Inspection on 31/01/08 for Belvedere House

This inspection was carried out on 31st January 2008.

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

Belvedere House 29/10/06

Belvedere House 14/11/05

Belvedere House 18/05/05

Belvedere House 08/11/04

Belvedere House 07/06/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Belvedere House Belvedere House Weston Acres, Woodmansterne Lane Banstead Surrey SM7 3HA Lead Inspector Joseph Croft Unannounced Inspection 31st January 2008 10:15 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 Belvedere House DS0000033885.V357602.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. Belvedere House DS0000033885.V357602.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belvedere House Address Belvedere House Weston Acres, Woodmansterne Lane Banstead Surrey SM7 3HA 01737 360106 01737 353436 home.bns@mha.org.uk 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) The Royal Alfred Seafarers` Society Ms Bridgette Anne Kasey Care Home 56 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number disorder, excluding learning disability or of places dementia (2), Old age, not falling within any other category (56), Physical disability (2), Physical disability over 65 years of age (15), Sensory impairment (2), Sensory Impairment over 65 years of age (5) Belvedere House DS0000033885.V357602.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Out of the 56 (FIFTY SIX) beds registered 12 (TWELVE) may be for Dementia Care of the elderly DE (E) Out of the 56 (FIFTY SIX) beds registered 15 (FIFTEEEN) may be used for Physical Disabilities/Elderly (PD(E)) Out of the 56 (FIFTY SIX) beds registered 5 (FIVE) may be used for Sensory Impairment/Elderly (SI (E)) Out of the 56 (FIFTY SIX) beds registered 2 (two) may be used for service users under the age of 65 (SIXTY FIVE) Out of the 56 (FIFTY SIX) beds registered 3 (THREE) may be used for Respite Care 29th October 2006 Date of last inspection Brief Description of the Service: Belvedere House is registered with the CSCI (Commission for Social Care Inspection) as a care home with nursing for fifty six service users. The home is purpose built and located in Banstead in Surrey and close to public amenities. Accommodation is on two floors accessed by stairs or a lift and comprises of lounges, dining rooms, a kitchen, laundry room, bathrooms, toilets, showers and single bedrooms with en-suite facilities. The home has a large garden, which is private, secure, and accessible with private parking available. The fees charged by the home are £668 per week. Belvedere House DS0000033885.V357602.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 31st January 2008 using the ‘Inspecting for Better Lives’ (IBL) process. Regulation Inspector Mr Joe Croft undertook this visit and the deputy manager and the administrator assisted him throughout. The registered manager was attending a previous appointment, but attended the home in the late afternoon. This site visit took place over a period of seven hours, commencing at 10:15 and concluding at 17:45. People living at the home prefer to be known as residents, therefore this term of reference is used throughout this report. The inspection process included a tour of the premises and sampling of residents’ care plans and risk assessments. Other documents sampled included the menu, a sample of policies and procedures, records of medication, training records, staff recruitment files and health and safety records. The Inspector had discussions with the manager, deputy manager, and four members of staff, the cook, seven residents and one relative who were present at the time of this site visit. Residents informed the Inspector that they were happy living at the home, and were complimentary about the care they receive from staff, stating that the staff look after them well. Residents informed the Inspector that the food was very good, and they are offered a choice of foods. One resident stated that “Breakfast is excellent.” During observations staff and residents were interacting in an appropriate manner, and residents were being addressed by their preferred names. The Annual Quality Assurance Assessment (AQAA) completed by the manager of the care home, and completed surveys from residents, their relatives or other associated professionals have been used as a source of evidence in this report. The quality rating for this service is 2 Star. This means the people who use this service experience good quality outcomes. The inspector would like to thank the manager, members of staff and residents for their cooperation during this visit. Feedback was provided during this site visit to the deputy manager and the administrator, and to the registered manager at the end of this site visit. Belvedere House DS0000033885.V357602.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: All application forms must have satisfactory written reasons for gaps in employment. Belvedere House DS0000033885.V357602.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Belvedere House DS0000033885.V357602.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 Belvedere House DS0000033885.V357602.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): Standards 3 and 6 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Assessment documentation is in place to ensure the individual needs of residents can be met. EVIDENCE: Information provided in the Annual Quality Assurance Assessment (AQAA) informs that the trained manager undertakes the pre-admission assessments to determine if Belvedere House can meet the needs of prospective residents. Three care files were sampled as part of the case tracking process. These provided evidence that prospective residents had a pre- admission assessment undertaken prior to admission to the home that included personal, health and social care needs. These assessments were signed and dated. Belvedere House DS0000033885.V357602.R01.S.doc Version 5.2 Page 10 The deputy manager informed the Inspector that visits to the home are encouraged. This was confirmed during discussions with residents, who stated that they had an assessment of their needs undertaken, and they did visit the home before moving in. One resident infirmed the Inspector they stayed for a weekend visit. Care plans are developed from the pre-admission assessments. The home follows the organisation’s Admissions Policies and Procedures that ware last reviewed in April 2006. The home does not offer intermediate care. Belvedere House DS0000033885.V357602.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): Standards 7, 8, 9 and 10 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are protected by the home’s storage and administration of medication procedures. Physical and health care is offered in such a way as to ensure residents’ personal, physical and health care needs are met. EVIDENCE: Three care plans were sampled during this inspection. Care plans were appropriately maintained and included information in regard to meeting the personal, physical and health care needs of residents. Care plans had been reviewed on a monthly basis, which was a requirement made at the previous inspection, and were signed by residents and/or their representatives. During discussions, staff were knowledgeable in regard to the care plans, and stated that these are reviewed on a monthly basis. Belvedere House DS0000033885.V357602.R01.S.doc Version 5.2 Page 12 Some residents stated they were aware of the care plan. One visiting relative stated that they were aware of their relative’s care plan. Completed surveys returned from relatives informed that they considered their relative’s needs are being met, and that they are informed of important issues that affect their relative. Care plans sampled contained risk assessments that included frequency of falls, nutrition, Waterlow score for skin care, and moving and handling. Evidence was observed that risk assessments had been reviewed regularly and as and when required. From discussions with staff and residents, and from viewing records, it was clear that residents have access to health care professionals as required. These include a General Practitioner, Dentist, Optician and Chiropodist. Staff and residents informed the Inspector that the GPs visit the home three times a week, and consultations take place in the privacy of individual’s bedrooms. Staff informed the Inspector that records of monthly weights for residents are maintained. Some of these were sampled during the site visit. One member of staff stated the GP requests specific information about individual residents every six months so as to monitor their health care needs. From the completed surveys returned to the Commission For Social Care Inspection, and discussions with residents during the site visit, it was clear that residents are receiving the medical support they need. One comment in a survey informed “Excellent contact from the GP services.” Information provided in the AQAA informs that the home has a comprehensive Medication Policy and Procedure that was written with advice from a pharmacist. The Inspector viewed this document. The home uses hand written Medication Administration Record sheets (MARs) for the recording of medicines. Discussions took place with the manager in regard to this, who stated that the home would now move towards using the printed MAR sheets from a local pharmacist outlet. Running totals for some identified medicines had not been recorded on the MAR sheets, therefore it was not possible to follow an accurate audit trail of these medications. A good practice recommendation has made in regard to this. Medicines are appropriately stored in locked medicine cabinets. The home maintains records of medicines received and returned to the Pharmacist. However, one MAR sheet viewed did not correspond to the balance left, and there was one omission for the signing of one medication, although the balance of this medication was correct. This was discussed with the deputy manager and later with the manager. The manager informed the Inspector that the records of medication are monitored on a three monthly basis. Since the site visit, the manager has informed the Inspector that this Belvedere House DS0000033885.V357602.R01.S.doc Version 5.2 Page 13 issue in regard to one omission of signature had been dealt with. The manager also stated that the other identified issue in regard to medication would be attended to. Controlled Drugs are stored in secure metal cabinets. The manager informed the Inspector that the metal cabinets had been secured the walls with the fittings that were supplied with the cabinets. The home maintains a Controlled Drug register that is signed by two members of staff. During discussions staff informed the Inspector that they respect residents’ privacy and dignity through knocking on bedroom doors, calling residents by their preferred names and providing personal care in the privacy of their bedrooms and bathrooms. Evidence of these practices was observed during this site visit. Information provided in the AQAA states that the organisation has a detailed Equal Opportunity Policy that indicates the responsibilities for staff. Throughout the site visit staff were observed to be interacting with residents in a professional manner, and providing support as and when required. Belvedere House DS0000033885.V357602.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with opportunities to improve their lifestyle, and where possible they are able to maintain contact with family. Meals are varied with individual choices and preferences, and special dietary needs are catered for ensuring that residents receive an appealing and balanced diet. EVIDENCE: The home employs an activity co-ordinator who organises activities twice a day from Monday to Friday. Lists of activities are clearly displayed on the notice board at the home. Activities provided include reminiscence, art, book club, bingo and exercises to music. The home also organises external outings for residents that include visits to Buckingham Palace. During discussions residents informed the Inspector that the activities provided are very good, and that they are able to choose whether or not to join in. Surveys returned from residents and their relatives informed that there are sufficient activities and outings organised by the home. Comments in surveys Belvedere House DS0000033885.V357602.R01.S.doc Version 5.2 Page 15 included “Plenty of activities organised,” “Social life and outings are good,” “They organise lots of things to do in the lounge.” Residents and staff informed the Inspector there are no restrictions on visitors to the home. This was confirmed during discussions with one visiting relative during this site visit. They stated they can visit the home at any time and are able to see their relative in private. Residents stated that they make choices every day about their lives, and that they like their bedrooms with the en-suite facilities. Residents informed the Inspector that they are able to maintain contact with their families and friends, can make and receive telephone calls, and receive their own mail. Staff informed the Inspector that the majority of residents have their own telephones in their bedrooms. Staff stated that residents could access the local community, visit pubs and the cinema, and have attended events further away such as Wimbledon. This was confirmed during discussions with residents. All residents living at the home are white British, and hold Christian beliefs. Staff and residents informed the Inspector that local church leaders of different denominations attend the home on a regular basis to provide a religious service, and residents are able to attend the local church if they choose too. Information provided in the AQAA informs that the home has a dedicated Chaplain, and liaises with various local churches to provide worship for various faiths and denominations. Information provided in the AQAA informs that plans for improvement in the next twelve months include the organisation examining their market strategy to ensure the home is accessible and attractive to older people from minority ethnic communities. The home employs a cook who plans and devises the menu. During discussions the cook informed the Inspector that she holds the NVQ levels 1 and 2, and is to commence training in “Advanced Public Health and Hygiene.” Menus are discussed with the residents, and the cook holds meetings every two months with residents. The menus were viewed. These provide a choice of meal and include meat, fish, pasta, fresh vegetables and fresh fruit. The cook caters for special diets, and four residents are provided with liquidised foods. The Inspector viewed special moulds that had been provided by the home. These enable the liquidised foods to be formed in the shape of the particular meals on the menu. Residents are provided with drinks and snacks throughout the day, and all have access to fresh fruit and drinks in their bedrooms. Belvedere House DS0000033885.V357602.R01.S.doc Version 5.2 Page 16 The cook stated that residents could request to have a different meal to the one on the menu. However, records of these meals are not maintained by the home. A good practice recommendation has been made that records of alternative meals taken by residents should be maintained. The home had a visit from the Environmental Health Organisation on 12th July 2007, during which one recommendation was made that the organisation is in the process of addressing. The cook informed the Inspector that the kitchen has an annual deep clean, the next one is taking place on 5th February 2008. Residents informed the Inspector that the food is very good at the home, you always get a choice, and you can ask for something different from the menu. The lunch meal was observed during the site visit. This was seen as a relaxed occasion with sufficient staff to provide support to residents as and when required. Dining room tables accommodate four residents and a copy of the day’s menu was placed on each table. Surveys returned from residents informed that meals provided at the home are usually and always good, one resident informed the Inspector “Breakfast is excellent.” One comment stated that the tea times could be improved. This was discussed with cook who stated that she was aware of this, however, there is always a choice of meals for tea, and that she had discussions with all residents in December 2007 about these. The requests are being accommodated in the menu planning. On the day of the site visit all comments made to the Inspector in regard to meals were very good and complimentary. Information provided in the Annual Quality Assurance Assessment (AQAA) informs that the home is working with the National Association of Providers of Activities for Older People (NAPA) to further develop their services in line with current thinking. Belvedere House DS0000033885.V357602.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): Standards 16 and 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a satisfactory complaints system that enables residents and their families to raise concerns. Staff having knowledge, training and an understanding of adult protection issues protect residents. EVIDENCE: The Commission For Social Care Inspection has not received any concerns, complaints or allegations in regard to the home. The home has a Complaints Policy and Procedure that includes the timescales for responding to the complainant, and will be updated to include the most recent Commission For Social Care Inspection contact details. Information provided in the AQAA informed that the home had received eleven complaints since the previous inspection, and had resolved all these within the 28-day timescale. The complaints records were viewed and evidenced that the home had records of complaints, and the actions taken. Surveys returned from residents and relatives informed that they knew how to make a complaint. During the site visit, residents and one visitor informed the Inspector that they knew how to make a complaint, but have not had the need to do so. Belvedere House DS0000033885.V357602.R01.S.doc Version 5.2 Page 18 From discussions with staff and evidencing the complaints records, it was clear that the home are proactive in regard to responding to, and resolving complaints made. Staff at the home follows the organisation’s Protection of Vulnerable Adults Policy and Procedure that is due to be reviewed in April 2008. A copy of the recent Surrey Multi-Agency Safeguarding Procedures is available in the office for staff to read. Evidence was provided to the Inspector of training that is ongoing for all staff in regard to Safeguarding Adults. The Administrator maintains these records, through which refresher training dates, and staff who have missed the training for whatever reason, are identified. During discussions, staff gave an account of who they would report suspicions of abuse to, and stated they would not hesitate to report bad practice. Staff informed the Inspector they had received training in regard to the Protection of Vulnerable Adults and read the Policies and Procedures in regard to this area. The manager stated that all staff have been informed that any allegation of abuse would follow the Surrey Safeguarding Procedures. Belvedere House DS0000033885.V357602.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): Standards 19 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. It is accessible with a pleasant and homely atmosphere that ensures residents live a safe and well-maintained environment. EVIDENCE: A tour of the premises was undertaken during the site visit. The Inspector only viewed a sample of residents’ bedrooms. The accommodation is on two floors that is accessed by stairs or a lift and comprises of lounges, dining rooms, a kitchen, laundry room, bathrooms, toilets, showers and single bedrooms with en-suite facilities. The home has a large garden, which is private and secure. The home is currently having an extension added to the main communal room on the ground floor. Belvedere House DS0000033885.V357602.R01.S.doc Version 5.2 Page 20 The accommodation was appropriately furnished and the decoration was bright and clean. Residents’ had their own personal belongings in their bedrooms that included family photographs and televisions. Bedrooms viewed specialist beds and mattresses, and bathrooms and toilets were furnished with the appropriate adaptations to enable the needs of residents to be fully met. Bedrooms had been furnished with lockable facilities for residents. Communal bathrooms and toilets had liquid soap dispensers and paper towels. It was noted that one shower room had a stained mirror, and the seat in the shower requires attention as it is beginning to develop cracks. Communal parts of the home are fitted with handrails, and residents have unrestricted access. On first arrival at the home in the morning, the Inspector observed that domestic cleaning was being undertaken by domestic staff. During a tour of the premises in the morning, and again in the afternoon, the home was observed to be clean, tidy and free from offensive odours. Surveys returned from residents and relatives inform that the home is always fresh, clean and tidy. Information provided in the AQAA informed that the home has annual repairs and renewals plan, detailed annual self-assessments results and have a generic and specific risk assessments in place. Belvedere House DS0000033885.V357602.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): Standards 27, 28, 29 and 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are satisfactory, ensuring staff have the qualities and training to meet the needs of residents. People who use the service are protected by the organisation’s recruitment policy and procedures; however, staff recruitment files require further information. EVIDENCE: The home has a multi-cultural staff team that includes male and female staff. Staffing at the home consists of the registered manager, deputy manager, registered nurses, and catering and domestic staff. The manager informed the Inspector that the duty pattern is a two-shift system, early and late shift. There are nine care staff and two qualified nurses on duty each shift. The requirement made at the previous inspection in regard to the manager undertaking a review of the staffing levels for the home had been complied with. The manager stated that there are sufficient staff on duty to meet the number and needs of residents. Information provided in the AQAA, discussions with the manager and the viewing of training records provided by the administrator informs that more than 50 of staff working at the home hold an NVQ level 2 and above. Belvedere House DS0000033885.V357602.R01.S.doc Version 5.2 Page 22 The home follows the Organisation’s Recruitment Policy and Procedure. Three staff recruitment files were sampled and each contained the relevant documents as detailed in Schedule 2 of The Care Homes Regulations 2001 that included Criminal Record Bureau reference numbers, photographs and proof of identification. However, application forms did not record the reasons for gaps in employment. A requirement in regard to this has been made. Discussions with residents, and surveys returned to the Commission For Social Care Inspection informs that staff are available at the home. Comments from surveys received from residents and their relatives include “Very caring staff, aware of needs, always kind and helpful,” “Very approachable and caring staff,” “Find all staff helpful and caring.” Staff surveys returned, and discussions with staff, informs that staff are receiving the training they require to undertake their roles. Training provided to staff has included Dementia Awareness, Bereavement, Catheterisation, Incontinence and Leg Bag Care. The home has obtained a training programme from E Learning that will enable the home to also provide in-house mandatory training. All surveys returned from staff inform that they receive training that is appropriate to their role. This helps them to understand the individual needs of residents, and keeps them up to date with new ways of working. Surveys also informed that staff receive induction training when they commence duties at the home. Information provided in the AQAA informs that staff are properly inducted through a programme in line with the Skills for Care, and mandatory training is provided. An allowance of five days per person is made in the staffing budget. Belvedere House DS0000033885.V357602.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): Standards 31, 33, 35 and 38 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The arrangements for management and administration ensure the home is run in the best interests of residents, and their safety is promoted and safeguarded. The manager must attend to the one identified issue in regard to the recruitment practice of the home. EVIDENCE: The home has a registered manager who holds a professional nursing qualification and has completed the RMA (Registered Manager Award) qualification to ensure the home is run by a person who is fit to be in charge of the home. The manager informed the Inspector that training during the last twelve months has included the mandatory training as required, Disciplinary Belvedere House DS0000033885.V357602.R01.S.doc Version 5.2 Page 24 and Grievance, Clinical Waste management and Protection of Vulnerable Adults. During discussions, staff informed the Inspector that the manager has an open door policy, is approachable and supportive. Staff stated that they receive supervision, however, the manager informed the Inspector that she is aware that supervision is not undertaken as required, but is working towards this. Quality assurance is undertaken through two monthly meetings with residents, and quarterly meetings are held with residents and their relatives. Annual surveys are undertaken to ascertain the views of residents, their relatives and other associated professionals. The home had a summary of the surveys, and an action plan to address any issues identified. The organisation conducts monthly Regulation 26 visits, and copies of these reports were available at the home. The manager informed the Inspector that residents and their families are responsible for their finances. The administrator for the home maintains records of the mandatory training undertaken by staff. Staff have had training in fire safety, first aid, moving and handling, and health and safety. Discussions took place in regard to First Aid training, as the home was questioning as to whether this was mandatory training. Staff at the home follows the organisation’s Health and Safety Policies and Procedures. Information provided in the AQAA returned to the Commission For Social Care Inspection informed that health and safety records are appropriately maintained and up to date. During this site visit the following records were viewed, annual servicing and testing of the fire alarm systems, fire drills, Portable Appliance Testing (PAT), and daily records of fridge/freezer temperatures. The Fire Officer visited the premises on 7th February 2007, during which the home’s fire risk assessments were viewed. Belvedere House DS0000033885.V357602.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 X X 3 X X N/A 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 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Belvedere House DS0000033885.V357602.R01.S.doc Version 5.2 Page 26 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. 1. Standard OP29 Regulation 19 (1) (b) Sch 2 (6) Requirement All application forms must have satisfactory written reasons for gaps in employment. Timescale for action 28/02/08 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. Refer to Standard OP9 Good Practice Recommendations Running totals of medication should be maintained on the Medical Administration Record sheets to enable an audit trail to be followed. Records of alternative meals taken by residents should be maintained. 2. OP15 Belvedere House DS0000033885.V357602.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Belvedere House DS0000033885.V357602.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!