Inspection on 08/06/05 for Belmont House

This inspection was carried out on 8th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Belmont House 01/03/07

Belmont House 06/12/05

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 S36 1AH Lead Inspector Mike ONeil Unannounced 8 June 2005 08:50 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Belmont House Nursing Home Address Belmont Drive Stocksbridge Sheffield S36 1AH 0114 2831030 0114 2830641 Not known Redrose Care Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Sheila Dugdale N Care Home with Nursing 52 Category(ies) of DE(E) Dementia - over 65 (52) registration, with number of places Belmont House J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. 52 beds are registered for personal care (PC), only 25 of the 52 beds are registered for nursing (N). Date of last inspection 30th November 2004 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. Belmont House J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 08:50 to 15:30. Sheila Dugdale , registered manager and B.Kalar , registered provider were present during the inspection. Six residents, seven staff and three relatives were spoken with. A sample of records was examined and a partial inspection of the building was carried out. The inspector wishes to thank the manager, staff, relatives and residents for their time, friendliness and co-operation throughout the inspection process. What the service does well: What has improved since the last inspection? The grounds around the home had been improved and new garden furniture had been recently purchased. Further safeguards had been implemented to protect the financial welfare of the residents. The residents and relatives said that they felt there was not a lot to improve on since the last inspection, as they were as happy now, as they were then, with the care provided at Belmont House. Belmont House J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 6 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 J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Belmont House J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 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 standard(s) 2,3 and 4. Standard 6 is not applicable to this home. The resident contracts did not contain a breakdown of all the fees charged by the home. Residents’ needs had been assessed. Specialist medical and nursing staff were regularly consulting with the staff at the home and advising good practice. EVIDENCE: A relative said that the contract they had did not provide a breakdown of the fees charged by the home. The manager and registered provider of the home said that they would check all contracts of the residents to ensure that residents’ finances are fully safeguarded. Two resident files were checked and each contained a copy of their full needs assessments. The information from the full needs assessment had been incorporated into the resident care plans. Details of medical/nurse specialists who had been consulted with regard to the residents care were recorded in the care plans. This will assist in ensuring residents needs are met. Belmont House J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 and 11. Care plans detailed information relating to residents health, personal and social needs. A range of health care professionals visited the home to assist in maintaining the health care needs of residents. Residents themselves said that they were very satisfied with the care they were receiving and that the staff were friendly and polite. Relatives said that the care delivered by staff was excellent. In the main the residents’ privacy and dignity was maintained. Current medication practices undertaken by staff were safe. Belmont House J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 10 EVIDENCE: Two care plans set out in detail the residents needs and the action to be taken by the qualified and care staff of the home to ensure all these could be met. The care plans had been regularly reviewed by the staff. Residents and their relatives said they were involved in drawing up and the review of the plans. Residents said that they were happy and that all the staff were very nice. Relatives said that the staff of the home were” very nice”. Relatives said that the care given by staff was “very good or excellent”. Residents were well dressed in clean clothes and had received a good standard of personal care. Residents’ nails were clean and their hair was well groomed. The male residents had been shaved and some of the ladies were wearing makeup. Medication procedures provided protection to residents. Medicines were securely stored around the home in locked cupboards within treatment rooms. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. The inspector saw that one resident did not receive personal care in a manner that respected their privacy and dignity as they were having their toe nails cut in a lounge occupied by other residents. Other residents were observed to receive personal care in a manner that respected their privacy and dignity as staff knocked on residents door and waited before being invited in. Residents and relatives said that said that staff were polite and helpful. The residents’ wishes concerning terminal care and arrangements after death were recorded in the care plans. Belmont House J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15. Residents had a choice of lifestyle within the home and they were able to maintain contact with family and friends. Meals served at the home were of a good quality and offered choice, however two residents were not offered assistance to eat in a discreet and sensitive way. EVIDENCE: Activities were occurring during this inspection. Some residents were taking a walk outside with their relatives. Other residents were sat outside, on the new chairs that had been purchased, having a cup of tea with their family. Residents said that they were able to maintain contact with their family and friends. Relatives said they were always made to feel welcome when they visited. A friendly and welcoming feel was evident in Belmont House. Residents said they chose when they got up and went to bed. Residents were having breakfast at different times in the morning. Lunch was generally served in a pleasant relaxed manner, however two members of staff assisted residents to eat whilst they were stood up. Residents said the quality of food served was good and that “there was plenty of it”. Residents said that they enjoyed their lunch. Belmont House J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 12 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 standard(s) 16 and 18. The homes complaints procedure was clear and accessible. Complaints made were listened to and action taken to deal with any issues promptly. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home. EVIDENCE: Complaints procedures were displayed around the home. Relatives and residents said that if they had any concerns that they would feel comfortable in talking to the staff or the manager. Records checked indicated that staff had received information and training on adult abuse. This will help to ensure that residents are protected from abuse. Belmont House J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 13 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 standard(s) 19,20,21,22,24,25 and 26. The environment within the home was on the whole well maintained and clean providing a comfortable, safe environment for residents. Belmont House J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 14 EVIDENCE: The grounds around the home were very welcoming and residents and their relatives were sat in the new garden furniture that had been recently purchased. Since the last inspection refurbishment of the home has commenced. The lounge and dining areas on the ground floor had been redecorated and new carpet had been laid which had markedly improved the aesthetics of this room. Some corridors and communal areas in the home are in need of decoration, as the décor is looking rather tired. However the environment within the home was on the whole, well maintained providing a comfortable, safe environment for residents. Four bedrooms were checked in detail and many others seen, all were comfortable and homely. Residents said their beds were comfortable. Bed linen checked was clean and in a good condition. The home on the whole was clean, with no unpleasant odours noticeable. However two chairs in the lower ground floor lounge were marked with food splatters and had food debris down the inner arms of them. These chairs were cleaned prior to the end of inspection. Relatives and residents said that the home was always kept clean. The home was warm in all areas. Window restrictors were fitted to all windows checked. Staff said that there were enough hoists available to ensure that residents could be safely moved. Belmont House J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30. Staff were employed in sufficient numbers. Further detail was required in staff recruitment files in order to protect residents who lived at the home. New and existing staff had undertaken training in various subjects. EVIDENCE: The manager stated that agreed staffing levels were being maintained. The staff rota identified agreed staffing levels had been met. This will assist in making sure that service users needs are met. Residents said there was always a member of staff available when they needed them. Staff said staffing levels were adequate. Fifty per cent of care staff had not achieved their level 2/3 NVQ qualification although the manager said that several staff were undertaking the course. The recruitment information obtained for new staff was insufficient to adequately protect the welfare of residents who lived at the home. The recruitment practices were generally sound although a reference was not obtained from the actual manager from the member of staffs last employer. The staff application form used at Belmont did not request the employee to specify the actual dates they were employed at their previous employments. The staff files did contain references from the staffs’ last employer and a Criminal Record Bureau (CRB) check. Staff said that there were good training opportunities available to them, which enabled them to feel competent to do their job. Belmont House J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,36,37 and 38. There was a positive style of management in the home. Staff said they were appropriately supervised on a continuous basis. The homes policies and procedures promoted the health, safety and welfare of residents and staff. Belmont House J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 17 EVIDENCE: The manager said that she had nearly completed her NVQ level 4 in management and care. Relatives and residents said that they met regularly with the manager and spoke positively about her approachability and helpfulness. Resident and other professional questionnaires, which had been returned to the home, were seen. This quality assurance monitoring will help to ensure that the home is run in the best interests of the residents. No records were available to indicate that recorded visits by the registered provider had been carried out, although residents and relatives said they regularly saw the registered provider. Staff said that they enjoyed working at the home and regularly attended staff meetings. Residents’ financial interests were safeguarded as the residents’ personal money accounts were up to date and a receipting system and statement sheets were seen for each resident, interest was paid by the bank on residents monies. Bank statements were held at the home. Staff said they were receiving supervision and management support on a regular basis, Records were securely stored around the home, which protected the residents’ best interests and confidentiality. Staff said they had received recent fire safety training .A sample of records showed that staff were receiving this and other statutory training. At the time of inspection no fire exits were blocked and window restraints were in situ at first floor windows checked to prevent falls. Hazardous products were safely stored in the home. This will promote the safety and welfare of the service users. Belmont House J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 3 3 3 x 3 3 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 2 x x 3 3 3 Belmont House J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 2 Regulation 5 Requirement Each resident receiving nursing care must have a contract, which provides a breakdown of all the fees charged. (Previous timescale of 01/04/05 not met) Residents privacy and dignity must be maintained whilst any personal care is being given. Residents must be offered assistance to eat in a discreet and sensitive way. All areas of the home used by residents must be well maintained. Furniture must be kept clean. (Actioned at the time of inspection) A thorough recruitment procedure must be followed and this must be demonstrated on individual staff files together with information required by the regulations and standards. The registered provider must visit the home and produce a report. The report must contain the information as highlighted in regulation 26. Timescale for action 01/09/05 2. 3. 4. 5. 6. 10 15 19 26 29 12 12,13 23 23 17,19 01/07/05 01/08/05 01/04/06 01/07/05 01/09/05 7. 33 26 01/09/05 Belmont House J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 28 31 Good Practice Recommendations Preparations should be made to ensure that 50 of staff are trained to NVQ level 2 or equivalent by 2005. The registered manager should achieve a level 4 NVQ qualification in management or equivalent by 2005. Belmont House J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Unit 3, Ground Floor 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 J51 S63332 Belmont House V230022 08.06.05 UI Stage 4.doc Version 1.30 Page 22 - 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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