Inspection on 30/04/08 for Belper Views

This inspection was carried out on 30th April 2008.

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

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

Other inspections for this house

Belper Views 29/09/09

Belper Views 22/04/09

Belper Views 19/11/08

Belper Views 02/05/07

Belper Views 12/05/06

Belper Views 10/03/06

Belper Views 23/11/05

Belper Views 19/07/05

Belper Views 02/02/05

Belper Views 10/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Belper Views 50/52 Holbrook Road Belper Derbyshire DE56 1PB Lead Inspector Helen Macukiewicz Unannounced Inspection 30th April 2008 09:00 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 Belper Views DS0000019936.V363689.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. Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belper Views Address 50/52 Holbrook Road Belper Derbyshire DE56 1PB 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) (01773) 829733 Mr Alan Kilkenny Margaret Catherine Stone Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd May 2007 Brief Description of the Service: The home is a large detached brick building with its own large garden and patio area, set on a hill on the outskirts of Belper. The home offers access to a good range of community and leisure facilities, although there are no shopping facilities in the immediate area. The home offers accommodation for 25 older people in single rooms, some with en-suite facilities available, and has a good range of communal areas, offering a variety of spaces for residents and their visitors to use. Residents at the home are registered with one of the two local Doctor’s practices and there is a small community hospital in the town. The current range of fees for the home is £345.52 to £364.31 per week. The last Inspection report was kept in the foyer. You can obtain further copies of this report on www.csci.org. Belper Views DS0000019936.V363689.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 1 star. This means the people who use this service experience adequate quality outcomes. This Inspection was unannounced and lasted 7.5 hours during one day. 2 preinspection questionnaires were received from people living in the home, five staff and four family members. Computer held records of all contact between the Home and the Commission for Social Care Inspection since the last Inspection were referred to in the planning of this visit. During this Inspection discussion with people who use the service and staff took place. Time was spent in discussion with the Manager, owner and administrator. Three care files for people living in the home were looked at in detail and their care was examined to see how well records reflect care practices within the home. Relevant records belonging to the home were also examined such as complaints and policy documents. A brief tour of the home took place including some bedrooms. Throughout this report ‘us/we’ refers to the Commission for Social Care Inspection. What the service does well: People living in the home told us they were happy with the decision they had made to live there and were satisfied with admission procedures. People felt their dignity and privacy was respected/upheld by staff at the home. People led a varied and flexible daily life and staff supported them to integrate within their local community. People felt able to complain to the manager and owner and were confident that their issues would be sorted out. People said they were happy with the environment within the home and the laundry service. Staffing levels ensured the wellbeing of people living in the home and staff felt supported by the manager. Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. Standard 6 does not apply. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are able to choose a home that can meet their needs although documentation did not always support that people were appropriately admitted. EVIDENCE: The latest Inspection report was seen in the foyer. The information about the home contained within the Statement of Purpose and Service Users Guides was seen. This was largely accurate although they needed some minor updates in terms of who the manager was, arrangements for smoking in the home and the contact point for us. This would ensure that people choosing the service had the right information on which to base their decision. Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 9 People were not routinely receiving visits from the manager before they were admitted to the home, but an introductory visit by the person, to the home, formed part of admission procedures. The manager said that it was at that time that a decision was made as to whether the home was mutually suitable. She did not have specific forms to use to record the assessment and outcome. However people told us they were happy with the admission procedures. One person told us ‘from the moment you walk through the door you are made to feel part of it’. One person confirmed that they had visited the home before being admitted. Three peoples’ care files were seen. These all contained a social services assessment of need. However, there was no documentation in place to assess the needs of privately funded people, in line with Standard 3.3. Because of this the home could not fully demonstrate that they were identifying individual needs and routines at the point of admission to the home. Despite this people told us they thought the staff were able to provide for their individual needs. As no thorough assessment documentation for assessments was available, the requirement made at the time of the last Inspection, to ensure all people had a complete assessment at point of admission remained unmet. One relative, in a completed pre-inspection questionnaire told us ‘the home is clean, staff are friendly and my aunt is well looked after. She is always clean, well fed and does not have any complaints’. Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Peoples’ wellbeing could be adversely affected by gaps in care planning. EVIDENCE: The manager showed us a new trigger tool that she had started to fill in each care file, to alert staff as to when they needed to contact the tissue viability nurse for advice. Some basic care plans were in place but these were not fully person centred and provided only a brief summary of care needs. However, new documentation had been purchased since the last Inspection. Each person had a complete new set of care documentation. The manager had started to fill one or two in at the time of this visit and said she intended to allocate some extra time to completing all the new care plans fully. As this process had only been Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 11 partially completed, the requirement made at the time of the last Inspection, to ensure all people had a complete care plan remained unmet. Some basic risk assessments were in place but these did not cover all required areas. Again, when the new documentation is used this will prompt staff to do a thorough risk assessment of all areas of need and ensure people are safeguarded. The manager had booked onto a course on risk assessments to help her to do this. There was information about the home to support that people see the dentist and optician. People told us that the staff attended to their care needs well. In their completed pre-inspection questionnaire, one relative wrote ‘they (staff) have shown a great deal of love and concern for my aunt. I have seen them deal very well with people with age-related difficulties’. One person told us ‘the staff are very good to you here’, ‘the care is marvellous’. The person went on to say ‘the care staff give love, care and attention to people’. A check of the medications store showed that peoples’ medicines were securely stored. Some tablets belonging to staff were seen in the general medicines store and it was advised that a small box be obtained to ensure these were kept separate from other people’s medicines. Similarly, medicines stored in the fridge needed a secure box to separate them from food items, although none were being stored there at the time of this visit. None of the medicines from the previous evening had been signed for. The manager accepted responsibility for this as the home had been dealing with an emergency around that time. People were able to confirm that they had received their medications that day, and that they always received the correct medications, at the correct time. A check of at least 3 months medication records preceding that incident showed no recording gaps and had been completed to a good standard. In view of this there did not appear to have been any risks to people caused by this error, and this appeared to be a ‘one off’ incident. The manager told us that staff had received medication training. People told us that staff ensured their privacy. One said ‘you can have a bit of privacy’. People told us that staff treated them with respect and upheld their dignity. One said ‘they talk to you on a level’, another said ‘they don’t talk down to me, they don’t try to boss or bully’. Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12-15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to lead a varied lifestyle of their choosing. However, lack of a structured approach to activities means that person centred care may not occur for all people living in the home. EVIDENCE: Talking newspapers were seen for those people who were registered blind. The manager, staff and people living in the home told us that visitors from local churches undertook individual visits and singing. The manager had recorded the activities that took place between January and March 2008, this showed individual and group activities had occurred. She also had photos of staff doing ‘keep fit’ sessions with people. One person told us that entertainers sometimes came into the home and said they were ‘very good’. Some people told us they led an active life at the home and that staff took them out. However, one person told us ‘there is not much to do in the day’. The manager was considering allocating a member of staff as an activity person to improve record keeping and give more structure to this area. Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 13 People were moving freely around the home, people told us they could go to their bedrooms at any time. A few people, who were physically able, went out unaccompanied using local bus services. People went to the local shop. One person told us they had been for a cup of tea in a local supermarket with a staff member the previous day. Another told us they were going on a holiday abroad with a staff member in the summer. They also went on shopping trips with a volunteer. People told us they had visitors at the home, and one person told us they went out with their relatives. People told us they were happy with the food provided. The cook had devised set menus since the last Inspection, which we saw. Menus had been thoughtfully planned and were varied. The cook had knowledge of peoples’ individual dietary needs and both catering staff had certificates to prove they were appropriately qualified. A vegetarian option was being cooked each day, although the menus did not include the alternative to the main meal. Breakfast and tea time menus were also missing. However, people told us they have some choice and that a hot alternative is sometimes prepared at tea time. Work was being done with the catering staff to further develop menus. One person told us ‘you do get alternatives to the menu; the food is very good. There is a varied menu and it’s enjoyable’ Plenty of food was seen in the kitchen and this included regular deliveries of fresh fruit and vegetables. The lunch time meal served during the Inspection was well presented and people told us it was tasty and plentiful. Staff were very attentive to peoples’ needs throughout the meal. Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 14 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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have their rights upheld through effective complaints procedures. Gaps in staff training on safeguarding reduce the amount of protection people receive. EVIDENCE: In their completed pre-inspection questionnaires 2 relatives told us they did not know the complaint procedures. However, people living in the home said ‘I can discuss any problems with the management quite openly’. And ‘I could see the manager if I have problems, or the owner’. They were confident that the manager would deal with their issues. People living in the home told us they were not aware they could contact us with concerns, but one added ‘I can’t think of any reason why I would want to’. We had received no complaints about the home. The complaints records showed that no complaints had been received for a number of years. The Manager told us she dealt with minor concerns directly with the person, but was not recording these incidents. There was a safeguarding adults procedure in the office. The manager was aware of procedures and some staff had attended safeguarding training. More training was planned. However, there were still sections of staff who had not Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 15 received this training such as the catering and domestic staff. This would ensure better safeguards for people living in the home. Certificates of training were seen for those who had attended. The manager had received some information about the Mental Capacity Act but had yet to receive training on this. Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 16 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): Standards 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment of the home is well maintained and is suited to the needs of the people who live there. EVIDENCE: A brief tour of the home took place. A person living in the home and a staff member showed us around. Many areas of the home had been redecorated. Since the last Inspection new lounge chairs had been purchased and a new lounge carpet was on order. A person told us they had been consulted regarding the choice of décor and colour of the carpet, supporting user involvement. Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 17 People told us they had been able to bring in small items of furniture from home to decorate their rooms, people had televisions and small furniture items as required. People told us they were happy with their bedrooms. The bedrooms seen had personal lockable space within, but not door locks. One person told us they did not want a door lock and were happy with existing arrangements. However, care documentation did not record peoples’ individual decisions regarding door locks. The laundry area was seen. Equipment was sufficient to deal with soiled laundry and to maintain infection control. Gloves and alcohol gel for hand cleansing were seen in the main areas. People told us that the home was fresh and clean and that they were happy with the laundry service. Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 18 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): Standards 27-30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are cared for by sufficient numbers of staff. Gaps in training and recruitment means that people may not be fully safeguarded. EVIDENCE: One person told us that in their opinion, there were enough staff. One said ‘the staff are always there, the night staff are very good’. They added that they ‘can’t speak highly enough of staff’. The staffing rotas showed there were 3 staff during the day and 2 at night. The manager had an occasional supernumerary shift. Domestic staff and catering staff were on the rota for most days, except there was no weekend cleaner. The administrator was looking at reviewing patterns of working for the cleaning staff. Regular staff provided cover for gaps in the rota. There was a very low staff turnover. Pre-inspection questionnaires completed by staff recorded ‘the manager is very good and supportive’ ‘members of staff work as a team and the residents are treated as individuals’. Staff recorded that they received regular training. Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 19 Because of the low staff turnover, only 1 member of staff had been employed since the last Inspection. The recruitment file contained some gaps in essential information such as no statement as to physical/mental health, no declaration of criminal offences, full employment history missing, no training certificates relating to qualifications already achieved. The Manager felt the gaps were down to her inexperience of recruitment. She had obtained some new forms and guidance to assist her when recruiting staff in future. The person had been subject to a CRB check before they started and references had been obtained so people had been largely safeguarded against the risk of exposure to unsuitable staff. Recruitment files were not confidentially stored although the Manager outlined plans for a secure storage area to be built. The need to ensure safe recruitment systems was a requirement of the last Inspection that has not been met. A blank induction form was seen, staff told us they completed this with new members of staff although there were no completed ones to see. The induction sheet was very basic and there was no structured foundation training to follow. However, due to the low staff turnover most staff had achieved National Vocational Qualifications (NVQ) to level 2 or 3 in care. The Manager had recently obtained a comprehensive induction and foundation training pack, which she intended to use for staff who had not achieved their NVQ’s and for new starters. The Manager told us that she gave all staff the GSCC code of conduct, which stated their responsibilities as care providers. Staff told us that they had received some, but not all the mandatory training. The manager told us that she used Derbyshire County Council for all training and found them useful. Some certificates to support staff had received training were seen. Although the Manager had a good idea of when the staff needed updates to their mandatory training, there was no comprehensive list of all training that staff had attended so it was hard to identify training gaps. Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 20 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): Standards 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management ensures that the service is user focused and maintains peoples’ general safety, although gaps in policy and practices in terms of staffing means people may not be fully safeguarded. EVIDENCE: The home’s manager continued to have a positive influence on the running of the home and remained very involved with residents and staff on a day-to-day basis. She had completed the Registered Manager’s training award (NVQ level 4). She told us that she was going to attend a course the next week on risk Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 21 assessment. Also that she attended all the mandatory training as it was planned. One person told us ‘the manager runs a tight ship but a happy ship’. The manager was very knowledgeable about day to day care but less so about management systems such as the need to report incidents under regulations 37 and 38. She also needed to further develop recruitment practices and forms, staff training forms and supervisions and update some policies. The registered person (owner) had recruited an administrator to assist with the development of all these areas. Discussion with the administrator confirmed his knowledge of management systems and ‘best practice’. The manager had started to develop some quality assurance systems. Questionnaires had been issued to people or their relatives. One person told us that the owner or his wife visited them regularly and asked them how things were going, making sure they were all right. Both these initiatives supported that the management do make attempts to make the service user-led. The manager had completed a self-assessment questionnaire for us, but this had not been received at the time of this visit and the manager had not kept a copy. This would have demonstrated further internal quality measures that were in place. Although these initiatives were happening, there was no formal system for quality assurance. The administrator hoped to develop this area further within the next 6 months. The manager had a safe system in place for dealing with peoples’ weekly allowances. Some people managed their own money. Receipts were kept for purchases and a 2-signature system was in place for deposits/withdrawals. Peoples’ money was held separately and not ‘pooled’. Staff told us they had appraisals once or twice a year and felt supported, staff said they could go to the manager at any time with problems and that issues would be dealt with. Such meetings were not formally recorded as supervisions; keeping records would have supported the management of staff that took place. Some risk assessments for the environment were seen. Where sampled, there were up to date service records for equipment such as gas appliances and electrical wiring which showed that the environment was being safely maintained. Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 22 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 2 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1-2) Requirement The needs of all people must be fully assessed at the point of admission, areas of risk in their lives clearly identified and controlled, and these must be recorded fully and kept under regular review so that care can be provided by staff in ways that are safe and help them all to work in the same way. Former timescale of 31/5/07 not met. People must have a personal care plan that clearly show how their needs are being met, and must include how risks in their lives are managed in order to maintain their welfare and safety. All aspects of their care must regularly reviewed and kept up to date and must show that residents and/or their families are involved in decisions about how they are being supported, so that the best quality of care can be provided. Former timescale of 31/5/07 not met. Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 24 Timescale for action 30/04/08 2. OP7 15(1-2) 30/04/08 3. OP8 13(4)(c) 4. OP9 13(2) 5. OP18 13(6) 6. OP29 19(5) Schedule 2 People must have their needs risk assessed. All risk assessments must be reviewed as needs change. To ensure staff know what care people require and to ensure care needs are not overlooked. All medications must be signed for at the time of administration to support that people are receiving the medications they require. All staff must receive safeguarding training in order to protect people living in the home against abuse. The procedures by which staff are recruited must be reviewed and revised so that all the checks required by law are carried out, all the necessary information about applicants is obtained and all documents used in the process support a safe system that only recruits the right people for the job. Confidential information about staff must be stored in a secure area so that it is not freely available to people who have access to the home’s office. Former timescale of 31/08/07 not met. All staff must receive training appropriate to their work. Staff training must be recorded in a way that easily identifies gaps in training needs. This is to ensure suitably trained staff look after people. The manager must be fully aware of regulations that she is required to comply with. She must also have sufficient knowledge of management systems to ensure staff are suitably recruited, inducted and DS0000019936.V363689.R01.S.doc 30/06/08 31/05/08 30/09/08 30/04/08 7. OP30 18(1)(c) 30/09/08 8. OP31 9(2)(b)(i) 31/07/08 Belper Views Version 5.2 Page 25 9. OP36 18(2) trained. This is to ensure the safety of people living in the home. The registered person must ensure that care staff are given the opportunity to meet with members of management regularly so that their work can be more closely monitored and they can be offered individualised support to help them do their jobs better. Such supervision must be recorded to support this process and offer better protection for people living in the home. 31/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP1 OP3 Good Practice Recommendations The Statement of Purpose and Service Users Guide should be updated so people have accurate information about the home. The proprietor should review and modernise all assessment and care-planning documentation to ensure that delivery of care is made in the most effective and reliable ways. Small storage boxes should be purchased to keep staff medications separate from those for people living in the home. A similar secure box should also be provided to store medications in the fridge to ensure medications are kept away from food items and are not generally accessible. More structured activities should be planned, after consultation with people about their needs, particularly for those less physically able. Menus should be planned that include a second option to the main meal, teatime and breakfast choices. This will provide people living with the home more opportunity to DS0000019936.V363689.R01.S.doc Version 5.2 Page 26 3. OP9 4. 5. OP12 OP15 Belper Views 6. OP16 experience a wider variety of food, and to make informed choices about their diet. Wider communication about the role of the Commission for Social Care Inspection in complaints should occur so that people living in the home and their relatives have the information they need regarding their rights to complain. Minor complaints should also be documented to support that the manager is addressing issues. Staff should receive training on the mental capacity act so they can advocate fully for people living in the home. Peoples’ decisions regarding door locks should be documented in their files to support they had made an informed decision in this area. The manager should keep a copy of the AQAA to support internal quality auditing. A formal system for quality assurance within the home should be developed to support that the service is userfocused. 7. 8. 9. OP18 OP19 OP33 Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. Extracts may not be used or reproduced without the express permission of CSCI Belper Views DS0000019936.V363689.R01.S.doc Version 5.2 Page 28 - 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. 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