soiled laundry can be placed directly into the washing machine on the sluice programme, however the policy on the wall in the laundry still makes reference to soiled linen being sluiced before being laundered. Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Residents can expect to be supported by a staff team, who have received training and have the skills and knowledge to care for them, however they cannot expect to be protected by a staff team who have the appropriate recruitment checks in place. EVIDENCE: Staff rotas were seen. The home operates with 1 senior member of staff and two care staff on an early shift from 7–2.30pm, and two 1 senior and 1 care staff on a late shift between 2.15-9.15pm, supported by an additional member of staff between the hours of 4-6pm to help over the tea time period. The home has 1 waking night staff between the hours of 9.30pm and 7am, supported by the manager or deputy or company secretary who are on call in case of emergencies. The member of staff recruited to take the post 4–6pm in the afternoons was in the process of making transition to a full time position as a care staff. On the day of the inspection they were working a full late shift and the inspector was informed that there would be no additional support between 4-6pm to prepare the evening tea, however the manager was trying to recruit to the post. The inspector was informed that staff are divided to work across the three sections of the home and that each member of staff carries a phone to maintain contact with the staff team if they required help with a resident and that staff worked with a “care and share” approach. Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 17 Two staff files were inspected. One file of a new employee starting work on 9th May 2005 did not have a criminal records bureau (CRB) check returned and had not had a protection of vulnerable adults (POVA) first check carried out until the 31st May 2005. Only 1 reference was held on file. The company secretary informed the inspector that they had had problems getting references for the employee, as they had only had one job since leaving school. The inspector advised them that a character reference should be sought in this case. The member of staff had been issued a contract of employment but this was not completed. The new member of staff was spoken with during the inspection and confirmed that that they had been supported through their induction period and had shadowed staff on shift. They told the inspector that they had recently started their induction training and were booked to undertake other basic core training in moving and handling, health and safety and medication. The second file seen had all employment checks in place and had a signed and dated contract of employment. This employee had a personal record card of training undertaken, which included their sector skills council for social care (TOPPS) induction and foundation, and core training, which included moving and handling, food hygiene, infection control and first aid. The home has provision for one resident diagnosed with dementia and to meet the requirement from the previous inspection in March 2005 the deputy manager informed the inspector that all staff are booked to attend an in house dementia awareness training day on the 24th October 2005. They also told the inspector that 1 staff member had been on a three-day dementia training course and three staff had attended a one-day course. The deputy had recently attended a one-day training course in psychiatric care at the Whitehouse in Ipswich. Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 18 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, 34, 35, 37, 38 Residents can expect to live in a home that is well managed, however they cannot expect their health and safety and welfare is protected until action has been taken to regulate water temperatures. EVIDENCE: The owners of Bellstone used to live in the flat above the premises and have moved out since the last inspection, but are still involved in the running of the home financially and have some involvement with the residents. They visited the home on the day of the inspection to assist a resident to attend an appointment with their general practitioner (GP). The registered manager was not present on the day of the inspection; they are a registered nurse and maintain their registration through working at the local hospital one day a week. Residents and staff spoke of the manager and deputy manager as being very supportive and approachable. Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 19 A requirement from the last inspection in March 2005 was for the registered person to introduce an effective quality assurance and monitoring system. Discussion with the company secretary confirmed this had not yet been implemented however said that some work had been undertaken to devise a questionnaire. The home has employers liability insurance through Ecclestone Insurance company and is protected against loss of registration, personal accidents, terrorism, employment practice and directors and officer’s liability and computer breakdown. The certificate was seen which had recently been renewed and will be due to expire in September 2006. Two files seen indicated that residents are able to keep control of their own money. Residents are able to keep small amounts of money however there was no provision of secure facilities in their rooms for residents to keep their money or small items of value and had to have these locked in a communal safe in the office. Evidence was seen that the home does not have control over resident’s finances and that relatives act as the residents power of attorney if necessary. The fire logbook was seen and all tests for the fire fighting equipment and alarm systems were up to date. All staff including the night staff had received fire instruction and drill practice in July 2005 and records showed that these were repeated six monthly. The logbook was old and falling a part and made it difficult to track the recent entries and needs to be renewed to ensure that record are kept in good order. The hot water in the bathroom on the first floor was found to be 48 degrees centigrade, which presented a risk to residents and staff being scolded. Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 20 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 2 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 3 3 2 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 3 X 3 2 Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 21 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 OP2 Regulation 5 (c) Requirement Each service user must have a statement of terms and conditions (or contract if paying privately), which is signed and agreed and dated by the service user, and the manager of the home. Each service user must have an assessment of need undertaken prior to admission that is signed, agreed and dated. The home must have safe systems for administering, disposal, handling and storage of homely remedies and records kept of when homely remedies have been administered to a service user. The registered manager must also ensure that the home has a written policy or procedure for guidance to staff on the implications of administering homely remedies medication alongside prescribed medicines. Risk assessments must be undertaken to ensure that suitable arrangements are made for a safe system of moving DS0000064695.V258106.R01.S.doc Timescale for action 23/12/05 2 OP3 14,c,Sch 3,1,a 13,2,Sch, 3,i 23/12/05 3 OP9 23/12/05 4 OP22 13,4,c,13, 5 23/12/05 Bellstone Residential Care Ltd Version 5.0 Page 22 5 OP29 6 OP33 7 OP38 service users between floors and that any unnecessary risks using the stair lifts are identified and minimised. Sch 2,5,7 The registered manager must 12/10/05 make sure that employees are confirmed in post only after following completion of 2 satisfactory references and a satisfactory criminal records bureau check and a check of the vulnerable adults register. 24,1,3 The registered person must 23/12/05 introduce effective quality assurance and quality monitoring systems, based on seeking the views of service users. A copy of the home’s quality assurance must be forwarded to the CSCI. This is a repeat requirement. 12,1,a,13, The hot water in the bathroom 12/10/05 4,a on the first floor was found to be 48 degrees centigrade and presented a risk of scolding to service users. The registered person must take action to minimise this to ensure the health and safety of service users. 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 Refer to Standard OP26 Good Practice Recommendations The procedure for dealing with soiled laundry on the wall in the laundry room still makes reference to soiled linen being sluiced before being laundered and should be changed to reflect new procedures in place. The fire log book seen was old and falling apart and would benefit being replaced with a new copy to ensure that records are kept in good order. DS0000064695.V258106.R01.S.doc Version 5.0 Page 23 2 OP37 Bellstone Residential Care Ltd Bellstone Residential Care Ltd DS0000064695.V258106.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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. 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