Inspection on 08/05/07 for Belmont Castle

This inspection was carried out on 8th May 2007.

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 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 05/02/06

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 Mrs Pat Hibberd Unannounced Inspection 09:30 8th May 2007 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.V335731.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. Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 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 belmontcastle@lrh-homes.wanadoo.co.uk 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.V335731.R01.S.doc Version 5.2 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 5th February 2006 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 individuals. Potential people in receipt of a service may obtain good information about services and facilities in a service user’s guide. There are good car parking facilities at the home. Current weekly fees range between £385.00 and £750.00 exclusive of personal items such as hairdressing, chiropody, newspapers, escort duties and toiletries. This information was provided by the provider in a pre inspection questionnaire received by the commission in April 2007. Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection visit to the Home. The inspector toured the building; spoke with ten residents, ten staff members and the Registered Manager Michelle Shann. The inspector also looked at records such as recruitment checks and care plans. As well as a visit to the home we have reviewed information sent to us from the home prior to the visit. What the service does well: What has improved since the last inspection? There were no areas requiring improvement identified at the last inspection. Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 6 The Home continues, however, to provide and develop a range of activities for residents with a full time activities coordinator employed for that purpose. 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. The summary of this inspection report can be made available in other formats on request. Belmont Castle DS0000062222.V335731.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 Belmont Castle DS0000062222.V335731.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): 3. Standard 6 does not apply to Belmont Castle. Quality in this outcome area is good. The manager ensures that new residents have been assessed and that the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager visits prospective new residents in hospital or at home to undertake an assessment. Prospective residents are also encouraged to spend some time at the home so that they can be assessed in the environment. The manager also seeks other assessments from doctors or local authority adult services. Prospective residents 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 Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 9 all homes within the group. A copy was seen to be placed in each resident’s bedroom. Residents 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. Residents met during the inspection stated that they were satisfied with the care and attention they received. Residents are not admitted who are solely in need of intermediate care. Belmont Castle DS0000062222.V335731.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 and 10. Quality in this outcome area is adequate. The home generally ensures residents have access to healthcare professionals. Resident’s privacy and dignity is respected. Some improvement is required to ensure individual plans of care help to enable resident’s assessed and changing health, personal and social care needs to be met. Resident’s are safeguarded by the Home’s medication policy and procedure. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents’ care plans were inspected including an individual who had recently experienced a number of falls. Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 11 The documents examined contained a range of information and the plans were based on the assessments the home carried out in order to identify what help individuals needed. Assessments included a range of potential risks to residents e.g. falls; moving and handling; isolation / mental health support; social care needs and dietary requirements. The plans examined also set out clearly the actions staff had to take and what specialist equipment was needed to provide the support and assistance each person required. Where care plans referred to the use of equipment or how a specific need was to be met this was observed to be available, provided or in place e.g. Zimmer frame; or hoist. At the time of the visit there were no residents with a pressure area. Records indicated that care plans were reviewed at least monthly and daily notes referred to the actions taken by staff to provide the needs set out in those plans. Staff spoken to were aware of the needs of the individuals whose records were sampled and they were able to describe the contents of the care plans. Some staff indicated that they have received training in Dementia care and indicated that this had been beneficial to their practice in supporting the needs of residents. However, a number of staff said they had not attended the training and would like to attend a course in the future. Comments received in comment cards and discussions held with residents during the visit as to the abilities of staff the care and support that they provided included: • “The staff are good, they are friendly, nothing is too much trouble …if I press the call bell staff generally come when I need them and know what was wrong and what to do”. • “The staff are helpful and kind “ “ I feel comfortable when the staff help me”. • “You can’t moan about the care here “. The records examined indicated that a range of healthcare professionals visited the home and that in general arrangements were made for treatment for residents when it was necessary. Residents said that they saw and received treatment from among others, doctors, podiatrists and opticians and when required arrangements to attend outpatient clinics were made by the home. There were also very specific plans in place where weight loss or eating difficulties had been identified as a problem for an individual. The plans specified how this would be managed. Where able residents are involved in compiling their care plans. However, following an inspection of the accident book it was evident that two residents had fallen on six occasions suffering injuries to their face or head with staff failing to consult or gain advice from a health professional. The manager indicated that staff were aware of the need to consult with either a residents GP or call an ambulance and on some occasions the accident book confirmed that staff had followed procedures. Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 12 The manager agreed that all staff would be reminded of the policy and, that she would ensure a regular check is made of the accident book. The manager contacted one residents GP during the inspection to arrange for him to visit the individual who had fallen over the weekend. There was further evidence in two care plans viewed that bed rails had been fitted to both residents’ beds with no risk assessment having been completed to identify that this was the only means of ensuring the resident’s safety. The manager agreed that a risk assessment should have been completed, monitored as to the ongoing need and kept under review. Mrs Shann further agreed that such a decision should be reached as part of a multi disciplinary agreement. A requirement was made for this work to be completed. The home had written policies and procedures concerned with the management and administration of medication. Only senior members of staff administer the medication in the home, unless a resident is able and wishes to manage their own. There are currently no residents self-medicating at this time. The manager indicated that the Home is proposing to use a monitored dosage system that will continue to be supported by the use of the MAR sheet [medication administration record sheet]. The drugs’ cupboard was clean and tidy. Records are kept of the ordering, receipt, administration and the disposal of medicines and these were accurate and up to date. The majority of bedrooms are single and, as a consequence the privacy of residents was promoted by the fact that they were accommodated in singe rooms. However, one double room was seen which had a screen to promote privacy. Residents spoken to said that staff always knocked before entering their rooms. This latter practice was observed during the fieldwork visit. Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 13 Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 14 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 and 15. Quality in this outcome area is good. The home offers residents a range of activities and choices in everyday life. Visitors are always made welcome. Meals provided meet residents’ individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents 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 co-ordinator to assist each resident in an individual way. Some residents also said that the contract caterers asked them for their food preferences. Two residents 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 care plan records. Residents were seen to have personal leisure facilities in their rooms including radios, televisions, talking books and videos. One resident has satellite TV installed and a number have their own telephone. Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 15 Residents can attend church and a minister visits the Home with details of religious preferences and wishes held in care plans and support offered as required. Most residents spoken to indicated that their life style preferences were respected and that routines in the home were flexible and relationships were informal. Comments from residents about the activities that were organised, their ability to exercise choice and day-to-day routines in the home included: • “I join in the activities if it is something that interests me.” • “There are sometimes things to do I enjoy but not always”. The activities coordinator is employed for 30 hours a week and provides a programme of activities which is very much resident led in that they choose what they want to do each day. The manager explained that records are kept of the activities to ensure all residents; including those individuals with dementia have an opportunity for stimulation and activity. A range of information was seen on a board in the entrance of the home and in a corridor relating to planned activities and details about an organisation that could provide impartial advice, information and guidance to residents and/or their families. The residents told the inspector that they were looking forward to the garden party that was due to take place in the summer. Residents were able to bring personal items into the home including furniture and it was apparent from discussion with residents and observation during a tour of the building that many individuals had taken trouble to personalise their bedroom accommodation. Sensitive information that the home held about residents was kept secure and the home had written policies and procedures about maintaining confidentiality and residents rights to access their personal files and case notes. Residents were complimentary about the food provided and confirmed that they had 3 meals a day and could have snacks and drinks at other times. The menus and records of food provided indicated that the food was nutritious and there was a wide range of meals provided with a selection of choices every day. Care plans hold details of special dietary needs and how this was to be managed with special diets and individual preferences and needs catered for e.g. soft and pureed meals, diabetics and vegetarian. Documents and the information were also readily available to catering staff in the kitchen area. Fresh ingredients were used in the preparation of meals and the ready availability of fluids was noted. If required the ingredients for some pureed meals were prepared separately. Residents could choose where to eat and some preferred to eat in their rooms. The list of menu choices for the week was on display in the home. A member of staff asked individuals what choices they wanted during the morning of the meal in question. Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 16 The main meal of the day was observed and it was unhurried and staff were sensitive when providing assistance. It was apparent from conversation around the dining room tables in the dining room that the meal was enjoyable. Comments from residents about the food provided included the following: • “The food is very good, we have 2 choices every day and they cater for my needs”. “ I get plenty of vegetables and the food is good “ and “we get a choice “. “I did not like the meal today so I had an omelette”. In discussion with the cook it was evident that she was aware of the dietary needs of individuals and had written details of likes and dislikes of all residents. Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 17 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 and 18 were inspected on this occasion. Quality in this outcome area is adequate. The home had a clear and satisfactory complaints procedure to address the concerns of residents and relatives/representatives. Procedures were in place to protect residents although training of staff in safe guarding adults awareness and protection is not consistent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure that has been given to residents and their relatives at the point of admission. Two complaints have been received since the last inspection both of which were seen to have been appropriately dealt with by the manager. All the residents who spoke with the inspector said they felt able to raise complaints with the manager if they needed to. They were confident that she would deal with any complaints appropriately. The home has appropriate procedures in place should there be an allegation of abuse and the manager is aware of how the process of an investigation works. However, in discussion with staff it was evident that not all had undertaken training in the protection of vulnerable adults. Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 18 All said they would talk to the manager if they suspected abuse or, if a resident made a disclosure. A requirement was made for all staff to complete the training. There have been no adult protection investigations reported since the last inspection. Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 19 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 and 26. Quality in this outcome area is excellent. Resident’s benefit from a clean, hygienic and well-maintained Home. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well-decorated and clean environment. EVIDENCE: All communal areas and bedrooms are decorated to a high standard with welltendered grounds surrounding the building of which a number of residents commented how much they enjoyed. A passenger lift assists residents 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, residents and visitors. Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 20 All areas of the Home were clean, bright and free from any odours. There are four domestic staff employed of which two spoken to indicated that they have sufficient time to ensure the cleanliness of the Home is kept to a high standard. This was evident during the visit and confirmed by a number of residents spoken to. Staff confirmed they were provided with aprons, gloves and ample washing facilities that were seen around the Home and had undertaken infection control and hygiene training. The Home has a separate laundry area with a number of washing machines and a separate sluice facility. Resident’s laundry was seen to be held in individual baskets with residents spoken to confirming they were happy with how their clothes were laundered. Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 21 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): All of the above standards were inspected on this occasion. Quality in this outcome area is adequate. There are sufficient staff on duty at all times to ensure the needs of residents are met. Staff have the skills to meet residents’ needs but would benefit from additional training. The home’s recruitment procedures for contracted staff are not sufficiently robust. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents stated that they feel well cared for by members of staff and, that there are always sufficient staff on duty to meet their needs. Rotas indicated that there are 3 awake members of staff on duty plus a sleeping member of staff. There are 6 – 8 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 coordinator, domestic assistants, laundry assistant, housekeeper, contract caterers, administrator and maintenance engineer also within the home A minimum of 50 of care staff have achieved National Vocational Qualifications. Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 22 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. However, it was evident that the Home did not have any written confirmation of either the recruitment checks or training undertaken by the kitchen staff that are contracted through an agency. The manager confirmed that she would ensure this information was held in the Home and available for inspection. All members of staff receive formal recorded supervision. They also receive annual appraisals. Staff indicated that this was helpful to their practice and working with residents. The training matrix showed that staff undertake a range of training including moving and handling, death and dying, first aid, and mandatory training during induction to include infection control and food hygiene. It was evident however, that not all staff had completed training relevant to their role. In discussion with a number of staff they indicated that they would like to attend a course on pressure care, dementia awareness, challenging behaviour and communication. The manager explained that there has been some difficulty providing training to staff due to the training coordinator having additional duties within the company. The manager agreed to undertake a full audit of training completed by staff and prioritise needs identified by staff and, courses relevant to their practice. Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 23 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, and 38. Quality in this outcome area is adequate. The home’s manager provides positive leadership with effective systems and procedures in place for monitoring and maintaining the quality of the service provided. Some improvements are required to promote the safety and welfare of everyone living and working in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mrs Shann has been the registered manager of Belmont Castle for a number of years. Mrs Shann is supported by a matron and a deputy matron. Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 24 Both residents and staff praised Mrs Shann for her leadership and support. Mrs Shann has achieved The Advance Management in Care and indicated that she will be discussing any further qualifications she requires with a local college. A system is now in place for monitoring the quality of the service that the Home provides including the use of questionnaires to obtain the views of residents and relatives. The home’s registered manager also said that residents meetings were in place as part of the Home’s quality assurance programme. Some recently returned questionnaires were seen and the registered manager said that the results were due to be collated and then if necessary an action plan would be set out. The home had a range of policies and procedures that staff spoken to said were useful for reference and advice. Copies were available in the office. The manager indicated that they were being reviewed and up-dated as necessary. Mrs Shann demonstrated an awareness of equality and diversity legislation including the recent Gender Equality Scheme and Mental capacity Act. 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. The Home holds some monies for residents but this was not inspected on this occasion. No unsafe practices were observed during the inspection although previous sections of this report refer to requirements identified in relation to risk assessments and recent falls experienced by two residents. Certificates were available for required checks of systems and equipment. Risk assessments where necessary have been completed. The fire drill records showed that all staff had attended at least one fire drill in the last year. Regular risk assessments are undertaken and recorded to ensure that the safety within the home room by room. These were sampled and found to be satisfactory. All the residents and relatives spoken with stated that they felt safe at the home and some confirmed that the fire alarms are regularly tested. The manager explained the recording system for fires safety maintenance, training, evacuation and visual checks. The visual checks of all fire safety equipment has been recorded and undertaken at appropriate intervals to ensure the safety of the residents. The home has a satisfactory reference file for the Control of Substances Hazardous to Health (COSHH) information leaflets for each chemical being utilised within the home The home has a policy, procedures and information on health and safety. A sample of policies and procedures were seen that are reviewed regularly. There is an ongoing system in place that ensures that all appliances are serviced, records and certificates seen indicated that the systems such as the electrics and specialist equipment including bath aides received regular Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 25 servicing and maintenance. The employer’s insurance liability certificate was displayed and current. However, although the manager Mrs Shann confirmed that the Home had a fire risk assessment this was generic rather than specific to each individual resident. A requirement was made for a fire risk assessment to be undertaken for each resident, kept under review and shared with all staff. There was further evidence that not all staff had undertaken fire training with one staff member indicating that they had been working at the Home for three weeks and had only received fire safety training the day before the visit. A requirement was made for all staff to receive fire training. Incidents are generally reported to the commission as required under Regulation 37 although they must be sent on a consistent basis. However, it was noted in the accident book that a member of staff had fallen and incurred an injury but that the injury had not been reported under RIDDOR and no follow up action including a risk assessment had been completed. A further requirement was made to this effect with the manager indicating that she would investigate the incident fully. Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 26 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 2 Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A 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 OP7 Regulation 12 (7) (8) Requirement If it is identified following a risk assessment that the only means of ensuring a resident’s safety whilst in bed is with the use of bed rails this must be recorded, monitored and kept under review. The decision should be reached as part of a multi disciplinary agreement. If a resident has a fall a risk assessment must be put in place, or, any existing risk assessment reviewed. This should be shared with all staff. Timescale for action 15/05/07 2. OP7 15 (2) (b) 15/05/07 3. OP8 13(b) The Home must take advice from 08/05/07 a health professional in the event of a resident falling. Documented evidence of all recruitment checks and training undertaken of contracted staff working in the Home must be available for inspection. Staff must receive training in dementia awareness, pressure area awareness, safe guarding DS0000062222.V335731.R01.S.doc 4. OP29 19 11/05/07 5. OP30 18 (c) 08/08/07 Belmont Castle Version 5.2 Page 28 adults and fire. 6. OP38 23 (4) (c) (iii) A fire risk assessment must be 15/05/07 undertaken of residents’ individual needs in the event of a fire evacuation. This must be shared with staff and kept under review. Any serious injury to a resident must be reported to the commission. 08/05/07 7. OP38 37 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.V335731.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 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 Belmont Castle DS0000062222.V335731.R01.S.doc Version 5.2 Page 30 - 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. 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