Inspection on 11/01/07 for Belma

This inspection was carried out on 11th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Belma 24/06/09

Belma 07/11/05

Belma 10/05/05

Belma 26/11/04

Belma 21/04/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Hunters Care Centre

Manor Lodge

The Garden House

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

CARE HOMES FOR OLDER PEOPLE Belma 120 Torquay Road Newton Abbot Devon TQ12 4AH Lead Inspector Megan Walker Unannounced Inspection 11th January 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Belma DS0000003649.V314794.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. Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belma Address 120 Torquay Road Newton Abbot Devon TQ12 4AH 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) 01626 356465 01626 333625 Mr Gerald Reginald Symonds Mrs Jennifer Mary Symonds Mrs Jennifer Mary Symonds Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 Brief Description of the Service: Belma is registered to provide accommodation and care for up to twelve people who need residential care for reasons of old age, not falling within any other category. It does not provide intermediate care and it is not registered to provide nursing care. The home is situated on a main road about half a mile from the centre of Newton Abbot and is close to a GP surgery, within easy access to public transport routes, and other amenities. It was originally two houses and has been extensively renovated and refurbished over the years by the current Registered Providers, Mr Gerald and Mrs Jennifer Symonds. They both work full-time at the home, including sharing an “Emergency On Call” night duty as they live on the premises. There is a television lounge, a “quiet” lounge that can be used by visitors and also houses a small library, a dining room, and mostly single bedrooms, some of which have an en-suite. All the bedrooms are connected to a call bell system and have television points. Disability equipment available includes stair lifts, bath hoists and a portable hoist. There are gardens at the front and rear, and a car parking area at the front. The rear garden includes a sheltered patio area with garden furniture for residents’ use in good weather. The home has a pet duck that lives in the garden and a caged budgie kept in the quiet lounge. The current fees at Belma range from £290.00 to £330.00 and are expected to rise in April 2007. The fees do not include hairdressing, chiropody, newspapers and magazines, toiletries or other sundries. Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The fieldwork part of this inspection was unannounced and took place on Thursday 11th January 2007 between 11h30 and 18h15. It included a tour of the premises, observation of interactions between staff and residents in the home, talking to residents and staff, and inspection of care plans, staff files, medication and other records and documentation. The Registered Providers, Mr Gerald and Mrs Jennifer Symonds were present at the time of this visit. Part of the time was spent talking with each of them about the day-to-day routines, as well as the management of the home. In addition other information used to inform this inspection: • The Pre-inspection Questionnaire completed by the Registered Provider. • The previous two inspection reports • All other information relating to Belma received by the Commission since the last inspection. Of thirty-two Comments’ Cards and Surveys sent out, the Commission received back – • Four Residents “Have Your Say About Belma” Care Homes Surveys • Five “Relatives/Visitors” Comment Cards • Seven Care Workers Surveys No General Practitioner (G.P.) or any other Health/Social Care Professional in contact with the home returned a Comment Card. There are no requirements and two “Good Practice” recommendations made as a consequence of this inspection. What the service does well: What has improved since the last inspection? What they could do better: Although door locks have been fitted to each bedroom door these are unsuitable for reasons of safety and/or in an emergency. They must be Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 6 removed and should be replaced either if the occupant expresses an immediate wish for a lock on their room, or when a room becomes vacant. The Registered Providers should progress with the quality assurance surveys to gather the views of residents’ relatives, staff and other visitors to the home to determine whether the home is meeting the needs of residents and that the services that the home is providing are of a satisfactory standard. 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. Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families can feel confident that their needs will be assessed before moving into the home and that they can have the information they need to make an informed choice about where to live. EVIDENCE: A copy of the home’s Aims and Objectives is available to prospective residents as well as everyone living in the home. The Registered Provider explained that the home was not publicised other than in the “Yellow Pages” directory because referrals tended to be recommendation by word of mouth. During this visit a copy of the revised contract and terms and conditions was seen. The Registered Provider stated that each resident or their representative would be given a new contract in the near future that they would be asked to Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 9 agree and sign. Some minor amendments were suggested including that the new contract must state the bedroom that was to be occupied. The home’s fees are expected to increase in April 2007. The Registered Provider stated that a letter of the proposed increase would be sent to each resident or his or her representative as soon as the amount was confirmed. Inspection of individual care files found that each had a thorough assessment of care needs and a care plan. The Registered Provider confirmed that prospective residents and their families could visit the home prior to choosing to move in here. Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents can feel confident that a staff team that is respectful and reliable will ensure that all their health, personal and social care needs are met. EVIDENCE: Inspection of a random selection of care plans found that each one had a very detailed assessment of care needs. There was also a care plan describing in detail specific help and assistance to be given to each individual. Other records on the file included Resident Risk Assessment, Falls Risk Assessment, medical history and prescribed medication, and a record of all medical appointments. The Registered Provider confirmed that staff would accompany a resident to any medical appointment should they wish. Daily records were seen that were informative for staff to monitor individual residents as well as use the information to inform a review of the care plan. Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 11 One resident said that her health had improved greatly since she had moved into the care home and she felt like “a new woman”. In a general conversation with another resident she spoke about her room, the pleasure she has in having a room in which she can have all her “bits and pieces” around her, about becoming frailer with age, and having to thinking about moving around safely. The Registered Provider was reassuring in such a way that did not fail to appreciate the underlying anxiety being glibly expressed by the resident. At the time of this visit the “Nomad” system was in use for medication, supplied weekly by “Boots”. The medication was seen kept in a fixed lockable metal cupboard with a separate fixed metal cupboard inside it for controlled medication. At the time of this visit this was not in use. A separate fixed cupboard was seen being used for items of first aid. All the staff at Belma have been trained in administration and handling of medications. At the time of this visit two residents had chosen to be responsible for taking their medication themselves although they preferred it to be kept in the medication cupboard. A “Self Administered Medicine Check-In” book was seen with the medication records. The Registered Provider explained that staff used this to monitor that medication was being taken regularly. Although it was dependent on the resident to request their medication, they were asked to sign the book to confirm that they had had it, and the staff member also signed to confirm that the resident had requested and been given the medication. The Registered Provider agreed that she would consider attaching a photograph to each medication record for the safety and protection of each resident. She confirmed that the local chemist that supplied the medication always informed her if anything, a tablet colour or shape for example, had changed, and this was noted on the resident’s care file for staff attention. Belma is promoted as “a home for life”, and the staff and Registered Providers confirmed that as long as it was possible they would provide care for residents. Prior to this visit a resident had been terminally ill, and with the agreement and assistance of the local district nurses and G.P., this person had been cared for in the home. Staff rotas had been changed to ensure staffing levels continued to be good and the other residents’ care was unaffected. Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents are satisfied with their lifestyle at Belma and are encouraged to exercise choice and control over their lives. EVIDENCE: Residents spoken to during this visit expressed their contentment with their lifestyle in the home. A few residents chatted about the bad weather and how it prohibited them from going out for a short walk, something they liked to do when possible. Some said that they preferred to sit in their own rooms to watch television whilst others enjoyed the companionship of the lounge. One resident explained that he liked preparing the vegetables. Apparently everything is brought to him so he can sit in the comfort of his chair in the lounge whilst doing this. He informed the inspector that he does have occasions to remind the staff that some days he needs more time especially if there are a lot of carrots and potatoes! Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 13 During the afternoon of this visit an external contractor provided a programme of activities that the Registered Provider explained was arranged according to the residents’ preferences. Card games and quizzes seemed to be popular rather than arts and crafts. A local mobile book club comes to the home regularly to offer a library service. A large selection of large print books were seen housed in the “Quiet” lounge and residents are at liberty to take them and read as they wish. At present no one would prefer audio books although these would be available if requested. Families and friends are encouraged by the Registered Providers to visit on an “ad hoc” basis in order to maintain an element of surprise and pleasure rather than expectation and chore. Residents who were asked said that they saw their families regularly and they could either sit in their bedrooms or the “Quiet” lounge was available for them to use. Before lunch each resident was seen being offered a glass of sherry as an aperitif and lunchtime became a social occasion as residents began to arrive in the dining room to take their places. The staff team confirmed that this was the norm. A resident who was poorly had lunch taken to them in bed. Later during a tour of the premises, in the kitchen, trays were seen laid out with an individual’s mug or cup and saucer, and individual teapots, milk jugs and sugar bowls. The Registered Provider explained that for breakfast the residents preferred to have a tray taken to them in their bedroom and, the current residents, at teatime again preferred a tray either in their room or in the main lounge. It was also observed that residents were provided with a carafe filled with juice of their choice sand a glass so they could help themselves to a cold drink throughout the day. The menu of the day was seen written on a board in the hall. Although there is one main meal offered at lunchtime, residents can opt for something else if they wish. On Fridays when fish is traditionally served the menus showed that residents have a choice of how the fish is cooked as well a type of fish. Staff monitor closely anyone who is poorly or not eating properly. One staff member responded in the Care Workers Survey: “Residents have a good and varied menu. If they do not like the meal for the day they are always asked what else they would like. If they are nor eating well this is also done, and they can basically have what they want to encourage them to eat.” Residents who returned surveys varied in their response to the question “Do you like the meals at the home?” One ticked “Always” and added: “Home made – excellent” Others ticked “Usually” or “Sometimes” without adding any further comments. Observation throughout this visit showed that residents were treated in a manner that was respectful. They were not patronised and their daily life was one that encouraged individuals to feel comfortable with making choices and decisions for themselves. Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 14 Belma DS0000003649.V314794.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 families and friends can feel confident that any issues of concern or complaints raised by them will be dealt with appropriately. EVIDENCE: Since the last inspection neither the Commission nor the Registered Providers has received any complaints about care provided at Belma or other matters relating to the home. The Service User’s Guide has recently been revised along with the contract and Statement of Terms and Conditions for residents at the home. This includes details of how to make a complaint, and also contact details for the Commission should the complainant feel any matter is unresolved or inadequately dealt with by the Registered Providers. The Registered Providers promote the well being of each of their residents and the staff team is expected to treat residents accordingly. The staff team has been consistent for an extended period of time and any indication of potential abuse of any nature towards any resident would be picked either by the Registered Providers or amongst the staff team. Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25, 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Belma has a homely, safe and well-maintained environment that is clean, pleasant and hygienic. EVIDENCE: A tour of the premises found that the home was well maintained and suitable for the needs of the residents living here. Each bedroom was personalised to suit the needs of the occupant. One resident said that she had a lot of her own things around her yet she felt that her bedroom was a good size to accommodate it all. Other residents who were in their rooms during this tour expressed a number of other reasons why they liked their rooms including views across the back garden or the road, the sunshine, and having an ensuite. Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 17 All the radiators have been attractively covered since the last inspection. Although bedroom doors have locks fitted these are unsuitable for reasons of safety and in an emergency. The Registered Providers were advised to dismantle the existing locks (none of the residents currently use them), and to fit more appropriate type locks when rooms become vacant. This would then ensure that any new resident would have a choice about whether to lock her/his bedroom door. The Registered Providers were also advised to ensure that they had written consent from each current resident explicitly stating that s/he did not wish to have a lock fitted on the bedroom door at this time however one would be fitted should it be requested in the future. Standards of cleanliness and hygiene were found to be of a high standard throughout the home. Each resident’s room has a soap dispenser fixed to the wall and a paper towel dispenser also fitted. The Registered Provider explained that these are primarily for use by care staff to reduce risk of any cross-infection. One anomaly was found in the communal bathroom where a hand towel was provided for hand drying. The kitchen is domestic in size. It is functional with easy access to things stored on open shelves although access to the home’s ‘fridge’ was restricted. There is additional storage for refrigerated and frozen foods in the garage that also houses the washing machines and tumble drier. Both of these are domestic machines. There is no sluice facility however care staff have been trained on how to deal appropriately within the home with soiled items. In the back garden there was evidence of garden furniture that the Registered Provider confirmed was well used in warmer periods. The garden itself looked pleasant and appealing even for a blustery winter’s day. It was evident that certain areas would be sheltered and attractive for residents to sit out and enjoy good weather as well as watching the birds coming to feed from the bird table. There was also access to stroll around the garden for those who were more mobile and chose to do so. Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The staff group is motivated and caring. The training programme enhances this and promotes the quality of care being given to residents. EVIDENCE: At the time of this visit the home had a staff group that worked well together. A minimal turnover helped to maintain good morale and promote residents’ confidence. In response to the Care Workers Survey staff comments included: • • • • “The care home is well staffed and this gives us quality time with our clients.” “You are made to feel part of a team.” “All staff are given good training and the opportunity to achieve training at NVQ Level 2”. “Belma is a very friendly and caring atmosphere to work in. I feel all the staff work well and are very caring and patient towards the clients providing a home from home environment.” DS0000003649.V314794.R01.S.doc Version 5.2 Page 19 Belma The staff rota showed a good ratio of staff to residents. Two care staff share the cooking between them during the week and the Registered Provider is responsible on Sundays. There are always at least three care staff on duty with the Registered Provider giving additional support and assistance. There is a Care Manager who takes responsibility for a proportion of the administration relating to staff and residents such as the training programme and residents care plans and daily records. A random selection of staff files was inspected. All the relevant and necessary checks had been completed. The Registered Provider was advised during this visit that for further protection of the residents the application form should request more information about previous employment. This would enable her to follow up on any apparent gaps should there be an incomplete chronological history of employment. The number of staff with a National Vocational Qualification (NVQ) in Health and Social Care was below the required 50 at the time of this inspection. However inspection of the home’s training programme and information provided by the Registered Provider in the Pre-inspection Questionnaire showed that at least three staff members have recently started a NVQ Level 2 course or will start in the near future. It was also evident from the training programme that training is taken seriously and is on-going from an induction programme for new staff to annual updates on mandatory subjects. Regarding a query about an aspect of hygiene and infection control during this visit, the staff members who were asked were confident in affirming the home’s policy and how they put that into practice. The Registered Provider confirmed that she and other care staff who handled food had attended a Basic Food Hygiene course. She also said that she had been notified and requested a place at a seminar about “Safer Food, Better Business”, a manual and training programme produced by the Food Standards Agency about the change to food handling regulations in January 2006. As has been found at other care homes in this area of Devon the Registered Provider had not received any further details about this training so it was agreed during this visit that the Registered Provider would try again. The residents who expressed an opinion felt that they were well cared for and that the staff team was approachable and friendly. Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Health, safety and welfare is promoted and protected by competent and capable Registered Providers who achieve positive outcomes for residents, their families, and staff. EVIDENCE: The Registered Providers are experienced in management of a care home and have done so for many years. They are “hands on” in their style of management and administration of Belma. Residents’ and staff surveys, conversations with staff and residents, and observation during the visit showed that they are respected and approachable. They have worked hard to improve the environment of the home as well ensure that the home meets the National Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 21 Minimum Standards. They were receptive to the few issues identified during this visit and these were noted for attention in the near future. The home was seen being run in an open and transparent way with responsibilities delegated appropriately amongst staff. Staff training is taken seriously and a rolling programme ensures mandatory training is kept up to date for all staff as well as offering individual staff members opportunities to go on courses that may be more relevant to their post. Periodically residents are given questionnaires about the care that they receive and about the home in general. An example of the last one, about six months ago, was seen during this visit. The Registered Providers were encouraged to give future questionnaires to residents and their families/representatives, staff, and any other regular visitors to the home such as health and social care professionals to meet new legislation about quality assurance. (This was explained to them at the time of this visit.) It became apparent during this visit that due to small size of this care home that it is more intimate and for example, residents likes and dislikes would be expressed in a variety of ways. This could be directly to a staff member or the Registered Providers, or around the dining table in general conversation after lunch. Likewise staff tended to pass information more informally such as sitting over a cup of coffee or whilst working together. There was, therefore, little evidence of formally written records, for example, residents’ meetings, or staff supervision. Nonetheless observing the staff and residents interactions it was evident that the staff know the residents well, and excellent, clearly written care files underpin the care that staff provide to each individual resident on a daily basis. The residents living at Belma are encouraged to either handle their own financial affairs or to make alternative arrangements. The Registered Providers confirmed that all the maintenance and fire safety checks as stated in the Pre-Inspection Questionnaire were complete and up to date. Mr Symonds carries out general maintenance of the premises and outside contractors are called in as necessary to, for example, service and/or repair lifting equipment, the stair lifts, boilers and central heating. The Accident Book was seen and accidents had been recorded correctly. The Commission had been notified of any incidents affecting the health, safety or well being of any of the residents. Care plans inspected had risk assessments included in them that were relevant to the individual resident. The Registered Providers agreed to contact the local council about “Safer Food, Better Business” in order to implement a new kitchen routine that would comply with the Food Standards Agency regulations and recommendations. Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 22 Belma DS0000003649.V314794.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 4 3 4 X 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 3 4 X X 3 2 3 4 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X N/A X X 4 Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP24 OP33 Good Practice Recommendations The Registered Provider should continue with the proposed plan to install locks on doors of bedrooms that are vacant, and on any doors of rooms where residents request a lock. Any quality assurance undertaken in the future should be extended to include the views of staff, relatives and residents’ advocates, health and social care professionals in contact with the home and other regular visitors to the care home. Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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 Belma DS0000003649.V314794.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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