Inspection on 01/03/07 for Belmont House

This inspection was carried out on 1st March 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 House 06/12/05

Belmont House 08/06/05

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

CARE HOMES FOR OLDER PEOPLE Belmont House Belmont Drive Stocksbridge Sheffield South Yorkshire S36 1AH Lead Inspector Ivan Barker Key Unannounced Inspection 10:20 1st March 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 House DS0000063332.V308702.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 House DS0000063332.V308702.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belmont House Address Belmont Drive Stocksbridge Sheffield South Yorkshire S36 1AH 0114 283 1030 0114 283 0641 none None Redrose Care Limited 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) Mrs Sheila Dugdale Care Home 52 Category(ies) of Dementia - over 65 years of age (52) registration, with number of places Belmont House DS0000063332.V308702.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 52 beds are registered for personal care (PC), only 25 of the 52 beds are registered for nursing (N). Three service users from the age of 60 years may be accommodated at the home. 6th December 2005 Date of last inspection Brief Description of the Service: Belmont care home is a 3-storey part converted old building with modern additions, which provides care for service users with dementia who require either nursing or personal care. The home is situated overlooking the Stocksbridge valley and the hills beyond, and has easy access to Sheffield, Manchester and the motorway network. The home is situated in a residential area, however there are no shops within the immediate vicinity. Copies of Service User guides were available to service users and stored in their rooms. The manager advised the inspector that the fee range is between £348 and £440 including third party top up fees. Belmont House DS0000063332.V308702.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Only a limited number of the National Minimum Standards were examined at this inspection (with emphasis on the ‘key standards’), and the previous requirements. The person present at the inspection was: Mrs S Dugdale, manager. Within this site visit, which occurred over a six hour twenty minute period, the inspector toured the building, examined requirements relating to the previous inspection, case tracked 3 service users (Case tracked means looking at the care and service provided to specific service users living at the home; checking records relating to their health and welfare (care plans and other records); by talking to the service users themselves; viewing their personal accommodation as well as communal living areas) and spoke with other service users, and a relative and also 3 staff and examined assessments, care plans, risk assessments, activity records, menus, staff files and quality audit information. The history of the service was examined prior to the site visit. This included telephone contacts, letters, notifications etc. What the service does well: Comprehensive assessments are obtained prior to the service user’s admission to the home. The relatives prior to admission completed ‘Profiles’. These profiles contained information regarding the service user, from a relative’s prospective. The information from the assessments and profiles were used to produce extensive care plans, which will contribute to the delivery of care. Service users were satisfied with the care and service they received. The positive comments were’ The service users were ‘looked after’, ‘the care was excellent’. The room was ‘nice’ The staff were ‘excellent’ and ‘nice people’ The food was ‘good’. ‘They make whatever we like’ ‘Activities did occur and mum did do some, but there could be more. Some service users were ‘not bothered about activities’ Belmont House DS0000063332.V308702.R01.S.doc Version 5.2 Page 6 The service users and relative commended the efforts of the staff, particularly the manager and registered person, who took the time to talk to service users and relatives. The good practices within storage and administration of medications should provide protection for the service users. An experienced registered manager is in post. This will contribute to the effective organisation and operation of the service. The relatives could contact the manager on her mobile phone as relatives were given the number or could contact her via the e-mail system. Extensive quality assurance systems were in place that should assist the manager and company to measure the service against expected outcomes. 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 House DS0000063332.V308702.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 House DS0000063332.V308702.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Accurate comprehensive assessments were in place either from the care management team or from the staff of the service, for the self funded service users. This ensured that the service have sufficient information to be aware of the service user’s needs prior to admission. EVIDENCE: On examination of the service users’ care management assessments, two service users had care assessments from the care management team. The other service user was a self-funded individual, who had been fully assessed by the staff of the service. All assessments documents were signed and dated prior to the admission date. Belmont House DS0000063332.V308702.R01.S.doc Version 5.2 Page 9 Documentation regarding the assessment undertaken by the staff of the service, was examined and found to be comprehensive, and detailed the service users needs which would assist in providing sufficient information for a care plan to be drawn up. The manager provided evidence of ‘profiles’, which were completed by the relatives, prior to admission. These profiles contained information regarding the service user, from a relative’s prospective. The manager advised that no intermediate care was provided within the service. Belmont House DS0000063332.V308702.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Accurate care plans and care reviews with service users and relatives enabled them to offer their input, and will contribute to the delivery of care. Service users were satisfied with the care they received. The good practices within storage and administration of medications should provide protection for the service users. EVIDENCE: On examination of the care plans, from three service users, it was established that all three care plans were up to date, and had been evaluated on a monthly basis, and had evidence that the service user or family had been consulted on the content of the care plans. Belmont House DS0000063332.V308702.R01.S.doc Version 5.2 Page 11 Risk assessments were included within the documentation and included moving and handling, behavioural and nutritional risk assessments. Service users and relative expressed their views, during the inspection. Their opinions were; The service users ‘were looked after’ ‘Care is excellent’ The storage, ordering, administration and disposal of medication procedures were discussed with the manager. The procedures explained were satisfactory. On examination of the medication administration records it was found that there were no omissions of signatures. All medication records had been signed when being checked in from the pharmacy. There was an initial and signature sheet, within the medication administration file. Belmont House DS0000063332.V308702.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Various activities were organised within the service, which would provide stimulation to service users and enhance their quality of life. Service users were given the opportunity to exercise their right of choice regarding the provision of meals. EVIDENCE: The manager advised that the staff were responsible for organising activities. Upon arrival at the home, a member of staff was observed to be undertaking a therapy session with a ball, in the lounge. Five service users were participating in the session. The manager provided evidence, in the form of a list displayed within her office, which included activities planned on a weekly basis and outings and entertainers, which were planned throughout the year. Belmont House DS0000063332.V308702.R01.S.doc Version 5.2 Page 13 On discussing the activities with the service users, and relative their opinions were that; Some service users were ‘not bothered about activities’. ‘Activities did occur and mum did do some, but there could be more. Regarding the meals, the manager advised that the service users were offered a main meal and other choices were available. The manager provided evidence that there was a four weekly menu. Positive comments were received from the service users and relative regarding the food. The general comments were that; ‘The food is good’. ‘They make whatever we like’ On discussing the positive comments with the manager, it was noted that although it was accepted that a choice was available because of the comments received and because of the varied meals being served at the time of this visit, there was no documentary evidence that a choice was served, prior to this site visit. A document, which would provide this evidence, was provided, but the manager identified that a different type of information, rather than the information, the form was designed for, had been recorded on the form. Regarding the requirement from the last inspection, which required that service users must be offered assistance to eat in a discreet and sensitive way, the manager advised that the member of staff observed assisting the service user to eat, had been spoke to following the visit and her practices observed as part of her supervision. Belmont House DS0000063332.V308702.R01.S.doc Version 5.2 Page 14 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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service had a complaints procedure in place, however there was minimal available evidence, of one entry, to judge, if it was operating according to the company policy and if complaints were resolved within the expected timescales. The service was able to evidence that the staff had received Safeguarding Adults training. Therefore staff would be aware of their responsibility regarding the protection of vulnerable adults. EVIDENCE: The complaints procedure was displayed and available to the service users and relatives. On discussing complaints with the service users, and relative they stated that they were satisfied with their care, and had no complaints. During the discussions with the manager and relative, it was identified that there had been concerns regarding the service and as the relative had the current manager’s mobile phone number and e-mail address, she had been contacted regarding the concerns. At the time the current manager had taken up the post as area manager for the company, but following the investigation had returned to the post of manager for the home. Belmont House DS0000063332.V308702.R01.S.doc Version 5.2 Page 15 Regarding safeguarding adults, the service had policies and procedures which were available to staff. Staff had undertaken safeguarding adults training, and the manager was able to evidence this by showing training records and certificates. Belmont House DS0000063332.V308702.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment, monitored at the site visit, had not been maintained to the required standard to provide a safe, well-maintained environment for services users. EVIDENCE: On touring the building, the home was found to be clean and that extensive redecoration had occurred and was in a reasonable state of repair except for the following areas: Belmont House DS0000063332.V308702.R01.S.doc Version 5.2 Page 17 The corridor carpet, outside of room 53 and room 54 was torn and was a tripping hazard. When the issue was raised, the manager instructed the handyman to place tape over the tear, as an interim measure. This action occurred immediately. The provision of a new carpet was discussed with the manager. She advised that she would replace the carpet within this section of the corridor within 3 months. This timescale was accepted, however reservation was expressed regarding the on going maintenance of the tape to ensure the tear remained covered and did not became a hazard. Within room 53 (hairdressing room) the wallpaper and boarder paper was torn and the room was in need of redecoration. The service users’ rooms had been personalised and many contained photographs, personal belongings and items of furniture, which the individual or the family had provided. Each door was fitted with contact points, which were linked into the call system. These contact points were ‘activated’ during the night and played an active part of monitoring service users, should they wonder from their rooms unobserved by staff. This system will make staff aware of service users leaving their rooms and the need to take prompt action to prevent falls etc. One service user identified that his room was ‘nice’. Belmont House DS0000063332.V308702.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager was not able to provide evidence that staff had received training, which could reflect on the quality of care being delivered to the service users. The staff recruitment process should provide protection for the service users. EVIDENCE: On examination of the staff rotas and examination of staff on duty, the following was established: Am – Pm – Night shift – Plus A manager Caring for a present occupancy of 24 service users, receiving personal care and 20 receiving nursing care. A total of 44 service users. Belmont House DS0000063332.V308702.R01.S.doc Version 5.2 Page 19 1 qualified nurse 1 senior carer and 6 care staff 1 qualified nurse 1 senior carer and 6 care staff 1 qualified nurse 1 senior carer and 3 care staff Ancillary staff included. An administrator And domestic and catering staff. A full assessment of the dependency levels of the service users was not undertaken and compared with the indicated staffing levels. On examination of the three staff files, all contained the required documentation, including Criminal Records Bureau and POVA (Protection of Vulnerable adults) checks. On examination of the staff training records there were records and certificates that indicated the majority of staff had received moving and handling, fire. However it was established that some staff had not attended moving and handling or fire training for over 1 year. The manager identified that she had returned to her post for two months and staff training was an area she was yet to address. She identified that some staff had received training, but had yet to receive the certificate. On further analysis of the training records it was established that a small minority of night staff were required to attend for training. The manager gave assurance that training would be delivered to these staff, within the next week. This timescale was accepted. Safeguarding Adults training and other specific training regarding the client group that they were caring for, had occurred. Staff advised that they were satisfied with the care and service provision and did not express any concerns. They stated that there was a ‘good atmosphere within the home’. The service users and relatives commended the staff as ‘excellent’, ‘nice people’ and particularly named the manager and registered person, who were identified as ‘having time to speak to service users and relatives’. The manager advised that since the last inspection and the recommendation to increase National Vocational Qualification training, (NVQ) 70 of the staff had a NVQ. Belmont House DS0000063332.V308702.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An experienced registered manager is in post. This will contributed to the effective organisation and operation of the service. Extensive quality assurance systems were in place that should assist the manager and company to measure the service against expected outcomes. EVIDENCE: A registered manager was in post. Regarding her qualifications and experience she identified that she had over 10 years experience and had obtained the Registered Managers Award. Belmont House DS0000063332.V308702.R01.S.doc Version 5.2 Page 21 Regarding the Quality Assurance there was regular monitoring with monthly, quarterly and annual monitoring by the manager and registered person. The monthly audit consisted of an analysis of the expected costs of refurbishment, analysis of accidents / falls, number and reason for complaints, enquires for a place at the home and staffing cover. Quarterly and annual monitoring covered areas of care i.e. care plans, to the environment within the service provision. Also 6 monthly questionnaires were sent out to families and care professionals, (care managers, GPs, health professional etc), as part of the service user’s care review undertaken by the staff of the service. Copies of these were observed. Regulation 26 documentations, which are a record of the registered person’s monthly visits, had been completed on a monthly basis and were on site for inspection. Regulation 37 notices, which are documents that are sent to the Commission regarding untoward occurrences, including falls, accidents etc; had been received by CSCI (Commission for Social Care Inspection). The pre inspection questionnaire confirmed that the necessary maintenance and servicing had occurred. Belmont House DS0000063332.V308702.R01.S.doc Version 5.2 Page 22 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 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Belmont House DS0000063332.V308702.R01.S.doc Version 5.2 Page 23 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. 1 Standard OP19 OP38 2 3 OP19 OP30 23 (2) 18 (1) Regulation 23 (2) Requirement The carpet, which is worn and a tripping hazard must be replaced. The hairdressing room must be adequately decorated All staff should receive training in moving and handling and fire, at least on a annual basis Timescale for action 01/06/07 01/06/07 01/04/07 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 House DS0000063332.V308702.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 House DS0000063332.V308702.R01.S.doc Version 5.2 Page 25 - 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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