Inspection on 05/02/06 for Belmont Castle

This inspection was carried out on 5th February 2006.

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 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

Belmont Castle 09/02/09

Belmont Castle 21/05/08

Belmont Castle 08/05/07

Belmont Castle 25/04/05

Belmont Castle 08/11/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Belmont Castle Portsdown Hill Road Bedhampton Hampshire PO9 3JW Lead Inspector Eamonn Kelly Unannounced Inspection 9th February 2006 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 Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Belmont Castle Address Portsdown Hill Road Bedhampton Hampshire PO9 3JW 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) 023 9247 5624 023 924 50910 London Residential Healthcare Ltd Mrs Michelle Shann Care Home 40 Category(ies) of Dementia (40), Dementia - over 65 years of age registration, with number (40), Old age, not falling within any other of places category (40), Physical disability (6), Physical disability over 65 years of age (6) Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All service users must be at least 55 years of age A total of six service users may be accommodated in the PD and PD(E) category 25th April 2005 Date of last inspection Brief Description of the Service: Belmont Castle is set in three acres of well-maintained gardens. It is situated in a quiet residential area with views of Portsmouth and the Solent. Belmont Castle has 30 single and 5 shared bedrooms. Most have en-suite facilities. There are two dining areas, two sitting rooms, a TV lounge and a small library area. The home has a shaft lift that services the three floors on which bedroom accommodation is situated. Twenty-four hour care is provided with 3 awake members of staff on duty at night. An activities co-ordinator is employed. Contract caterers provide meals for service users. Potential service users may obtain good information about services and facilities in a service user’s guide. There are good car parking facilities at the home. Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced between 9.30 am and 3.00 pm and consisted of meeting with the manager, members of staff, visitors and some service users. Some of the homes records were seen for example care plans, medication records, pre-admission information. All bedrooms and communal areas were visited. What the service does well: What has improved since the last inspection? What they could do better: The new care plans will assist members of staff to identify where service user’s health is failing and enable them to take appropriate action. The progress on administering medication will help reduce any potential for errors. Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 Page 6 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 Castle DS0000062222.V281846.R01.S.doc Version 5.1 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 Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 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, 3, 6. The information available to prospective service users and the assessment process helps to ensure service user’s needs are met. EVIDENCE: Prospective service users receive good written pre-admission information including a copy of the terms and conditions of the home. The service user guide has been amended so that it relates specifically to the home and not generalised to all homes within the group. A copy is placed in each service user’s bedroom. Service users admitted in the previous 6 months have had a thorough assessment of their needs undertaken by the manager before a place was offered at the home. Service users met during the inspection stated that they were satisfied with the care and attention they received. Service users are not admitted who are solely in need of intermediate care. Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 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, 9 Individual plans of care help to enable service user’s assessed and changing health, personal and social care needs to be met. Changes to medication procedures have benefited staff and service users by making the system simpler and less susceptible to error. EVIDENCE: Existing care plans seen contained information that reflected the care needs of the service users. The new individual care plan format had additional relevant information about the service user’s needs and how these were being addressed. The new care plan format had the advantage that reviews of care were recorded clearly. They also included information about service user’s activities of daily living and they measured indications of improvement or deterioration in service user’s health or general well being. Service users take part where they wish to in the preparation of care plans and in reviews. The manager has made changes to medication procedures. Previously medicines were prepared for the day ahead. The manager felt that this procedure potentially posed a risk to service users. Clear photographs have Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 Page 10 been added to each service user’s medication file, medication is prepared by nominated members of staff just before it is dispensed, and service users are observed when taking medication. Members of staff administering medicines receive training through distance learning. Service users met did not administer their own medication but they could do so if they wished subject to a risk assessment being undertaken first. Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 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): 13, 14 Service users are encouraged to maintain contact with their friends and relatives. They are helped to remain independent and to exercise control over their lives. EVIDENCE: Service users stated that they could receive guests at any time and that their guests were made welcome at the home. Visitors confirmed that they feel welcome at the home. Service users described how they are helped to remain as independent as possible. An example was that they generally felt staff had a good knowledge of their interests and capabilities. This helped staff and the activities coordinator to assist each service user in an individual way. Some service users also said that the contract caterers asked them for their food preferences. Some service users said that they generally wished to spend time in their bedrooms including having their meals there. In these circumstances, a note of these wishes was included in new care plan records. Service users are helped to obtain an independent advocate when they become unable to look after their financial or legal affairs. All service users received the opportunity recently to take part in a customer satisfaction survey. The manager said that their views were taken into account by staff. Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 Page 12 Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 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): These Standards were not assessed on this occasion. EVIDENCE: Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 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 Service users benefit from a comfortable and well maintained premises. EVIDENCE: A passenger lift assists service users to easily gain access to all 3 floors where there are bedrooms and other facilities. The home has 30 single and 5 shared bedrooms. The maintenance engineer has a schedule of refurbishment for the internal and external parts of the home. The home was well decorated throughout. There are good communal areas that benefit staff, service users and visitors. Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 Page 15 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): 29, 30 Service users are protected by good recruitment procedures. The home provides good training for all members of staff. EVIDENCE: Service users generally stated that they feel well cared for by members of staff. At night, there are 3 awake members of staff on duty plus a sleeping member of staff. There are 6 care staff on duty between 8am and 2pm, 3 care staff between 2pm and 6 pm, and 4 between 6pm and 10pm. The manager works hours additional to this on weekdays. There is an activities co-ordinator, domestic assistants, laundry assistant, housekeeper, contract caterers, administrator and maintenance engineer also within the home Recruitment procedures are common throughout the group’s homes. References are taken up for all new members of staff. CRB (criminal record bureau) and POVA (protection of vulnerable adults) checks are taken up in all cases. The manager has identified instances where the procedures for taking up references were prone to error and she has rectified this problem. All members of staff receive formal recorded supervision. They also receive annual appraisals. The training matrix showed that all members of staff received appropriate training. Some training initiatives are provided through staff employed within the group. In other cases, training was bought in with the objective of ensuring that each member of staff received the appropriate training and support Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 Page 16 identified during supervision. The training matrix showed outstanding training for each member of staff highlighted in red. Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 Page 17 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, 38 Service users benefit from a well managed home. The health and safety of service users is promoted. EVIDENCE: A matron and deputy matron supports the registered manager. Service users met on this occasion said that they felt secure in the care of senior staff and care assistants. The manager has achieved a City & Guilds advanced management certificate in care. She is actively considering the registered manager’s award. The home’s maintenance schedule has the benefit of keeping the premises suitable for the care of service users. The annual development plan developed by the manager helps to ensure that the aims and objectives of the home continue to be met and that this progress can be monitored within the group. Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 Page 18 Results of a recent customer satisfaction survey indicated that most service users responded and members of staff acted upon their comments. Risk assessments contained in individual care plans identified specific and upto-date actions that care staff must be aware of to protect service user’s health and meet their needs. New arrangements are in place for locking the front door following consultation with the fire safety officer. Training in manual handling, infection control, adult protection and health & safety is provided to members of staff. Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 Page 19 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 x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 3 x x x x x x x STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x x x x 3 Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 Page 20 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. Refer to Standard Good Practice Recommendations Belmont Castle DS0000062222.V281846.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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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