Inspection on 27/09/07 for Belmont Villa Care Home

This inspection was carried out on 27th September 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Belmont Villa Care Home 22/08/06

Belmont Villa Care Home 23/11/05

Belmont Villa Care Home 15/09/05

Belmont Villa Care Home 01/03/05

Belmont Villa Care Home 29/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Belmont Villa Nursing & Residential Home 58-62 Weymouth Road Frome Somerset BA11 1HJ Lead Inspector Justine Button Unannounced Inspection 27th September 2007 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.V349014.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.V349014.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 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Up to 31 places for elderly persons of either sex, not less than 60 years, who require nursing care. Up to five persons of either sex, in the age range 45 - 60 years, who require nursing care. 22nd August 2006 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 31 service users with nursing care needs. Currently there are twenty-nine single rooms with en-suite facilities. The service has five 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-£726 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.V349014.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out the inspection over 8 hours on one day. The Registered Manager provided the Commission with the required preinspection information about the home and surveys were sent to service users, relatives and visiting professionals. In addition the home has conducted it’s own surveys. Information has been included in the relevant areas of the report. On the day of the inspection 31 people were living in the home. The current fee rates are: £450 and £726 for nursing care. Free Nursing Care payments are included in this fee level. The inspector spent time during the visit observing care and daily life at Belmont Villa, toured the building and spoke to staff, service users, relatives and a visiting professional. A range of records was inspected and the care of a selection of individuals examined in detail. Throughout the visit the atmosphere in the home was calm and relaxed. Staff interactions with service users were respectful, clear and appropriate. The home does not currently employ an activities organiser but staff spent some time during the afternoon engaging service users in social activities and conversation. Feedback received during the visit and through the surveys was positive about the home, including comments such as ‘staff are lovely’ and ‘they care for me well’. The Registered Manager, Sharon Welsh, was available throughout the inspection and was given feedback at the end of the day. The inspector would like to thank the service users and staff for their welcome and assistance during the inspection. What the service does well: Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 6 The home provides detailed information about the home that is made available before a person chooses to move into Belmont villa. The home provides suitable accommodation to meet service user needs with accessible communal areas both inside and out. The home is clean and tidy. Medication is well managed and minimises risks to service users. Bedrooms are pleasant and personalised. Residents’ benefit from the aids and adaptations provided at the home to include adjustable beds, mobile hoists and grab rails throughout. Service users benefit from a committed staff team who provide a good standard of care in relaxed and friendly surroundings. Staff are provided with a range of training and exceed the standard for numbers of NVQ qualified staff. Meals are wholesome and provided in homely and unhurried surroundings. The home is well managed and organised. The home has systems which actively seek the views of people living at the home, relatives and visiting professionals. The home acts on the comments received and are always seeking to improve the lives of people living at the home. A service user comment received stated ‘I receive excellent care I could not ask for better’. What has improved since the last inspection? At the last inspection which was conducted in August 2006 no requirements were made at this inspection. Some of the bedrooms have undergone recent decoration and refurbishment and the home over all provides a good standard of care and support. Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 7 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 Villa Nursing & Residential Home DS0000003242.V349014.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.V349014.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1. 2. 3. 4. 5. 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make an informed choice of whether to stay at Belmont Villa from the information available to them. Residents were assessed prior to admission to ensure the home can meet their needs. Residents have a contract of terms and conditions, which informs them of what to expect including the fees and what is not included. EVIDENCE: Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 10 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. Residents spoken to confirmed receipt of a guide about the home. The home receives the single assessment process (SAP) paperwork for new service users and new admissions to the home. The manager would also meet 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 care plans sampled. 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. People who had recently moved into the home confirmed that they or their relatives had been able to visit the home prior to admission. Belmont Villa Nursing & Residential Home DS0000003242.V349014.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7. 8. 9. 10. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The care plans need additional development to ensure that they adequately reflect the care and support required by individuals. The management of medication within the home was generally very good although some minor improvements are required. Residents are able to have privacy in their own rooms. Personal support was offered in a way to promote the privacy and dignity of residents. Service users were treated with respect and looked well cared for. EVIDENCE: The deputy manager stated that three people at the home had pressure ulcers. The inspector sampled four care plans, including those with pressure ulcers, and met with the individual residents as part of the case tracking process. Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 12 A range of assessments were in place in all the plans viewed. The assessments had been completed and reviewed on a regular basis by the Registered Nurses. The assessments and the associated plans of care were however inconsistent. One individual has difficulties in swallowing. The nutritional assessment was not reflective of this issue and therefore inaccurate. The home had sought advise from the Speech and language therapist with regard to this issue. The care plan did not reflect the advice given by the therapist. This may have placed the individual at risk. The plan of care did not give clear guidance to staff on the consistency of food that should be served. Since admission to the home the individual had developed a pressure ulcer. The care plan relating to this area of care was not adequate. The plan stated, “change position at regular intervals”. This statement is not specific and does not give clear guidance to staff. No wound charts tracing or photographs were in place relating to the pressure ulcer. It is difficult for staff to assess the progress of the wound and if the ulcer is responding to treatment. Nutrition impacts on the body’s ability to heal. Given that this individual has a pressure ulcer it is even more important that the nutritional assessment had been completed correctly and accurately. A second individual was receiving nutrition via a PEG (a tube into the stomach via which specialist food is given. Usually used for people who are unable to swallow) The dietician had provided details of the food to be given. The staff had completed regular weights for the individual. The nutritional risk assessment stated that no weight loss had been noted over the last few months. The care plan however stated that some weight loss (9lb) had been noted between April and September 2007. The book in which staff record weights stated that 1 stone weight loss had been experienced. The information is therefore inconsistent. It could not be confirmed if the dietician had been informed of the weight loss in order that the calorific value of the feeds could be reviewed. The care plan did not give clear instructions with regard to the feeding regime to be implemented. The plan did not state what feed should be given nor at what rate the feed pump should be set. For the third individual the daily statements made by staff stated that the individual had a pressure ulcer. No wound charts were in place for this pressure ulcer. No sizes, tracings or photographs were in place to show the progress of the ulcer. There were no details what dressings were being used. It could therefore not be confirmed if the wound was responding to treatment. The care plans were very basic and included statements such as “ensure regular positional change” This does not give clear guidance to staff on the care and support required in this area. A change of position (usually two hourly) helps in the prevention and healing of any pressure damage. Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 13 None of the care plans viewed for all individuals were person centred. None contained a full social history. None detailed the individuals likes and dislikes nor how and when the individual would like care to be delivered. Details such as when the person liked to get up or go to bed, how frequently they would like a bath etc were not detailed. As stated the care plans contained many ambiguous statements such as “ensure bedrails positioned well” “make sure is in a comfortable position when eating”. The management need to ensure that the care plans give clear guidance to the staff on the care and support needs of all individuals and how these needs are to be met. In the plans viewed it could not be confirmed if any individual had received the opportunity to be involved in the development or review of their plan of care. In the survey completed by the home, however, seven out of the thirteen people involved in the survey stated that they were adequately involved in the planning of care. People spoken to during the inspection stated that they felt that their health care needs were met. The home currently supports a number of people who are frail and as such nursed in bed. The inspector visited these people at intervals throughout the inspection. All people seen had a regular change of position and were help by staff to have regular fluids. A number of people had charts in the room on which staff documents the care given. These had been completed inconsistently despite appropriate care and support being provided by staff. Charts should be used to monitor and influence the care being provided. If the charts are not being completed consistently by staff it is difficult to understand how this process is completed. This was discussed with the manager at the end of the inspection who agreed to review the usage of charts and to ensure that those in place were completed accurately. All people observed in both the communal areas of the home and those nursed in bed appeared to be clean comfortable and well kempt. Oral hygiene had been completed as toothbrushes and toothpaste had recently been used. People, both people living at the home and relatives were all very complementary about the care and support provided by staff. Comments on the recent survey included “ very caring”, “very good they are all very caring” 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. People spoken to during the inspection stated that they thought that their privacy was maintained. Staff were seen interacting kindly to residents and were seen knocking on doors before entering. Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 14 The medication systems a t the home were viewed during the inspection. Medication was on the whole well managed. Prescribed creams were seen in the majority of rooms assessed and all had been dated on opening however these had not been signed as applied on the medication administration record (MAR). Some people living at the home had received a change to their medication. Due to these changes staff had written the new medication on the MAR. It is could practise that a second person checks this entry to ensure that the correct details had been written. Both staff members should then sign the MAR. On the hand written entries seen only one staff member had signed the entry. This needs to be reviewed by the management team. Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 15 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 good This judgement has been made using available evidence including a visit to this service. Activities are well advertised and well managed. There is a good range of social events and for the less able there are opportunities for one to one social contact. Surveys indicated service users found the activities suitable Families were seen to be welcomed and to be part of the home life. The menu is varied. The food on the day of the inspection was of a good standard. EVIDENCE: The home does not currently employ an activities organiser. At least one of the care staff provides activities on a daily basis. Recent activities have included a trip to Longleat, the week before the inspection. Six people had recently visited a local market. A recent coffee morning had been held with the manager. This coffee morning gives the people living at the home an opportunity to Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 16 discuss any issues they may have in an informal setting. At a recent meeting a number of people had stated that they would like the opportunity to have “take away” food occasionally. A curry evening was therefore organised. All who chose to participate enjoyed this. A future evening having fish and chips has been arranged. The survey recently conducted by the home identified that people were overall satisfied with the activities and social opportunities provided by the home. 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 has a visiting minister who conducts Holy Communion on a monthly basis. The home stated in the information received prior to the inspection that the needs of people from other religious denominations will be met when required. 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. Visitors were observed coming and going throughout the day of the inspection. Lunch was observed in the dining rooms, the dining rooms are well presented with condiments and napkins. The inspector has visited the service several times and has always found the food to be of an excellent standard. This was confirmed by feedback form people living at the home. Staff were observed assisting service users in a manner which was relaxed, unhurried and respectful. 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. Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. 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. Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 18 Staff spoken to understand the lines of communication should they suspect any form of abuse. Abuse training is provided during new staff induction. Three staff recruitment files were viewed. These showed that robust pre employment checks are carried out. Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 19 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, 21, 22, 23, 24, 25, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 20 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. There was adequate equipment in respect of relieving pressure areas. The cleanliness of the home was very good at this inspection. Infection control measures were in place. When asked through surveys is the home always fresh and clean 100 residents indicated that it was. Comments included “good, spotless.” “ Cleaned everyday lovely” All laundry is completed in house. When asked about the laundry service twelve people stated that it was good. One person stated that laundry some times got mixed up. Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 21 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 or working towards an NVQ qualifications in care is 99 . The services recruitment procedures were good and protected residents from harm. EVIDENCE: At the time of this inspection there were 30 residents living at the home. The registered provider and registered manager were available throughout the inspection. Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 22 There was a Registered Nurse (RN) on duty and in charge of the shift from 88pm. There were six 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. The home has a stable staffing group which aids consistency and continuity. The home has not used any agency staff in the last 12 months. People living at the home 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. There are 22 care staff employed at the home. 19 of these staff have gained an NVQ in care. The remaining are working towards this award. This 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. The residents survey conducted by the home demonstrated that some people living at the home found communication difficult at times. The manager has addressed this issue with the nurses and concluded that this was due to cultural differences and accent. The staff are now aware of this issue and are working hard to improve. Three staff recruitment files were examined which evidenced good robust recruitment practice. Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 23 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, 32, 33, 35, 36 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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.V349014.R01.S.doc Version 5.2 Page 24 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 currently enrolled 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 April 2007. The home sought the help of an independent advocate to support people living at the home to complete the survey. This is very positive. 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. Staff stated that they felt well supported. The home completed a staff survey and all those who replied stated that they felt well supported and found the management approachable. 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 are well maintained and demonstrated that all necessary checks are completed. Fire alarms are tested weekly and records are maintained. 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.V349014.R01.S.doc Version 5.2 Page 25 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 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 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 3 3 X 3 3 X 3 Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15 (1) Requirement It is required that the management, in consultation with people living at the home, ensure that there is a written care plan in place for each individual. The plan of care should detail in full the individuals needs and give clear guidance to staff on how these needs are to be met. Timescale for action 18/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP8 Good Practice Recommendations The registered manager should audit the use of fluid balance charts and ensure staff responsible, complete and total them to determine individual residents hydration. It is recommended that the registered person ensure that two staff sign any hand transcribed entries, which are made on the Medication Administration Record. 2. OP9 Belmont Villa Nursing & Residential Home DS0000003242.V349014.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. 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