Inspection on 05/09/05 for Belmont

This inspection was carried out on 5th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Belmont 08/11/07

Belmont 05/06/06

Belmont 02/12/05

Belmont 22/02/05

Belmont 19/04/04

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Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Belmont Stone Street Stanford North Ashford, Kent TN25 6DF Lead Inspector Julian Graham Announced 5 and 6 September 2005 9:30 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Belmont Address Stone Street, Stanford North, Ashford, Kent, TN25 6DF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01303 813084 01303 813084 Counticare Limited Care home only 6 Category(ies) of Learning Disability x 6 registration, with number of places Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22/02/05 Brief Description of the Service: Belmont is situated in the village of Stanford North, between Folkestone and Ashford. It is a large country house providing accommodation and personal care for six residents with a learning disability. The home is owned by Counticare, a registered provider of approximately 15 homes in the East Kent area. Communal areas comprise a lounge, music/quiet room, dining kitchen area, conservatory and laundry room. Within the grounds of Belmont is a large outbuilding which provides a recreational area for music, relaxation and arts and crafts, and the managers office. The home has extensive gardens with a large swing and greenhouse. The home has use of a minibus and a car to access the wider community, as the village has no amenities other than a local pub. There is no regular public transport links to the home. Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place over a day and a half. Five of the residents were at home at varying times of the inspection and were spoken with, three individually in the privacy of their rooms. The sixth resident was in hospital. Time was spent with the manager and an area manager, and the senior team leader and the housekeeper/carer were interviewed in private. Two other staff were spoken with. A tour of the premises was undertaken which included being shown bedrooms by three of the residents. Some records were examined, including residents’ Life Plans, staff files and complaints records. The home is emerging well from a lengthy period of difficulty, including several changes of manager and two residents needing major operations. The manager has been in post now for five months and the commission have received a registration application from her. There is now a settled staff team in place and improvements are taking place. The residents, manager and staff are thanked for their welcome and assistance during the inspection. What the service does well: Most of the residents experience communication difficulties, but were either able to say or indicate that they like the staff and like living at Belmont. Staff were seen to interact with residents with warmth and good humour, and a relaxed and cheerful atmosphere was noted. Staff are good at involving residents in the life of the home, and during the inspection, residents were seen helping out in the kitchen and undertaking other household chores like doing the laundry with support. Over the past twelve months, two of the residents have needed major surgery and the home has and is providing much care and support to enable the residents to make the best possible recovery. Residents’ care and support plans (Life Plans) are very good and provide useful and detailed information to assist staff in meeting residents’ needs. Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,4,5 Despite there being no evidence that the needs of the last person admitted to the home were assessed, admission procedures are well understood, including the need to carry out a comprehensive pre-admission Needs Assessment. EVIDENCE: The last person was admitted to the home from another Counticare home in November 2004, before the manager was appointed. There was no evidence of a care management or Counticare pre admission assessment; and it was not possible to establish how the admission took place. However, the manager gave a good understanding of the admission procedure, including completing Counticare’s comprehensive Needs Assessment form, and offering the prospective resident opportunities to visit the home and stay overnight. This would enable residents admitted to the home in the future to know their needs would be met. The manager said that the views of residents already living in the home would be taken into account, and that compatibility issues would be looked at. The Statement of Purpose and Service User Guide were reviewed in March 2005, and the manager said that these documents would be given to prospective residents and their representatives to enable them to have information on what the home can offer. As required from the last inspection, the service user contract is in written and pictorial form, and there is greater clarity as to what additional fees may be incurred by the service user. Residents and their representatives are given the Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 9 opportunity to read and sign the contract at the time of the annual review, and evidence of this was seen. Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9 Life plans (care plans) are very clear, informative and accessible, and provide staff with the information they need to meet residents’ needs. Residents make decisions about their lives with support from staff when needed, and participate in the life of the home. EVIDENCE: A sample of Life Plans was viewed, and also “Client Packs” which contain information on residents’ daily routines, communication needs and practical issues such as travelling arrangements and so on which staff are more likely to need to refer to on a daily basis. Both these documents are clearly and respectfully written, are easy to follow and are accessible. They cover a wide range of need, from health care to social skills to personal relationships. Life Plans include a number of identified risks and how these are to be managed, including and why taking the risk should be supported as part of an independent lifestyle. Guidelines for staff to follow when residents are likely to display difficult behaviours are in place and are being reviewed. Key workers assist residents in choosing one or two personal goals, and a system is in place to ensure that these are properly monitored to see whether they are going according to plan or may need changing. Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 11 The communication status of residents is detailed in the client packs. It was noted in one that the person has “a few makaton signs”. It is recommended that there is information on which particular signs are known, so that staff can be sure to use them when communicating with the resident as effectively as possible. Life Plans and Client Packs must be signed and dated. Residents were seen being shown respect by staff during the visit, and staff were observed offering residents individual choices. One resident, for example, decided to stay in bed a little later and not go to the Martello centre. At the residents’ meeting held on the second morning of the inspection, residents were asked their views regarding the possibility of keeping two rabbits as pets. Residents were also observed helping to lay the table for lunch and do the washing up afterwards. One resident said she helps keep her room tidy and this person was later seen attending to her washing. Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,1617 Residents are supported in taking part in social, leisure and work activities. Routines are flexible. Residents have a healthy and varied diet and enjoy their meals. EVIDENCE: Staff were seen interacting with residents very positively and in a way that encourages their independence. Staff who were interviewed demonstrated sound understanding regarding the rights of residents to make choices in their lives and of their role to promote independence. One said she encourages residents to “do as much as possible for themselves”. Most of the residents have some difficulty in communicating and assistance is being sought from the speech and language therapist. Previous speech therapy assessments are incorporated within current Life Plans. Staff were observed communicating well with residents, with one resident making his needs known by pointing to pictures, symbols and so on. Residents attend the Martello Day Centre, which is owned and managed by Counticare, at different times and days in line with individual needs and Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 13 interests. One resident attends a local SEC on one day a week. Staff try and offer residents a wide range of activities both in the house and outside in the wider community. Activities at weekends and evenings include trips to the local pub, going to boot fairs, swimming and country walks. Staffing numbers at weekends, however, mean that activities cannot always be tailored to individual need and preference. Depending on the composition and number of residents at home, residents are sometimes having to all go out in a large group, as opposed to individually or in small groups, which may not suit every resident. See the section on staffing below. Belmont is located in an isolated position, so residents are dependent upon the home’s transport to enable them to make use of facilities and amenities in the area. Residents are taken in small groups to get the shopping for the home, and key workers assist residents to choose and purchase personal items. Understanding was demonstrated by staff regarding their role in supporting residents make informed choices in respect of their clothing that promotes a positive self image. Efforts are made by the home to involve the local community through open days and similar events to raise funds for outings and so on. Residents are helped to compile the menus, which looked varied , interesting and nutritional. Three residents said or indicated that they like the food. Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 Staff have good understanding of residents’ support needs and residents’ healthcare is promoted. Medication is being managed safely. EVIDENCE: Staff were seen demonstrating respect for residents during the inspection and provided support in a way that promoted their privacy, dignity and independence. Life Plans outlined the support and health needs of residents clearly and in detail. Current fashion accessories were noted with regards to one of the residents indicating staff are supporting the individuality of residents. The manager ensures that appropriate professional support is sought when necessary. Records showed that residents are receiving healthcare input as required. One resident is currently in hospital and is being supported there by staff for most of the week. Moving and handling training has been updated for staff in preparation for this person’s return home shortly. Work is currently underway in updating the medication policies and procedures. These should include ordering, receipt and disposal of medication, homely medication, refusal, covert use and errors. The majority of staff administering medication have recently completed a distance learning course leading to a Certificate of Safe Handling of Medication, and the staff member with delegated responsibility for medication in the home, said how much the course has expanded her understanding and knowledge of medicines handling, leading to the amendment of the existing policies and procedures. MAR charts Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 15 were in order, and the medication cupboard was clean and well ordered. It is a requirement of this report that staff’s competence in handling medication is assessed periodically and recorded. Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 There is insufficient understanding regarding who to inform in the event of an allegation or suspicion of abuse, which places residents at possible risk of abuse. EVIDENCE: The requirement made at the last inspection to update the whistle blowing policy to ensure compliance with the DOH “No Secrets” guidelines remains outstanding. The home’s policy on adult protection was viewed and does not clearly outline the steps to take to inform Social Services of an allegation of abuse in line with the Kent and Medway adult protection protocol; nor the regulatory requirement to inform CSCI. The manager was unsure of the correct action to take in the event of being informed by staff or residents of an allegation. Staff who were interviewed knew that allegations of abuse must be reported to the manager or the person in charge, but most staff have not attended adult protection training. There was also no evidence on the file of a staff member that a POVA check had been applied for. Urgent attention must be given to address these matters in order to protect residents. One complaint had been recorded since the last inspection. It is a recommendation of this report that all complaints, no matter how minor, are recorded and demonstrate the action taken. It was evident however, through observing a residents’ meeting which was carefully minuted, that residents’ views and concerns are important to staff. It remains a requirement that SCIP training is renewed for staff. Examination of the financial records relating to residents’ monies revealed a good system in place that is protective of residents. Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,30 Environmental standards are good, and residents are living in a safe, well maintained and spacious home. EVIDENCE: A tour of the home revealed good standards of decoration and furbishment generally, although it is recommended that the institutional plastic chairs in the dining room are replaced with more suitable, domestic style furniture. There is extensive communal space available to the residents with two lounges, separate dining room and conservatory area. There is also a large contained garden area and day room. Three bedrooms were seen with the permission of and in the company of the occupants, and these were all attractively decorated and individually personalised. Residents said they like their rooms. It is recommended that residents without a lockable facility in their rooms are consulted and provided with one if they so request with a record made of their response. Bathrooms and toilets were accessible and clean. Infection control training for staff, however, remains outstanding. Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36 Residents are being supported by competent and committed staff. Arrangements for the training and supervision of staff have improved. The number of staff available at weekends needs reviewing. Recruitment practice is generally sound, but would benefit from improved checking systems. EVIDENCE: The senior team leader and the housekeeper/carer were interviewed privately and both were clear as to their enabling role and demonstrated a positive approach to their work. Observations of staff going about their work with the residents showed much care and commitment. Staff said they feel supported in their work and confirmed that they receive regular formal supervision. Records of staff supervision were seen and show a wide ranging agenda of issues relating to their work, including training needs. There has been considerable improvement regarding staff training opportunities, with staff attending courses on for example, epilepsy, fire awareness, autism and moving and handling. One of the staff interviewed said that the session on autism has helped change the way she works with the residents with autism to positive effect. Six staff are currently working towards a National Vocational Qualification. The training matrix needs updating. Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 19 Recruitment practice is generally sound, although there was no evidence on one staff file that a POVA check had been applied for. The manager said that this person is not working unsupervised. With regards to staffing levels, there is a need for review. During weekdays, for the most part there are three carers on duty, with the manager supernumerary to these numbers for three days a week. Given that residents generally have their sessions at the Martello unsupported by the home’s staff, there appears to be a sufficient number of staff to work with residents not attending day care, individually or in small groups. It is, however, a requirement of the report that the manager works supernumerary on all five weekdays to ensure sufficient time is available for her to attend to her managerial responsibilities. In respect of the weekends, staffing levels may not always be sufficient to meet residents’ needs and this requires reviewing. A resident goes home every other week and staffing numbers are reduced to two carers during the day. This resident, when she is at the home at weekends, requires two to one support when she goes out. This can mean that in order for this person to go out, all the other residents have to go out as well, as to leave one staff behind with the other five residents would not be safe. Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,40,41,42 The manager is working hard to make improvements to the benefit of residents; and has some understanding of what still needs to improve in the home. EVIDENCE: The manager has been in post for just five months and took over at a difficult time. She is being well supported by the area manager and has done well to make a number of improvements in a short space of time. There remain gaps in her knowledge and experience, however, of which she has some awareness. She updates her knowledge by attending training courses and is well on the way to completing her NVQ Level 4 and RMA. Her management approach is an open one, to which residents and staff are responding well. The friendly and welcoming atmosphere was noted. Relatives are asked to complete an annual feedback survey, the results of which are analysed. There was evidence that appropriate action has been taken to address the findings. It is a requirement that residents are supported Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 21 in completing a similar survey, with the results published and made available to the residents and their representatives and to the commission. Feedback is regularly sought from residents in their weekly meetings, and establishing a process of regularly meeting individually with their key worker to talk about how they are getting on was discussed. The last three Regulation 26 reports received by the commission are dated March, April and June 2005. This is unsatisfactory. The Regulation states that there must be visits made to the home by the registered person on a monthly basis and that reports of the visits are sent to the commission. It is also of concern that residents and staff were not interviewed on any of these visits. Policies and procedures still require amendment to comply with current legislation and to be signed and dated. Records were generally in good order. No obvious health and safety hazards were noted, although staff still require training in infection control. Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x 3 3 Standard No 22 23 ENVIRONMENT Score 3 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 x 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 2 2 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Belmont Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 3 2 x H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 23 yes Are there any outstanding requirements from the last inspection? 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 20 Regulation 13 Requirement With regards to medication: a) The updating of the policy and procedure to continue as planned, and to include ordering, receipt and disposal, homely medication, covert administration, errors and refusal. b) record of the assessment of staff competence to be maintained. With regards to protecting residents from abuse, a) The adult abuse and whistle blowing policies to be updated to ensure compliance with the Kent and Medway adult protection protocol and the DOH guidance No Secrets b) Manager and all staff to be clear regarding reporting procedures, c) all staff to receive training on adult protection and abuse awareness and SCIP (timescale of 01/06/05 not met.), d)POVA checks to be obtained for all staff, and evidence of applying for the checks to be available before new staff commence their employment. With regards to staffing: a) Manager to be supernumerary to H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Timescale for action 05/11/05 2. 23 13 a) 05/10/05, b)05/09/05 ,c) 05/11/05, d) 05/09/05 3. Belmont 33 18 05/10/05 Page 24 Version 1.40 4. 34 19 5. 35,42 13,18 6. 39 24 7. 39 26 8. 40 19 the care staff on shift, b) Staffing levels at weekends to be reviewed. Recruitment policies and procedures to be amended to ensure two written references are obtained prior to a new starter commencing employment (timescale of 31/03/05 not met); Photos of staff to be maintained on staff files. With regards to staff training, a) training matrix to be updated, b) all staff to undertake infection control training (timescale of 01/06/05 not met.) Resident feedback surveys to be undertaken annually, and the results made available to the residents, their representatives and to the commission. Unannounced Regulation 26 visits to be undertaken in accordance with regulation, and reports of visits sent to the commission each month. Visits to include discussion with residents and staff. All policies and procedures to be amended to ensure compliance with current legislation, and signed and dated. (timescale of 31/05/05 not met). 05/10/05 a) 05/10/05, b) 05/11/05 05/01/06 05/09/05 05/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Belmont Refer to Standard 7 7 Good Practice Recommendations Evidence to be available of consultation with residents and their representatives regarding the use of baby monitors in bedrooms. Residents toiletries kept in staff sleep in room to be reviewed and risk assessed. H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 25 3. 4. 5. 6. 7. 8. 6 11 13 22 26 28 All Life Plan documentation to be signed and dated. Details of which makaton signs to use, to be recorded in Life Plans. Company signage to be removed from home vehicles. All complaints to be recorded. Residents to be consulted regarding lockable facilities in rooms. Plastic dining chairs to be replaced with more domestic, homely seating. Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection 11th Floor, International House Dover Place Ashford, Kent TN23 1HU 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 Belmont H56-H05 S23333 Belmont V238571 050905 Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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