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Inspection on 22/08/06 for Belmont Villa Care Home

Also see our care home review for Belmont Villa Care Home for more information

This inspection was carried out on 22nd August 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Prospective residents and their representatives are able to visit the home and have access to an informative Service User Guide before making a decision to move into the home and residents benefit from being assessed by the home before admission to see if it can meet their needs. Residents are able to have visitors at any time and keep links with the local community. Visitors seen during the inspection were satisfied with the provision of care at the home. Comments received from residents during the inspection included: `its very pleasant here`, `the garden is lovely`, `I feel very happy in this home and can please myself`, `the food is always nice`, `the staff are very nice`, and `the staff are kind and helpful`. Residents benefit from safe medication systems at the home.Residents and staff spoken to were aware of the complaints procedure, which forms part of the service user guide. One resident stated `I would tell the manager if I had any concerns` Residents` benefit from a good choice of wholesome, varied food. The gardens and the home are well maintained. The cleanliness of the home was good at this inspection. Residents` rooms are homely and personalised with their favourite items. Residents` benefit from the aids and adaptations provided at the home to include adjustable beds, mobile hoists and grab rails throughout. Residents benefit from staff being trained and competent to do their jobs and understand their individual needs. Residents benefit from being able to trust the home to look after their personal monies should they be not able to look after it themselves. Safe systems are in place.

What has improved since the last inspection?

New furniture has been provided in three bedrooms, the conservatory and lounges. Refurbishment is on-going. All hand transcribed medication had been signed and witnessed by a second person to demonstrate that what was written was correct, to protect residents from harm. Staff have not commenced employment before being checked for their integrity and fitness through POVAFirst and the Criminal Records Bureau to ensure that residents are not placed at any risk of harm.

What the care home could do better:

Residents would benefit more if, in consultation with them, their care plans were developed, to include their personal preferences and cultural needs being recorded, to ensure the home can meet their needs fully. Residents would benefit from their individual fluid balance charts being completed and totalled on a daily basis, and then monitored, to ensure they had received adequate fluids in accordance with their care plan. Staff responsible should ensure that syringes used as part of care for gastric `peg` feeding, in regard to flushes and administration of medication are disposed of in accordance with current best practice guidelines. Prescribed creams should be disposed of once they reach the recommended expiry date.

CARE HOMES FOR OLDER PEOPLE Belmont Villa Nursing & Residential Home 58-62 Weymouth Road Frome Somerset BA11 1HJ Lead Inspector Caroline Baker Unannounced Inspection 22nd August 2006 09:30 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 Villa Nursing & Residential Home DS0000003242.V305698.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 Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belmont Villa Nursing & Residential Home Address 58-62 Weymouth Road Frome Somerset BA11 1HJ 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) 01373 471093 Belmontvilla@aol.com Belmont Villa Residential & Nursing Home Ltd Mrs Sharon Welsh Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Up to 27 places for elderly persons of either sex, not less than 60 years, who require general nursing care. Up to 5 places for personal care. Up to five persons of either sex, in the age range 18-59 years, who require general nursing care. Date of last inspection Brief Description of the Service: Belmont villa is a family run Care Home set in a residential area of the town of Frome. The home is registered with the Commission for Social care inspection (CSCI) for 32 service users. There are twenty-seven places for the provision of nursing care (includes one twin room that can be used by married couples or those wishing to share) and five places for personal care. Currently there are twenty-nine single rooms with en-suite facilities. The service has four bathrooms, two shower rooms and eight separate W.C’s. In addition there are five day/quiet rooms. The service also has accessible gardens to the rear. All laundry is done in house. The current fees range from: £450-£625 per week. Hairdressing, chiropody, newspapers, personal installation of telephones and calls, escorting residents to appointments, checking and stamping personal electrical equipment, and toiletries are not included within the fee. Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key Inspection was unannounced and took place over one day and was conducted by Caroline Baker, which amounted to 7 inspector hours. There were 26 residents living at the home at the time of this inspection. Prior to the inspection the registered manager had completed a questionnaire about the service and ten residents, two GP’s and two Health Care Professionals had completed and returned commission questionnaires. The commission sent surveys to twelve residents. A tour of the premises took place where a selection of bedrooms and all communal areas were seen. The inspector consulted with at least 10 service users, 1 visitor and 4 staff during the inspection. During the inspection the inspector observed interactions between staff and residents. The inspector would like to thank the residents, manager and staff for their time during the inspection process. What the service does well: Prospective residents and their representatives are able to visit the home and have access to an informative Service User Guide before making a decision to move into the home and residents benefit from being assessed by the home before admission to see if it can meet their needs. Residents are able to have visitors at any time and keep links with the local community. Visitors seen during the inspection were satisfied with the provision of care at the home. Comments received from residents during the inspection included: ‘its very pleasant here’, ‘the garden is lovely’, ‘I feel very happy in this home and can please myself’, ‘the food is always nice’, ‘the staff are very nice’, and ‘the staff are kind and helpful’. Residents benefit from safe medication systems at the home. Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 6 Residents and staff spoken to were aware of the complaints procedure, which forms part of the service user guide. One resident stated ‘I would tell the manager if I had any concerns’ Residents’ benefit from a good choice of wholesome, varied food. The gardens and the home are well maintained. The cleanliness of the home was good at this inspection. Residents’ rooms are homely and personalised with their favourite items. Residents’ benefit from the aids and adaptations provided at the home to include adjustable beds, mobile hoists and grab rails throughout. Residents benefit from staff being trained and competent to do their jobs and understand their individual needs. Residents benefit from being able to trust the home to look after their personal monies should they be not able to look after it themselves. Safe systems are in place. What has improved since the last inspection? What they could do better: Residents would benefit more if, in consultation with them, their care plans were developed, to include their personal preferences and cultural needs being recorded, to ensure the home can meet their needs fully. Residents would benefit from their individual fluid balance charts being completed and totalled on a daily basis, and then monitored, to ensure they had received adequate fluids in accordance with their care plan. Staff responsible should ensure that syringes used as part of care for gastric ‘peg’ feeding, in regard to flushes and administration of medication are disposed of in accordance with current best practice guidelines. Prescribed creams should be disposed of once they reach the recommended expiry date. Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 7 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 Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 8 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 Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 9 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): 1 and 3. Standard 6 is not applicable to the service. Quality in this outcome group was good. Prospective residents and their relatives are able to make an informed choice before they make a decision to be admitted to the home. The service undertakes pre-admission assessments to see if it can meet the prospective residents needs. EVIDENCE: The home provides an up to date Statement of Purpose that clearly sets out the objectives and philosophy of the service. This is supported by a service user guide, which forms part of a residents contract with the home. Both documents were updated in April 2006 and a copy is held on file by the CSCI. Residents spoken to confirmed receipt of a guide about the home. Surveys received evidenced that 80 of residents had received enough information about the service before admission. The home receives the single assessment process (SAP) paperwork for new service users and new admissions to the home. The manager would also meet Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 10 and assess prospective residents for their suitability for the home to ensure that care needs can be met. Examples of pre-admission assessments and community care reviews were seen in the three care plans sampled. As discussed more information should be recorded and known before admission in regard to individual residents cultural needs and preferences, for example times of getting up or going to bed, to ensure the home can meet all the needs of individuals admitted. The manager agreed to add the information to the documents on the day of inspection, and the inspector was satisfied that action would be taken. The home does not offer its own intermediate care service. Social services have block-contracted places known as ‘step down’ beds for persons leaving hospital and requiring 4 to 6 weeks care. One bed place is paid for by the PCT and is used as for intermediate care provision but with the supplementary services such as physiotherapy and occupational therapy being provided by the PCT and not by the home. Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 11 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): 7; 8; 9 and 10 Quality in this outcome group was adequate. Each resident had an individual plan of care; those seen were detailed with clear actions for staff to take to deliver care. There was some evidence of input from the resident and/or their representative. Care planning practice was good however some areas in regard to residents’ records of hydration and nutritional needs needed improving. Medication administration and recording practise was overall very good, and protected residents from harm, however current policies on enteral ‘peg’ feeding and the disposal of syringes were not being followed. Many prescribed creams stored in residents’ rooms, although dated on opening had passed the recommended expiry dates. Staff showed respect towards residents and allowed their privacy and dignity to be maintained in regard to personal care. Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 12 EVIDENCE: The inspector sampled three care plans and met with the individual residents as part of the case tracking process. The care plans contained records of detailed actions for care staff to be able to deliver the correct care. Current care needs were reflected. There was evidence in one care plan that the resident and their family had had input into their care plan. As discussed care plans should be drawn up in consultation with the resident and/or their representatives in all cases to ensure the care delivered is agreed with the individual. The manager agreed, and told the inspector that she may involve the key workers to review care plans with their individual residents. Many residents were having their fluid balance, intake and output monitored, however at least three fluid balance charts seen had not been totalled making it difficult to determine whether adequate fluids had been given (this had been raised as an issue at the staff meeting in July 2006 according to the minutes). As mentioned previously individual residents preferences and cultural needs were not reflected in the three care plans sampled. Two care plans sampled contained social profiles. One care plan did not have a nutritional needs assessment and the resident had not been weighed when they were admitted. One care plan in regard to enteral ‘peg’ feeding was not detailed enough in regard to use of syringes for liquid medication and flushes. On assessment of the individual residents room at least five used syringes, containing debris and medication were found in a tub by the feeding pump. This was brought to the attention of the Nurse in charge who disposed of the syringes immediately. The home should follow current best practice guidelines and dispose of syringes in line with these to prevent any risk to residents. The home has good communication with the local hospital and community health care services. The home also benefits from having a regular weekly visit from one of the local G.P practices. Surveys from Health Care Professionals and GP’s indicated that they were satisfied overall with the level of care provision at the home. Visitors spoken to were satisfied with the provision of care. Residents consulted with told inspectors that the staff were kind and caring and the majority indicated that the home meets their needs. Residents seen looked well cared for and those seen nursed in bed were clean and comfortable. Those residents requiring specialist pressure relieving equipment had been provided with it and it being used effectively. The medication records of 14 residents were assessed and best practice was noted throughout. Controlled Drugs (CD’s) were stored appropriately and those checked reconciled with the CD register. Prescribed creams were seen in the Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 13 majority of rooms assessed and all had been dated on opening, however were noted to have expired according to expiry guidelines supplied by the CSCI pharmacist. The manager agreed to take action to audit all creams and to discard any out of date. Staff demonstrated a good understanding of how to promote privacy and dignity and examples of how they do this were seen. Health and social care professionals confirm that they see their residents in private through surveys received. Staff were seen interacting kindly to residents and were seen knocking on doors before entering. Residents spoken to confirmed that staff treated them with respect and helped to maintain their privacy when delivering personal care. Surveys received from residents (10 out of 12) indicated that 60 of residents felt that they always got the care and support they needed, and 40 thought they usually did. When asked if staff listen and acted on what they said 100 indicated that they did. When asked if the staff are available when they need them 50 of residents indicated that they always were, and 50 indicated that they usually were. Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12; 13; 14 and 15. Quality in this outcome group was good. There was evidence of individualised social care. Individual residents social care profiles were completed in two of the care plans sampled. Social activities records were maintained. Staff interaction with residents was good. Residents are able to maintain links with their families and friends. Residents are able to access their records, and are encouraged to manage their own finances. Residents were able to choose how they spend their day. Menus are available and appear nutritious with a specified choice. Residents enjoy the food provided. The dining area was a pleasant environment to eat a meal. EVIDENCE: In the care plans viewed an assessment of social needs was seen in two cases. Records of activities attended were maintained. People who gave an opinion during the inspection stated that activity provision was good. At the time of this inspection there was no activity organiser employed, however part of all the staffs work was social care, which is seen as good practice. A programme of activities is in place and includes morning prayers, flexercise, board games, Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 15 a sing-a-long, walks in the park, flower arranging, drawing and painting, and one to one chatting. At the time of this inspection residents at the home had planted hanging baskets in the garden. It was evident that the activity programme is developed in line with individual residents preferences and choices. Surveys received form residents indicated that 50 of residents thought that there were activities at the home that they could take part in, 30 thought there usually were and 20 thought they sometimes were. During the inspection residents were seen socialising with each other, watching TV, reading newspapers, knitting, or listening to the radio. Those consulted told the inspector that they were able to choose how they spent their day. The home encourages residents to continue to handle their own financial affairs fro as long as they wish. The service user guide points residents and their representatives to where they can access advocates should they need to. The home has an open visiting policy and people living at the home confirmed that visitors were welcomed. The visitors’ book indicated many visitors to the home. All residents in their rooms could access a call bell, and call bells are found in the communal areas to enable residents to summon assistance should they need to. The inspector was able to join the residents for lunch, and enjoyed a meal of chicken and beef stew, new potatoes and fresh vegetables. Residents spoken to were very complimentary about the food. They were given a choice of all meals. Menus look well balanced and varied and had been re-developed taking into account the recent document ‘Highlight of the Day’. Dining rooms were pleasant rooms to have a meal in and residents could stay in their rooms to eat if they wished. Most residents asked knew what they were having for lunch, some had forgotten. Residents are asked on a daily basis for their choices. Hot and cold drinks were available between meals and biscuits and/or homemade cake were available. Fresh fruit was available. Snacks are now available during the evening. Those residents needing assistance with meals were treated with respect and not hurried. The atmosphere at the home throughout the day was unhurried, happy and relaxed. When asked through surveys about the food provision 70 of residents indicated that they always liked the meals at the home and 30 stated that they usually did. Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 16 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): 16 and 18 Quality in this outcome group was good. Residents and visitors to the home have the information to enable them to make a complaint or raise concerns. Arrangements for protecting residents from harm or abuse were good. EVIDENCE: The home had a complaints procedure, which was available to service users, staff, and visitors. It forms part of the Service User Guide and is detailed in the Statement of Purpose. Service users who were able and staff spoken with informed the inspectors that they would not hesitate in raising concerns if they had any. No complaints had been received by the home since the last inspection. The CSCI had not received any against the home since the last inspection. Staff spoken to understand the lines of communication should they suspect any form of abuse. Abuse awareness is provided at induction for all staff. Staff spoken with and training records seen confirmed this. POVAFirst checks had been undertaken before staff had commenced working at the home. Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 17 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): 19; 22; 24 and 26 Quality in this outcome group was good. The homes provision of a safe environment for residents was good. Residents are able to individualise their private rooms. Arrangements for the control of infection were good. EVIDENCE: The home was well maintained on the day of inspection and according to records seen, complied with the local fire and environmental health departments. An employee at the home undertakes routine maintenance and records are maintained. The gardens were well maintained and pleasant areas for residents to access. The home was well equipped with mobile hoists and bath hoists to aid mobility. Corridors are of a good width for wheelchair access and adaptations such as hand rails and grab rails are available to aid with mobility. Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 18 The cleanliness of the home was very good at this inspection. Infection control measures were in place. When asked through surveys (10 out of 12) if the home is always fresh and clean 100 residents indicated that it was. Domestic staff spoken to had received COSHH training and had gained NVQ level 1 in cleaning. Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 19 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): 27; 28; 29 and 30. Quality for this outcome group was good. Staffing levels were good at the time of this inspection. The service encourages the development of a competent staff team; therefore residents are in safe hands. Training provided is good with areas identified and targeted at relevant individuals. Staff with NVQ qualifications in care was at 80 . The services recruitment procedures were good and protected residents from harm. EVIDENCE: At the time of this inspection there were 26 residents living at the home. The registered provider and registered manager were available throughout the inspection. The administrator at the home was very helpful and an asset to the home, it was evident residents and staff had respect for her. There was a Registered Nurse (RN) on duty and in charge of the shift from 8-8pm. There were five care staff on duty during the morning and five during the afternoon up until 21:00 hrs. Staffing levels were adequately maintained at this time. Duty rotas seen evidenced consistency of staffing levels. Residents spoken to indicated that staffing levels were adequate and that staff took their time and were always kind and caring. Staff spoken to felt that staffing was adequate. Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 20 There are 22 care staff employed at the home. 80 have gained an NVQ in care, which exceeds Standard 28. Records seen and speaking to staff evidenced that all staff had received mandatory training and induction. According to records seen training has been provided, to include palliative care, first aid, ‘stroke support’, wound management, medication training, continence promotion, dementia awareness, and diet and nutrition. Individual staff training needs had been identified and recorded, through supervision. Two staff recruitment files were examined which evidenced good robust recruitment practice. Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 21 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): 31; 33; 35; 36 and 38 Quality in this outcome group was good. Residents’ benefit from an experienced Registered Manager who is open to new ideas and any suggestions from them and their families for improving all aspects of the provision of care, through quality monitoring. The home encourages residents to deal with their own finances, however holds small amounts of individual residents personal monies safely at the home. Residents can be confident that staff receive the supervision and support they need to ensure they are always working effectively and in the best way. Service users are protected by the health and safety checks in place. Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 22 EVIDENCE: The Registered Manager is Sharon Welsh a First Level Registered Nurse with considerable experience in managing the care home. She keeps herself up to date with current legislation and attends training updates regularly to enable her to pass her knowledge on to care staff as part of their in-house training. She is a qualified NVQ Assessor, and is waiting funding to enrol on a Level 4 NVQ management course. Quality monitoring systems and policies were in place, and the home has actively sought views from residents and other stakeholders on the conduct of the home in February 2006. Residents and staff meetings have been held since the last inspection. Staff meeting minutes evidence that the home encourages its staff to keep up to date with current legislation, and best practice issues. Supervision of staff on a one to one basis had taken place, and records were seen to evidence this. Monies kept on behalf of residents were assessed as part of the case tracking process. Evidence was seen of a robust system being in place to protect resident’s personal monies and record all transactions. Servicing and maintenance records and pre-inspection information indicated: • • • • • • • • Hoists and assisted baths had been serviced in February 2006. The passenger lifts had been serviced in August 2006. The homes electrical wiring had been safety tested in November 05. The syringe driver was service in November 2005 The patient weigh scales had been calibrated in March 06. Nurse call systems were service in October 2005. Wheelchairs were serviced in February 2006. Fire equipment was serviced in April 2006. Fire alarms are tested weekly and records are maintained. Emergency lighting was last serviced in June 2006 and is checked monthly in-house. All COSSH assessments were last updated and completed in June 2006. Accidents records were maintained and audited by the manager on a monthly basis. Staff accidents were recorded. According to staff spoken to and staff training records all staff had received mandatory training including manual handling, food hygiene, fire awareness, infection control and first aid. Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 23 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 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 4 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 3 Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 24 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. 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 Refer to Standard OP3 Good Practice Recommendations The registered manager should further develop the preadmission assessment format to include prospective residents personal preferences and choices of daily living, and desired cultural needs and practice. Also assessments, care plans and reviews should always be developed in consultation with the individual residents and/or their representatives. 2 OP8 The registered manager should audit the use of fluid balance charts and ensure staff responsible, complete and total them to determine individual residents hydration. Also the registered manager should monitor the way syringes are used and disposed of after giving medication and ‘flushes’ in regard to enteral ‘peg’ feeds and ensure that current best practice guidelines are followed. 3 OP9 The registered manager should further develop the audit DS0000003242.V305698.R01.S.doc Version 5.2 Page 25 Belmont Villa Nursing & Residential Home of dating and disposing of prescribed creams issued to residents, in line with expiry date guidelines, and maintain a record. Belmont Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Villa Nursing & Residential Home DS0000003242.V305698.R01.S.doc Version 5.2 Page 27 - 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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