Inspection on 07/06/05 for Belmont House, Bodmin

This inspection was carried out on 7th 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 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, Bodmin 01/11/06

Belmont House, Bodmin 10/11/05

Belmont House, Bodmin 05/01/05

Belmont House, Bodmin 14/07/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOMES FOR OLDER PEOPLE Belmont House Love Lane Bodmin Cornwall PL31 2BL Lead Inspector Elaine Bruce Announced 07th June 2005 8.15 a.m. 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 D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Belmont House Address Love Lane Bodmin Cornwall PL31 2BL 01208 75057 01208 78836 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) Almondsbury Care Limited Mr Paul Seels Care Home 40 Category(ies) of Dementia - over 65 years of age (40) registration, with number Mental Disorder, excluding learning disability or of places dementia - over 65 years of age (40) Belmont House D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Variation in age in respect of one named person under 65 years Additional variation in respect of one named person under 65 years with Dementia (DE) Date of last inspection 05/01/05 Brief Description of the Service: Belmont House is a large mature property with a purpose built extension on the outskirts of Bodmin. The home is situated in a pleasant residential area and provides nursing care for older people with a dementia or a mental disorder. Car parking is available in the grounds of the home. The grounds include attractive gardens with a patio area. Accommodation is spread over three floors with an inter-connecting shaft lift available if required. The top floor of the home provides bedroom accommodation only. The ground and first floor have bedrooms and communal areas. Security in the home is supported by the use of key pads which allow the service users freedom of movement on each floor of the home. Belmont House D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection at Belmont House took place on the 7th June 2005 over 8 hours and was carried out as an announced inspection. A tour of the premises took place and staff were spoken to. Direct feedback from the service users is difficult to obtain due to their dependency levels. Care records, staff files and policies and procedures were inspected. The Chief Executive from Almondsbury Care was present during the course of the inspection as was the Registered Manager. What the service does well: What has improved since the last inspection? Since Almondsbury Care have taken over the running of the home continual improvements to the premises have taken place. At this announced inspection considerable improvements were noted in the decoration of the majority of the home. Paint colours for the environment have been chosen using proven research for the benefit of the service user group. Belmont House D52-D04 S38589 Belmont House V222661 Ann 070605 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 D52-D04 S38589 Belmont House V222661 Ann 070605 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 D52-D04 S38589 Belmont House V222661 Ann 070605 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) 1 and 4 The home’s statement of purpose and service user guide documentation (as well as a brochure) provide prospective service users/their representatives with details of what the home provides helping an informed decision about admission to the home. Senior management staff are involved in the service user pre admission assessment procedure to ensure that the home will be able to meet their care needs. EVIDENCE: The home has a statement of purpose document in place that meets all the requirements of The Care Homes Regulations (2001). The statement of purpose document is available in the home as is the service user guide. In addition a brochure is available which gives detailed information on Belmont House. All potential new admissions to the home are assessed by the registered manager ofrone of his senior nursing staff prior to admission. A pre admission Belmont House D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 Page 9 assessment document is then completed and signed and dated as required by this standard. Belmont House is providing a specialised service for service users with a dementia and all staff receive regular training in this area by one of the senior nursing staff members. Belmont House D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 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 standard(s) 7,8 and 9 The service user’s health, personal and social care needs are being met by the staff and multidisciplinary staff as required. Medication is being administered correctly to the service users in line with good practice guidelines. EVIDENCE: Each service user has a care plan in place. The care plans have generally been improved in presentation since the last inspection. Each care plan includes a large amount of information to include a risk assessment, current mental health needs assessment, moving and handling assessment and emotional well-being assessment. There is evidence of regular reviews taking place and the daily records that complement the care plans are very good. The daily records clearly evidence that care needs are being met. Health care needs are identified in the service user care plan and how the home is meeting these needs. In addition other health care information/services to include chiropody for example is documented. Documentation is in place for the service users to be weighed regularly but it is noted that there are some gaps in these records. Evidence of nutritional screening is available in care planning documentation. Each service user is Belmont House D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 Page 11 registered with a general practitioner. On the day of the inspection two social workers and a community psychiatric nurse were in the home. The home appears to have a good working relationship with healthcare professionals. The home has a medication policy and procedure in place to guide staff around good practice administration. All medication is administered by qualified nurses from a monitored dosage storage system. Medication administration records were found to be completed appropriately on the day of the inspection. For audit purposes it is recommended that the staff list of signatures and initials is updated. An audit of the controlled drugs was found to be correct as was the storage of. Belmont House D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 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 standard(s) EVIDENCE: These standards were not assessed at the inspection on the 7th June 2005 Belmont House D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a satisfactory complaints procedure provided to the service users in the service user guide/statement of purpose document. The home has in place adult protection policy and procedures and training to provide staff with the knowledge and understanding of adult protection issues to protect service users from abuse. EVIDENCE: The home has a complaints policy and procedure that is clearly displayed in the home. The complaints policy and procedure is also available in the service user guide and statement of purpose documentation. The home has in place a policy and procedure on adult protection. Policies and procedures are available to all staff in the office and the adult protection policy and procedure is individually issued to staff. Documentation is also available on whistle blowing. The registered manager provides basic adult protection awareness training to the staff with a training certificate issued. Two senior staff members have recently attended adult protection training at the local social services department. There are plans for all staff to ultimately receive this training. The home also has the “No Secrets” documentation and video for staff training. Belmont House D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25 and 26 The standard of the environment within Belmont House is constantly improving with the aim of providing service users with an attractive and homely place to live. EVIDENCE: Maintenance work externally and internally continues at the home. Since the last inspection a large amount of improvements to the environment were noted. The entrance to the home is welcoming and corridors are provided with handrails and painted in relaxing colours. Research has been undertaken by the registered managers on colours specifically to enhance the well being of the service users. A large number of bedrooms have now been totally refurbished and new carpets provided in corridors and bedrooms. The dining room is nearly completed and the main area of the home that is now left for refurbishment is the second floor only. Belmont House D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 Page 15 Communal space in the home includes a lounge and dining room, an upstairs lounge/dining room and a lounge extension on the ground floor. Communal space amounts to 3.7 square metres per service user. There is outdoor seating which is accessible to the service users. Toilet doors and bathroom doors in the home are being painted a specific colour with the aim of easy identification by the service users. Ground floor bathing facilities have been considerably improved and now include a walk in shower room. Specialist equipment is available in the home to aid the independence of the service users. This includes for example wheel chairs, hoists and grab rails. Corridors have recently been provided with hand rails. A key pad entry system is in place for the security of the service users. A lift is available to all levels of floors in the home. Call bells are available in all bedrooms. The home has twenty four single bedrooms (without en-suite facilities) and eight double rooms (again without en-suite facilities). Improvements to the bedrooms throughout the home are ongoing. Where this has taken place it includes new furniture, beds, carpets, decoration and bedding. Lockable storage facilities for valuables are available if required. Where bedrooms are shared individual wardrobes and chests of draws are provided. Radiators throughout the home are safe due to their low surface temperatures. Water temperatures for safe bathing are set at recommended temperatures as are the handbasin water temperatures. The home was found to be very clean on the day of the inspection with considerable attention to odour control. Cleaning takes place every day of the week and week end. Belmont House D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 Page 16 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) 27,29 and 30 Staffing levels are appropriate to meet the needs of the service users. Staff training is ongoing and enables the staff to meet the complex care needs of the service users. The staff team are a stable group with no changes since the last inspection. EVIDENCE: Staff work a variety of shifts to include twenty four hour cover with a qualified nurse always on duty. An inspection of the staffing rota confirms compliance with the home’s staffing notice and that a minimum of six care staff members are employed for the busy morning shift. It is noted that the staff team to include management are a very stable team and there has been no recent use of agency cover. The stability of the staff and the resulting continuity of care is of benefit to the service users. Staff files evidence that two written references are being taken prior to employment of new staff and criminal records bureau checks are also taking place. Job application forms are completed by staff and copies of documentation to include birth certificates and passports are held in files. The recruitment of overseas staff has worked very well at Belmont. There is a new induction programme in place ready to be used for the next new staff member employed. This documentation includes specialised training on meeting the care needs of the service user group. Statutory training is Belmont House D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 Page 17 taking place regularly. It is recommended that the fire drill training is logged in the County Council Fire department new book which is a good easy reference for training and the testing of the fire alarm system. Good practice training regularly takes place alongside the statutory training and has included recently training on nutrition. Belmont House D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 Page 18 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 The manager is supported well by the senior staff in providing clear leadership throughout the home. The staff are involved in the running of the home and views are sought from stakeholders and relatives on the running of the home. Recent feed back from relatives was very good on the standard of care in the home. EVIDENCE: The registered manager is a long standing staff member supported by a long standing senior management team. The manager is a qualified nurse and is undertaking his registered managers award qualification. He has also recently undertaken statutory training. He is supported in his duties by two senior staff members, who have each been given specific individual tasks and responsibilities. A representative from the Company regularly visits the home and supplies to The Commission for Social Care Commission evidence of a monthly visit. Belmont House D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 Page 19 Staff are involved in regular meetings which are minuted. These are planned to take place approximately every 2 months. The home has an equal opportunities policy and procedure in place which is evidenced by the staff recruitment application form. A quality assurance monitoring system has recently taken place in the form of a questionnaire to the service users and their family/representatives. The returned questionnaires indicate a very good satisfaction level on the way the home is being run and the standard of the care delivered. A number of relatives commented on the kindness of the staff. A questionnaire has now been designed to seek views from stakeholders on the running of the home. The company representative visits the home twice a month and is regularly involved in the day to day monitoring of the home. Considerable work has taken place by the manager to meet the requirements of the standard in relation to the service users finances. Individual records of the service user’s money are in place and only small amounts of money are being held on the premises. An audit of the finances was able to take place and was correct. All records as required by legislation were found to be in place on the day of the inspection. Belmont House D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 Page 20 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 3 x x 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 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 3 3 4 x 3 x 3 x Belmont House D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 Page 21 NO Are there any outstanding requirements from the last inspection? 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 8 9 Good Practice Recommendations To weigh the service users regularly and record this information To update the list of staff signatures and initials re medication administration. Belmont House D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection John Keay House Tregonissey Road St Austell, Cornwall PL25 4AD 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 D52-D04 S38589 Belmont House V222661 Ann 070605 Stage 4.doc Version 1.30 Page 23 - 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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