CARE HOMES FOR OLDER PEOPLE
Belma 120 Torquay Road Newton Abbot Devon TQ12 4AH Lead Inspector
Mark Sharman Unannounced Inspection 7th November 2005 01:10 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.V264330.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. Belma DS0000003649.V264330.R01.S.doc Version 5.0 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 Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Belma DS0000003649.V264330.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 10 and 11/05/05 Brief Description of the Service: Belma is a large house situated on a main road about half a mile from the centre of Newton Abbot, and on a bus route. The home has been operated by the resident owners for seventeen years and can accommodate up to twelve people aged 65 and over. The home is not registered to care for people suffering from mental health problems. There are two lounges and a dining room, and most of the bedrooms are single rooms. Disability equipment available includes stair lifts, bath hoists and a portable hoist. There is a call system and at night the owners provide sleeping-in cover, but there are no staff awake at night. 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. Belma DS0000003649.V264330.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection lasting about three and a half hours. All eleven of the residents and three of the staff were consulted, as well as Mrs Symonds. A small sample of the home’s records was inspected, and the communal rooms and most of the bedrooms were seen. What the service does well: What has improved since the last inspection?
The main lounge is being completely redecorated at present, which will result in a very comfortable room for residents to use. Some of them spend most of the day in this room. The refurbishment includes the fitting of covers to the radiators in the lounge, and a few other radiators in the home have also been covered. Belma DS0000003649.V264330.R01.S.doc Version 5.0 Page 6 What they could do better: 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. Belma DS0000003649.V264330.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 Belma DS0000003649.V264330.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): None of these Standards was considered on this occasion. Standard 6 is inapplicable to this home. EVIDENCE: Belma DS0000003649.V264330.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): 9 and 10. Residents’ medication is well managed and their health care needs are being fully met. It was clear that they are treated with respect by the staff and are afforded privacy as appropriate. EVIDENCE: Three residents said that they are looking after their medication themselves. The medication cupboard is a robust metal type and is kept locked. A sample of the medication administration recording sheets and the controlled drugs register were inspected. Medication training within the home has been updated and staff on duty confirmed that they are now receiving this training. Residents spoken to said that they are cared for very well and that professional medical help is obtained for them whenever necessary. All of the residents consulted were very complimentary about the attitude of the staff, and confirmed that they respect their dignity and privacy. Several residents have their own telephone and a cordless telephone is available to others, enabling them to make calls in private if they wish. There is one double bedroom, and a screen is used in the interests of the residents’ privacy.
Belma DS0000003649.V264330.R01.S.doc Version 5.0 Page 10 Belma DS0000003649.V264330.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 and 15. The activities and lifestyle offered suits the residents’ preferences and particular interests. The meals and catering arrangements are of a high standard. EVIDENCE: The residents said that as a rule they like to pursue their own interests and that the activities which are organised by the home for them are sufficient. These include a weekly activities afternoon with a quiz, reminiscence and indoor games, and there are regular light exercise sessions. Three of the residents said that they go out frequently on their own, and indeed they had all been out on the morning of this inspection. There is a notice in the hall welcoming visitors at any time, and several residents confirmed that they have regular visitors. One resident’s daughter visited during the afternoon and said that she sees her mother in the home on most days. All of the residents agreed that they were very happy with the meals provided, and one commented that at the end of meals their plates were always empty. The lunch on the day of the inspection was bubble and squeak with sausages, onions and beans, followed by raspberry crumble and custard. Belma DS0000003649.V264330.R01.S.doc Version 5.0 Page 12 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 There is a satisfactory complaints system, and residents were confident that any complaint would be addressed if at all possible. EVIDENCE: The home has a satisfactory complaints procedure, which was displayed on a notice board. All of the residents consulted were confident that if they expressed a complaint it would be dealt with satisfactorily, although none had any complaint to make. No complaint has been received by the Commission for Social Care Inspection since the last inspection. Belma DS0000003649.V264330.R01.S.doc Version 5.0 Page 13 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, 25 and 26. The home provides comfortable accommodation which is non-institutional in appearance. The programme of guarding radiators needs to be completed as soon as possible. EVIDENCE: The home was warm, clean and tidy, and is kept in good decorative order. The main lounge was being completely redecorated at the time of the inspection. The residents consulted said that the entire home, including their bedrooms, is always kept very clean and tidy. They were happy with their bedrooms, all of which are single rooms except for one. With regard to health and safety there is an ongoing programme for guarding the radiators and a few more have been covered since the last inspection, including those in the main lounge. The owners have carried out a written risk assessment, but most of the bedroom radiators are still to be guarded. Belma DS0000003649.V264330.R01.S.doc Version 5.0 Page 14 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 and 28. The staffing arrangements are satisfactory and meet the residents’ needs. The staff are well trained. EVIDENCE: This was an unannounced inspection and there was an adequate number of staff on duty. The residents said that staffing levels are sufficient for their needs, and they felt that they benefited from the fact that the owners live on the premises. They were very complimentary about the calibre of the staff employed in the home, and commented on the fact that there is little staff turnover. One of the staff on duty said that they receive good training, and nearly half of the staff have achieved (or are working towards) an NVQ qualification. Belma DS0000003649.V264330.R01.S.doc Version 5.0 Page 15 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 and 33. The home is run in the best interests of the residents, and the owner/manager manages the home in a competent and professional way. EVIDENCE: Mr and Mrs Symonds have run homes for the elderly since 1977, and have run Belma for over 17 years. Mrs Symonds is a registered general nurse and maintains her qualification, and is highly thought of by the residents and the staff. However the Standard is not fully met because she does not have the required formal management qualification. The home has achieved the Investors in People award. Mr and Mrs Symonds live on the premises and work alongside the staff, see residents on most days, and frequently see their relatives and other visitors. They receive direct feedback and get to know what residents, staff and relatives think of the services provided by the home.
Belma DS0000003649.V264330.R01.S.doc Version 5.0 Page 16 Belma DS0000003649.V264330.R01.S.doc Version 5.0 Page 17 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 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 3 x x x x x 1 3 STAFFING Standard No Score 27 3 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x x x x x Belma DS0000003649.V264330.R01.S.doc Version 5.0 Page 18 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 OP25 Regulation 13 Requirement All pipework and radiators accessible to service users must be guarded or have low temperature surfaces. (Some radiators have been covered). A standard Criminal Records Bureau disclosure must be obtained in respect of the junior helper employed. (Previous timescale of 30/6/05 not met). Timescale for action 30/11/05 2 OP29 19 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Belma DS0000003649.V264330.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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