Inspection on 24/09/07 for Belmont House

This inspection was carried out on 24th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 02/08/06

Belmont House 15/02/06

Belmont House 03/11/05

Belmont House 16/02/05

Belmont House 19/10/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Belmont House Belmont House 13 Greenover Road Brixham Devon TQ5 9LY Lead Inspector Stella Lindsay Key Inspection (unannounced) 24th September 2007 11:15 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 DS0000018326.V344627.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 DS0000018326.V344627.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belmont House Address Belmont House 13 Greenover Road Brixham Devon TQ5 9LY 01803 856420 01803 856420 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) Mr Patrick Simon Phillips Mrs Belinda Phillips RGN Mrs Belinda Phillips RGN Mr Patrick Simon Phillips Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20), Physical disability over 65 years of age of places (20) Belmont House DS0000018326.V344627.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2006 Brief Description of the Service: Belmont House is registered to provide care for up to 20 residents over the age of 65 years; their care needs are related to old age or physical disability. The home has seventeen bedrooms, three of which are large enough to be double rooms, though all are currently in single occupancy. Eight bedrooms have an en suite toilet. A call system is provided throughout the building and appropriate bathing and mobility aids are available for service users that have mobility issues. There is a shaft lift. There are two adjoining lounges which can be separated by glazed doors, and a large conservatory. Meals are taken in a dining room which leads from the conservatory, and can be separated with a curtain. At the front of the building is a well-tended garden area with a patio and raised pond with a fountain. On road parking is possible at the side of the home. The home is decorated and furnished to a high standard, and a very comfortable environment is provided for residents. Competent and caring staff are employed. At night the two staff are on sleeping in duty, with one on-call. Fees range from £330 to £350per week, depending on care needs. The most recent inspection report is available on request. Belmont House DS0000018326.V344627.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days in September 2007. It involved a tour of the premises and examination of care records, staff files and the medication system. The inspector met with the home owners, fourteen residents, two visitors and four staff on duty. One of the home owners, Mrs Belinda Phillips, is also the Registered Manager. She supplied supporting information about the home. Staff and relatives returned surveys to the Commission for Social Care Inspection (CSCI) and their views are represented in the text. What the service does well: Belmont House is an attractive, accessible and comfortable house, with good arrangements for maintenance and hygiene. Residents were coming and going freely during this inspection. They appreciated being able to go to the garden, and said, ‘we have a choice of lounges, and no restrictions.’ The home provides good clear information for prospective residents, and is happy to accept people for day care or short stays while they come to a decision. Assessment and recording of care needs is very clear, to enable staff to know what is required and provide good consistency of care. Residents were pleased to tell the inspector about the different ways they like to organise their days, able to bathe at a time that suits them, and having the amount of help they need. A good variety of social activities are provided. A relative returning a survey said their mother received more attention than they had expected, and that ‘all residents are given lots of TLC’. Another said that the home is very good at keeping in touch, and informing them of any important issue. Meals are very well balanced, highly nutritional, and attractively presented, with choices offered every day. Staff working at Belmont House know the importance of taking the views of residents seriously, and of listening to and responding to any issues raised. The Manager provides a good system of supervision and appraisal for staff. The home was seen to be run in the best interests of the residents, with staff encouraged to deal with individuals’ needs before household routines. Belmont House DS0000018326.V344627.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Belmont House DS0000018326.V344627.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 DS0000018326.V344627.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): 1,3 Quality in this outcome area is good. Useful information is provided, and careful assessment is carried out before accommodation is offered. This judgement has been made using available evidence including a visit to this service. Intermediate care is not provided at Belmont House. EVIDENCE: Information about Belmont House is clearly and accurately provided in their brochure. The inspector met with two residents who had been recently admitted to the home. Both had trusted relatives to make the choice, both had been to lunch before moving in, and both were content with the decision. The Manager had collected full information before offering accommodation. She has a format that she developed herself to ensure that all care needs are considered, and this was seen to have been completed before admission. She is also adopting a new set of care planning documentation. This included a Belmont House DS0000018326.V344627.R01.S.doc Version 5.2 Page 9 ‘Pre-service Family Review’ which had been completed with the family on the day of admission. In one case, Occupational Therapy and Physiotherapy reports had also been received, adding to the assessment. Residents are offered day care before making the decision to move in, when this is appropriate. One person who spoke to the inspector considered they are very lucky to be able to come to lunch regularly, and for short stays when needed, for example to recover strength after an illness. The Manager said that she had written to prospective residents, when it was appropriate, to confirm that the home was suitable for meeting their needs. Belmont House DS0000018326.V344627.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): 7,8,9,10 Quality in this outcome area is excellent. Personal and health care are given according to personal need, promoting independence and responding to changing needs and abilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care planning documents of four residents were examined. New formats had been introduced, and carefully completed to ensure that all needs were recorded. The preferred daily routine was recorded for each resident, in good useful detail. This included night care needs and toileting routine. Separate care plans were recorded for specific health care needs such as diabetes and catheter care. A mobility record was being kept for one resident, who was working to improve their mobility, and a record of skin care was being kept in another case where there was particular need. There were separate record sheets for Health care workers, Social Workers and GPs to record their own visits. The Manager works well with the staff, sharing knowledge and information for the good care of the residents. A new method of allocating work to care staff had been adopted. Staff are given a group of residents whose care they are responsible for that shift. Staff Belmont House DS0000018326.V344627.R01.S.doc Version 5.2 Page 11 said that they speak to staff going off duty about the group of residents with whom they will be working, and so are able to update themselves fully on personal details. This is good for consistency of care. They then provide personal care, deal with laundry and other practical details, and they will know when their people are ready for coffee. It has also resulted in carers writing the record of the person that they have been helping, instead of passing information to the Senior. Recording was seen to be good, as each was accurately recording their own work and observations. Moving and Handling assessments had been carried out, and risks to carers assessed. The Manager had requested equipment from the District Nurse team for the protection of pressure areas. She said that no-one had a pressure sore. GP visits had been requested on behalf of newly admitted residents, to discuss any treatment and review medication. The new care plan formats included care plan review forms, to include residents’ views, and a self-monitoring form, though the time had not yet arrived for these to be completed. An appointment had been made for a resident to go to an audiology appointment, and it had been arranged that a member of staff would come on duty early to escort her. Contacts were being made with a speech therapist and Mental Health Support worker who had previously helped a resident so that this support could be continued at Belmont House. Some residents had recorded their Life Story, so that staff can understand them better. This is good practice particularly when peoples’ memories become less reliable, or their speech less clear. A medication trolley had been provided. Storage and the system for administration were seen to be secure. Two residents had been assessed as capable of dealing with their own medication. Another had previously been able to do this, but due to decreasing ability, had been content to give up responsibility for all except night tablets. This shows that the home has a good personalised response to residents’ changing level of ability, and is prepared to help people maintain their independence as far as is safe. Some medications need the dosage to be altered frequently, in accordance with advice from the Medical Centre. Advice was given to write the dose on the Medication Administration Record sheet when it is altered, each day if necessary, to make it completely clear to staff. All records were seen to be accurate. The Manager was in touch with the local pharmacist for any urgent needs. Belmont House DS0000018326.V344627.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent. The routines, activities and plans for the home are flexible and can be quickly changed to meet individuals’ needs and choices. Meals are very well balanced, highly nutritional, and attractively presented. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents were pleased to tell the inspector about the different ways they like to organise their days. One likes to have their bath in the morning, then lie on their bed for a while, getting dressed in time for lunch. Another said how she likes to have breakfast in bed, and often ‘has a snooze’ after lunch. One said that she can have her shower (in the bath) at the time that suits her – ‘staff are accommodating’. One said she bathes on two particular days of the week, and washes her hair, in the early evening – ‘it suits me fine. I get on with all the girls’, she said, ‘I can do a lot myself, but I need help with certain things’. When the inspector first arrived, on a Monday morning, a carer was in town with two residents, supporting them to go to shops and a bank. One resident goes to work two days per week, in a Charity shop. A taxi was called to take her. Belmont House DS0000018326.V344627.R01.S.doc Version 5.2 Page 13 Activities are recorded for all residents each day, whether in a group or individually. Activity leaders are employed fortnightly and provide a variety of activities, the favourite of which is the Animal Handling afternoon. They had provided trips out, recently to Buckfast Abbey and Stoke Gabriel. Several residents mentioned that they enjoy the exercise group that a member of staff has been running successfully for over a year. The home has held fund raising events to support local charities. Residents have been involved in gathering items for sale, and the presentation gives a boost to their self-esteem. The garden at the front of Belmont House is sheltered, and residents were seen to enjoy time there. Some are able to come and go as they please, and others said that staff help them go out there when the weather is good enough. The home has an unrestricted visiting policy, and residents confirmed that they could have visitors at anytime and could come and go as they pleased. Residents’ individuality is appreciated, and many personal possessions were seen in their rooms. All residents have breakfast taken to their room. The cook keeps details of exactly how they like their breakfast, including their favourite cup. Then they all come down for lunch (unless they are unwell). If they have any problem they may eat in the little lounge out of sight of the others but not isolated. New plain crockery had been provided, to help people with visual impairments see what they are eating more easily. One resident said that the ‘food is lovely. Staff come every morning and ask you what you want.’ The cook also keeps a record of what each resident has eaten, including the vegetables. During this inspection delicious home made beef and tomato soup, or juice, were offered as starters at lunch, followed by ham with cheese sauce, mashed pots, fresh carrots, (frozen) peas and beans. People had different selections of these vegetables. Pudding was tinned pears and ice cream, except for one person who had fresh fruit for health reasons. Records showed that the previous day (Sunday) all had fresh fruit salad. Flowers are regularly picked from the garden, for residents to arrange. At the time of this visit there were roses on each dining table. Belmont House DS0000018326.V344627.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is excellent. Staff working at Belmont House know the importance of taking the views of residents seriously, and of listening to and responding to any issues raised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Complaints procedure is on display in the entrance hall, and included in the information given to prospective residents. A complaints form is available on request. No complaints had been received by the home or by the Commission for Social Care Inspection. Minor concerns are discussed with the resident, and recorded in their care plan. Over the past year, more staff are usually available in the mornings, which has meant they can make more time to listen to residents. They are finding that with the new way of allocating care responsibilities in the mornings, it is more focussed on the person, rather than the tasks. The Manager was in the process of following up a concern on behalf of a resident, for their protection. The home has a clear policy on the Protection of Vulnerable adults that includes the local reporting arrangements. Staff have received training in abuse awareness, and knew what they should do in the event of any allegation. Belmont House DS0000018326.V344627.R01.S.doc Version 5.2 Page 15 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): 19,20,22,26 Quality in this outcome area is good. Belmont House is an attractive, accessible and comfortable house, with good arrangements for maintenance and hygiene. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The location of Belmont House on the hill above Brixham is suitable as there is car parking space on the street at the side. The house is accessible, with a shaft lift and easy access to the garden from the conservatory. A stair lift had been installed on a flight of five stairs leading to two bedrooms, to ensure that the occupants would be able to continue to live in those rooms when their mobility decreases. A call bell system has been provided which enables residents to carry their call button with them, and there is a pendant available for wearing in the garden, should a resident need to be able to summon help while outside. Residents were coming and going freely during this inspection. They appreciated being Belmont House DS0000018326.V344627.R01.S.doc Version 5.2 Page 16 able to go to the garden, and said, ‘there are umbrellas for summer’. One said ‘this is a perfect place, we have a choice of lounges, and no restrictions.’ The residents indoors sometimes wanted the door open, and sometimes shut. A method of fixing the conservatory door should be found, as staff and residents were using a heavy flowerpot for this purpose. Smoking is permissible in the garden, and there is a porch at the back of the house which is suitable for people to smoke. There are two lounges. One is large and light, and leads into the conservatory. The other is smaller and suitable for private meetings and quiet times, and has sliding doors which can separate it from the main lounge. New easy chairs had been provided, and preparation work for a new carpet was being carried out at the time of this inspection. Eight of the 17 bedrooms have an en suite toilet. There are sufficient communal toilets, including one close to the lounge and dining room. Both bathrooms have bath hoists. The home does not have a hoist, and has no residents who are unable to weight bear. The Manager was pleased to report that she had recently purchased a piece of equipment to help people off the floor after a fall, and staff had been trained in its use. Safety issues have been met, with radiators covered, the temperature of hot water in baths restricted, and simple locks provided on residents’ doors for privacy that can be overridden by staff in an emergency. The laundry is in a separate building. It was seen to be clean and in good order. There is a system for avoiding any risk of contamination from soiled linen, and there is a good facility for washing commode pots. Belmont House DS0000018326.V344627.R01.S.doc Version 5.2 Page 17 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): 27,28,29,30 Quality in this outcome area is good. Competent and caring staff are employed in sufficient numbers to provide good care for residents. The recruitment process is sound, and good training is provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A rota was displayed, which showed that there are three care staff employed each morning, and two in the afternoon. The Manager may be one of these, or may be additional. The cook is additional, and works until 2pm each day, and a cleaner works three days per week. At night there are two care staff, both sleeping in. One of the staff is on-call, and answers call bells. Two residents need assistance regularly during the night, and two others are sometimes awake. The Manager said that these arrangements are kept under review, and when a resident has been ill and needing attention at night, a carer has been paid to work through the night. She also said that when their plans for extending the home come to fruition, a regular waking night carer will be employed. Staff were pleased to tell the inspector about the new system of allocating care tasks. They felt that it not only focussed attention on residents and made more effective use of their time, but also that it allocated work more fairly, contributing to even better team working and high morale. Belmont House DS0000018326.V344627.R01.S.doc Version 5.2 Page 18 The files of two recently appointed staff were examined. Both had CRB clearances and proof of identity, and references were gathered, all checks being carried out to protect residents from potential harm. A thorough induction training is given. Training with regard to Protection of Vulnerable Adults is provided for new staff as a priority. There has been further progress with achievement in the nationally recognised qualification known as National Vocational Qualification in Care, and three more staff are to start this training in October 2007. Photos of all staff were displayed, with their role and qualifications. Resources have been provided for training in Moving and Handling, Food Handling, control of infection, medicine management and Emergency First Aid. A Senior carer had received training in care of people with dementia. Belmont House DS0000018326.V344627.R01.S.doc Version 5.2 Page 19 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): 31,33,35,36,38 Quality in this outcome area is good. Overall management is very good, and all attention is given to running the home in the best interests of the residents, but some aspects of fire safety need to be resolved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager, Mrs Belinda Phillips, is a Qualified RGN with Diploma in Higher Education, giving her a good basis for daily assessment of residents’ health needs and for leading her staff in good health and personal care. Mr Patrick Phillips has a managerial background as a Quality Assurance engineer in industry. Mrs Philips upholds her nursing registration, and is an qualified as an NVQ assessor. The home was seen to be run in the best interests of the residents, with staff encouraged to deal with individuals’ needs before household routines. The Belmont House DS0000018326.V344627.R01.S.doc Version 5.2 Page 20 home owners are on the premises most days and fully involved in the life and work of the home. Feedback is gathered daily in an informal manner from residents and their relatives and other visitors. A visiting relative said that they feel that ‘everything is 101 ’ because of the daily involvement of the home owners. The owners had plans for the development of the home. It was recommended that they consider the best way of presenting these to residents and their relatives. The Manager said she gathers and records feedback from residents and their relatives in the care plan reviews, and this should be boosted by the use of the new care plan formats that have been provided. She is also planning to obtain the Quality Assurance programme from the same source, to enhance on-going quality audit and responsiveness to service users. The Manager looks after cash for eight residents, with records and receipts kept. These were checked for accuracy, and it was found to be a safe system. The Manager carries out six monthly appraisals with all staff, giving them feedback on their performance, including such attributes as initiative and motivation, planning and organisational skills. She gives care staff individual supervision sessions, with brief records kept, to give feedback on their performance, deal with any issues or training plans, and make sure they are up to date with any new policies and procedures. Not all staff had completed their fire safety training. The Manager was considering buying a DVD to train the remaining staff members, and for threemonthly up-dates for night staff. All equipment had been regularly serviced and records were maintained. The home had been assessed by an appropriately qualified occupational therapist and electrical checks are undertaken and recorded regularly. Risk assessments are in place and the home’s passenger lift is maintained under contract. The electrical circuit was certified in August 2005 (Montrose Electrics). The fire precaution system had been serviced professionally on 09/07/07. Not all fire doors were working properly. All should be surveyed, and any action taken to make sure they will shut firmly whenever the alarms sound, to ensure that residents are protected from possible harm. Fire training had been provided, but not all staff had undertaken it, which is necessary in order to act properly in the event of an emergency. Belmont House DS0000018326.V344627.R01.S.doc Version 5.2 Page 21 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 4 3 3 X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Belmont House DS0000018326.V344627.R01.S.doc Version 5.2 Page 22 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 OP38 Regulation 23(4) c&d Requirement The Registered Person must ensure all fire doors work effectively, and that all staff are up to date with fire safety training. Timescale for action 30/11/07 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 DS0000018326.V344627.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 House DS0000018326.V344627.R01.S.doc Version 5.2 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!