Inspection on 05/01/09 for Belong Macclesfield

This inspection was carried out on 5th January 2009.

CSCI found this care home to be providing an Good service.

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

Belong Macclesfield 03/01/08

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Belong Macclesfield Kennedy Avenue Macclesfield SK10 3DE Lead Inspector Wendy Smith Key Unannounced Inspection 5 and 13 January 2009 10:30 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 Belong Macclesfield DS0000070473.V373666.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. Belong Macclesfield DS0000070473.V373666.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belong Macclesfield Address Kennedy Avenue Macclesfield SK10 3DE 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) 01625 508700 belinda.jones@belongmacclesfield.org.uk www.clsgroup.org.uk CLS Care Services Limited Manager not yet registered Care Home 72 Category(ies) of Dementia (37), Old age, not falling within any registration, with number other category (35) of places Belong Macclesfield DS0000070473.V373666.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home with Nursing - Code N, to people of the following gender:- Either; whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP; Dementia - Code DE. The maximum number of people who can be accommodated is: 72. 23 July 2008 Date of last inspection Brief Description of the Service: Belong is a care home providing personal care and nursing care for up to 72 older people. The home opened in 2007 and is managed by CLS Care Services Limited, a not for profit organisation based in the North West of England. The home is situated on the outskirts of Macclesfield in a residential area. Local community amenities such as shops, a pub and a bus stop are within a short walking distance. The home consists of six households for either 11 or 13 people. Each unit has a lounge, dining area and fully fitted kitchen. All bedrooms are single occupancy with en-suite shower and toilet. There are also communal facilities that are shared with adjoining sheltered housing apartments. Details about fees are available from the manager. Belong Macclesfield DS0000070473.V373666.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use the service experience good quality outcomes. We visited Belong unannounced on 5 January 2009 as part of this inspection. Two inspectors carried out the visit. We were unable to visit one of the units on this day due to an infectious illness outbreak; so a second visit was made on 13 January 2009 to complete the inspection. During our visit we spoke with residents, staff and visitors in each of the households. We walked round the building to see all the communal areas and some of the bedrooms. We looked at care plans to check on the care that people who live in the home received. We checked a sample of records kept at the home and spent time talking with the support manager and the general manager. We also looked at any information that we had received about Belong since our last inspection there in July 2008. Before the inspection the manager was asked to complete a questionnaire to give us information about the service. We also sent out survey forms for staff and residents to give us their views about the home. This information helped us to plan our visit to the home and comments people made to us about the home are included throughout the report. What the service does well: People interested in going to live at Belong are assessed by the support manager to make sure their needs can be met. There is a six week trial period for people to decide whether this is the right home for them. People staying at the home for intermediate care receive the services they need to help them regain as much independence as possible. There is plenty of regular support from healthcare professionals as well as from the home’s own staff. The home provides good facilities for activities and recreation. There is a large function room, a café, a library, a hairdressing salon and a small gym. These facilities, together with activities that are provided, help to make sure that people living in the home can stay active and stimulated. Belong Macclesfield DS0000070473.V373666.R01.S.doc Version 5.2 Page 6 Belong provides a spacious, comfortable, warm, clean and very well equipped environment for people to live in. Residents live in small groups of eleven or thirteen people with, for the most part, their own team of staff. The individual households are now taking on their own identities. Good recruitment processes are followed to ensure that new staff are suitable to work with vulnerable older people. New staff receive thorough induction training so they know how to work safely and respect the wishes of residents. More than 50 of support staff have a national vocational qualification in care and others are working towards a qualification. These are nationally recognised qualifications for people working in the field of care. The home has a strong management team. They have developed ways of finding out people’s views about the service so that they know where they can improve. Regular maintenance checks are carried out to ensure that people living and working at the home are kept safe. What has improved since the last inspection? The standard of recording in the support plans has improved so that staff have access to important information about people’s needs and preferences and know how those should be met. The management of medicines has improved to ensure that medicines are stored safely at all times and people receive what has been prescribed for them by their doctor. An activities organiser has been appointed to help the support staff in meeting people’s social and recreational needs to help keep them active and not become socially isolated. Staff numbers have increased to ensure that people’s needs can be met in full at all times. A general manager has been appointed and he is working closely with the support manager to ensure a good standard of service across all areas. The home has moved forward considerably over the last year and we found that staff, residents and their relatives were much more positive about it. Belong Macclesfield DS0000070473.V373666.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. Belong Macclesfield DS0000070473.V373666.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 Belong Macclesfield DS0000070473.V373666.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): 3 and 6 People who use the service experience good outcomes in this area. We have made this judgement using available evidence, including a visit to this service. People who are interested in going to live at Belong are assessed by the support manager to make sure it will be the right home for them. People staying at the home for intermediate care receive the support they need to help them regain as much independence as possible. EVIDENCE: In the information we were sent before our visit, the manager told us, ‘We have a brochure that we can give to people that outlines the services that are provided at Belong, we also give out a copy of Belong Life which gives people an idea of the events that take place. We also have a guide to Living at Belong which can be read on a visit and is issued on admission. We also have a DVD which gives a virtual tour of Belong to potential customers which also protects the privacy of those who live in the households. We ensure that each individual is given the oportunity to visit Belong and spend some time with us perhaps have a meal and get the real feel of Belong, prior to making the Belong Macclesfield DS0000070473.V373666.R01.S.doc Version 5.2 Page 10 decision to move to Belong’. The support manager carries out a full needs assessment for anyone interested in going to live at Belong. If the person requires nursing care, one of the home’s nurses is also involved in the assessment. We saw that copies of the assessments done before people moved into the home were in people’s support plans for staff to read. This means that staff has information about the person’s needs and what care was needed for them as soon as they moved into the home. For some people there was also a copy of a social services assessment. There is an initial six week assessment period to help confirm whether the home is the right place for the person and to see if it meets their expectations. When we visited Belong there were eight people staying in the intermediate care unit (Willow). It was staffed by an agency nurse, a senior support worker and two support workers. There were also two physiotherapy staff working with service users, and a GP and rapid response nurse were visiting. An National Vocational Qualification (NVQ) assessor was having a meeting with the senior support worker, who has almost completed NVQ level 3. The nurse on duty told us that she worked at Belong regularly as Willow did not have its own nurse at the time of our visit. (Recruitment was taking place.) She told us that people are usually move into the home at short notice, approximately four hours, from their own home or from hospital. From the initial telephone information, the nurse on duty makes a decision whether the person’s needs can be met at the home. An assessment and basic care plans are written by the rapid response team and are brought to the home when the person moves in. The home’s staff add more detail. A GP visits the same day or the next day to examine the new person and prescribe any medicines they need. The people we spoke with were happy with the support provided for them. The rapid response nurse said that the care and the environment are excellent. At the time of our visit, she was spending a lot of time at the home, visiting nearly every day, for continuity as there is no regular nurse. The unit is supported by the housekeeping team and the rapid response nurse told us that new people do not move in until the bedroom they are to use has been thoroughly cleaned. We also observed that the kitchen was very clean and there was plenty of food in the fridge and cupboards. The senior support worker who we spoke with told us, ‘It’s much better now because everyone knows what they are doing. We have a brilliant team on Willow’. Belong Macclesfield DS0000070473.V373666.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 and 10 People who use the service experience good outcomes in this area. We have made this judgement using available evidence, including a visit to this service. The health and personal care needs of residents are met and the recording has improved so that staff have access to important information about people’s needs and know what to do to meet those needs in the way that people prefer. EVIDENCE: We looked at a selection of support plans on each of the households except Poplar. The support plans are kept in each person’s bedroom and this means that they are available for the resident and their family to look at. A visitor we spoke with said that he regularly reads his father’s support plan because his father has memory problems so forgets what he has been doing. Belong Macclesfield DS0000070473.V373666.R01.S.doc Version 5.2 Page 12 We found that the support plans had generally been completed to a good standard with plenty of detail about people’s daily needs, although documents were not always signed or dated. Some of the support plans for Beech residents were particularly well written. Daily progress reports were meaningful and detailed to give a good picture of what had happened during each day. Risk assessments had been completed for any identified risks to the health, safety or well being of the individual to make sure that there were plans on how to manage the risks well for each person. The plans had been reviewed regularly and updated when required. The quality of the reviews varied from one unit to another. The support plans that we looked at on Oak unit had very thorough evaluations, which showed that the staff had checked to see how the person had been during the last month. One plan that we saw on Holly unit did not have detailed evaluations and had a number of entries of ‘remains the same’, which does not give a good picture of the how the person’s condition was. Visits people had from healthcare professionals were recorded in the support plans. The plan for a frail person living on Oak unit showed there had been regular visits from his GP. Weight loss was charted, as was the action being taken to try and address this. The risk assessment stated that bedrails were not to be used for this person, as there is a danger that he may climb over. When we visited his bedroom there were rails attached to the bed. It would be advisable to take the rails out of the room so that they don’t get used by mistake. We spoke with a number of visitors in different parts of the home. Most of these people were very satisfied with the care provided. One visitor told us that she has continuing concerns about the personal care of her relative. She has had meetings with senior staff and feels they listen to her, but she still has some issues that are not fully resolved. We found that residents had been helped to maintain a good standard of personal appearance and appropriate clothing, which helps to promote their dignity and well being. A ‘dementia care mapping’ project has been started at the home and this should provide information about how the experience of people with dementia can be made as positive as possible. We looked at arrangements for the management of medicines on five of the households. We found that storage was good and secure. Administration records indicated that residents always receive their medicines as prescribed by their doctor. Controlled drugs were recorded appropriately to show how they were being used and that people were receiving them safely as prescribed. Belong Macclesfield DS0000070473.V373666.R01.S.doc Version 5.2 Page 13 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): 11, 12, 13, 14 and 15 People who use the service experience good outcomes in this area. We have made this judgement using available evidence, including a visit to this service. People living at Belong are supported to make choices about their daily routines, and social activities are provided for those who like to participate. This helps to keep them active and to make sure that they do not become socially isolated. EVIDENCE: The home has good facilities for social activities including a large function room, a library, a hairdressing salon and a small gym. These are shared with people living in the adjoining apartments. There is also a café on the ground floor that can be used by people who live at Belong and by the general public. This area was busy at lunchtime and the food was very good. Belong Macclesfield DS0000070473.V373666.R01.S.doc Version 5.2 Page 14 Unfortunately there had been no activities organiser for the home for a few months and we received some comments about lack of social stimulation for residents. A new activities organiser started in December 2008 and the residents, staff and visitors we spoke with were very pleased with her input at the time of our visit. One relative described her as ‘a breath of fresh air’. She told us she has many plans for future activities and her time will be shared between the households and the apartments. There are also shared activities and people living in the home and the apartments are encouraged to interact. The library is a recent addition and has videos as well as a good range of books and jigsaws. The lending book showed that people from the households were using the library. There is also a computer with large key keyboard that residents can use and can access the internet. Each household now has its own team of staff and is developing its own identity. Oak, Holly and Beech were quiet and relaxed. Holly had a very positive ambience. Poplar was not looked at in any depth at this visit, but it was pleasing to find that the entrance door to Poplar is no longer locked during the day which means that residents can use the communal facilities more easily. There are features in the environment that help people to remain as independent as possible. These include hand rails with raised buttons that indicate the end of the rail and memory boxes outside bedroom doors to aid people to find their room. All rooms have ensuite facilities including a shower with a seat and grab rails. We saw that mealtimes are flexible. The support staff make the breakfast and lunch in each household. We saw that there was plenty of choice available. A staff member told us how they help people who have communication difficulties to choose their meal, for example by taking them to look at the food in the fridge. A relative was helping at lunchtime in Cedar, which helps to maintain the homely feel in each household. Belong Macclesfield DS0000070473.V373666.R01.S.doc Version 5.2 Page 15 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 and 18 People who use the service experience good outcomes in this area. We have made this judgement using available evidence, including a visit to this service. There are clear procedures so people living at the home can be confident that any complaints they raise will be taken seriously and addressed and that staff know what to do to protect them from harm. EVIDENCE: We looked at the ‘feedback folder’ for the home. It contained a lot of information including details of any complaints or concerns that had been raised. The way that the folder was organised did not make it easy to track complaints. However, we saw there were copies of letters and responses made to people who had made complaints. We were told about a meeting held in August 2008 to discuss people’s concerns. A relative we spoke with had had meetings with the manager to discuss concerns she has raised. Four people who completed CSCI comments cards told us that they would know how to make a complaint. The complaints procedure for Belong is available in the entrance area of the home. We thought this could be improved by making it more clear and that it should state the names of the general manager and the support manager so that people know who they can make complaints to. The general manager addressed this straight away, during our visit. Belong Macclesfield DS0000070473.V373666.R01.S.doc Version 5.2 Page 16 CLS, the organisation that runs the home, has clear policies and procedures for the guidance of staff who may witness or suspect abuse of a resident. The training matrix showed that nearly all of the staff have had training about safeguarding vulnerable people from abuse. This means they know the correct action to take to make sure that people in the home are protected from abuse. Belong Macclesfield DS0000070473.V373666.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience excellent outcomes in this area. We have made this judgement using available evidence, including a visit to this service. Belong is well designed and maintained to make sure that people who live there have spacious, comfortable, warm, clean and very well equipped surroundings. EVIDENCE: Belong has six ‘households’ of either eleven or thirteen people. Each unit has an open plan lounge, dining room and fully fitted kitchen. Each lounge has either a balcony or patio so that people can enjoy sitting out. All bedrooms are single and have an en-suite shower with shower chair, toilet and washbasin. There is also a bathroom in each household with an adjustable bath and a hoist. All areas are well decorated and furnished to a high standard. Belong Macclesfield DS0000070473.V373666.R01.S.doc Version 5.2 Page 18 The home has good communal facilities including a large function room, a library, a hairdressing salon and a small gym. These are shared with people living in the adjoining apartments. There is also a café on the ground floor that can be used by people who live at Belong and by the general public. We received some negative comments about the cleanliness of the home. We saw during our visit that domestic staffing has been increased and there is now a housekeeper, a full-time domestic and three part-time domestics plus two laundry staff. This means that each household gets the domestic support needed to keep a good standard of cleanliness. During our visit we found that all areas of the home were clean and there were no unpleasant smells in any parts of the building that we visited. The household kitchens were clean and food stored appropriately. Bathrooms were also clean. Belong Macclesfield DS0000070473.V373666.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience good outcomes in this area. We have made this judgement using available evidence, including a visit to this service. There are enough qualified and experienced staff working at the home to make sure that residents’ needs can be met. EVIDENCE: The staff team consists of a general manager, suppport manager, registered nurses, senior support workers, support workers, assistant support workers, administrators, receptionists, head housekeeper, housekeepers, head chef, cooks, catering assistants, maintenance person and activities coordinator. Oak unit had ten residents, all requiring nursing care. There were four staff on duty including a nurse. Holly had thirteen residents and there were three support staff on duty. Poplar had ten residents. There were only two staff due to last minute sickness but they told us that they had managed fine. Cedar had three staff, including a carer from an agency who works at Belong regularly. Beech had ten residents and three staff, including the support manager who was covering for sickness. Belong Macclesfield DS0000070473.V373666.R01.S.doc Version 5.2 Page 20 Recruitment for a full staff team has been slow and we were told that there remain five or six staff vacancies; more interviews were planned to fill these vacancies. This meant that at the time of our visit, there was regular use of agency staff to make sure that the staffing levels were sufficient throughout the home. We spoke with two agency staff who often work at Belong. They were very pleasant and helpful. The manager told us that she was using a local agency that is very reliable and sent the same staff who know the residents. This helped to make sure there was continuity of care for people living in the home, from staff who knew them and how to meet their needs. We looked at the recruitment records for four members of staff who had been recruited shortly before our visit. The records showed us that robust recruitment procedures had been followed and all of the required checks had been carried out before these people stared working at the home. Residents and their families are playing a part in the recruitment of new staff so they could have a say in who would be providing care for them. We also saw evidence that new staff have a full programme of induction training before they work unsupervised. This includes mandatory training about health and safety subjects and training about the ‘Belong values’ to promote personcentred care. This helps to make sure that they work safely and understand the aims and values of the home so they can meet people’s needs appropriately. The information we were sent from the home before our visit shows that more than 50 of the care staff have achieved a National Vocational Qualification (NVQ) in care at level 2 or above. These are nationally recognised qualifications for staff working in the field of care that show they have knowledge and skills in basic care work. We spoke with an NVQ assessor who was working with a senior support worker doing NVQ level 3. She told us that all care staff have either started or completed an NVQ. The assessor said she receives excellent commitment and support from the home’s management team. The manager provided a training matrix that showed there had been a significant amount of staff training taking place in the home. This had included safe moving and handling, fire safety, first aid, food hygiene, safeguarding adults, medication and dementia awareness. We thought that the manager needed to review the training records to check where staff may have missed their mandatory training or were due to have this updated. This would help to make sure that all staff had up to date information on what to do to protect the health and safety of the people living in the home. Belong Macclesfield DS0000070473.V373666.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People who use the service experience good outcomes in this area. We have made this judgement using available evidence, including a visit to this service. The home now has a strong management team and this should ensure that it is run in the best interests of the people who live there. EVIDENCE: The home has a support manager and a general manager. The support manager has worked in care for twenty years and has developed expertise in caring for people with dementia. She has applied to CSCI to be registered as manager of Belong. This process helps to make sure that the manager is suitable to manage a care home. The general manager has a background as a manager in the hospitality industry. This management arrangement seems to be working well with the two people respectful of each other’s different skills and experience. A relative we spoke with on Holly unit told us that he has Belong Macclesfield DS0000070473.V373666.R01.S.doc Version 5.2 Page 22 seen much improvement at Belong, communication is excellent and the manager is visible and approachable. A number of ways of finding out people’s opinions about the home have been developed. A recent customer survey that was carried out received a very good response and showed a good level of satisfaction overall. The area identified as most in need of improvement was activities. Some relatives also wanted to be given more opportunities to be involved in the care of their own relatives. Over 90 of the respondents to the survey were either satisfied or very satisfied. There is a feedback book on each of the units and one of the nurses told us that he finds this a very helpful way for visitors to communicate. The books we looked at contained mainly positive comments although we did see a comment about a resident’s lost glasses in one of the books. There were records of household meetings that are attended by residents, relatives and staff. There had been no recent staff meetings at the time of our visit, but a staff forum has been set up with representatives from different groups of staff. The first meeting was in December 2008 and the plan is to have monthly meetings. The first meeting was to agree how the forum would work and to set up focus groups to look at different topics. In general we observed that staff morale in the home had improved greatly over the last year. A senior manager from CLS visits the home monthly and writes a report about how the home is running. The helps to make sure that improvements are being made. The support manager does regular checks of care plans and medicines to make sure these are being well kept and managed. We saw evidence of this in the households. The general manager is responsible for the quality of the housekeeping and catering services. Residents are able to put small amount of personal spending money in safekeeping at the home. We saw that good individual records are maintained. The home has a full-time maintenance person, who also provides an out of hours on-call service. We saw records of regular maintenance checks of water temperatures, fire alarms and emergency lighting. There were also records of regular fire drills to make sure that staff know what to do to protect people if fire breaks out. Risk assessments are in place for equipment and products used in the home. These are evaluated regularly and are accessible for staff to read and follow so they have the guidance they need to make sure that risks are reduced for the people living in the home. Belong Macclesfield DS0000070473.V373666.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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 4 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Belong Macclesfield DS0000070473.V373666.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. Refer to Standard Good Practice Recommendations Belong Macclesfield DS0000070473.V373666.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North West Region Level 3, Unit 1 Tustin Court Portway Preston PR2 2YQ 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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