Inspection on 12/12/07 for Bessmount House

This inspection was carried out on 12th December 2007.

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

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

Other inspections for this house

Bessmount House 29/07/09

Bessmount House 10/05/08

Bessmount House 20/07/07

Bessmount House 05/07/06

Bessmount House 15/11/05

Bessmount House 24/08/05

Bessmount House 07/04/05

Bessmount House 01/09/04

Bessmount House 13/04/04

Bessmount House 23/03/04

Bessmount House 06/01/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Bessmount House 1 Rose Hill Kingskerswell Newton Abbot Devon TQ12 3PP Lead Inspector Margaret Crowley Unannounced Inspection 12th December 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bessmount House DS0000003652.V355971.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. Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bessmount House Address 1 Rose Hill Kingskerswell Newton Abbot Devon TQ12 3PP 01803 872188 NONE 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) Mr David George Simpson Mrs Jacqueline Sheila Simpson Mr David George Simpson Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 2007 Brief Description of the Service: Bessmount House is a care home that is registered to provide accommodation and care for up to eleven people, who need residential care for reasons of old age, not falling within any other category. The home is situated in the village of Kingskerswell and is close to the Health Centre, local shops, church and other amenities. Mr Simpson is also the Registered Manager. Both Mr and Mrs Simpson work full-time at the home, including sharing the waking night duty. The home has seven single bedrooms and two double bedrooms, all except one have en-suite toilet facilities. All the bedrooms are connected to a call bell system and have telephone and television points. There is a quiet sitting room and a lounge-dining room. There is a bathroom/toilet on each floor. A chair lift provides access to the first floor. At the back of the house is an enclosed patio garden. The fees at Bessmount House range from £350 to £700, information given to CSCI by the Registered Providers in May 2006. Additional charges are made for made for chiropody, hairdressing, outings and newspapers. The homes service users guide, which contains a copy of the inspection report, is located in the hallway. Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report reflects a cycle of Inspection activity at Bessmount House since the last inspection in July 2007. To complete this report we looked at previous inspection reports and information given at the last inspection where available. We looked at information and documents sent to CSCI since the last inspection; a site visit was carried out by two Inspectors looking at any developments the home has made and the lifestyle experienced by the people living at the home; records that were available were seen; discussions were held with staff on duty, people living at the home and a visitor; and we looked round the home to see it was clean and safe, as well as comfortable. Following the last inspection an Improvement plan was sent to the home for completion. This tells us what the home owner is planning to do about things that need to improve. It is a legal requirement that this is completed and returned to CSCI by 1st November 2007. The form was not returned so part of this Inspection looked at what the owner was intending to do to improve things at the home. On the site visit a number of records were not available for inspection. An agreement was made with Mrs Simpson that these would be bought to the CSCI office to be copied within two days. This was to give Mr and Mrs Simpson an opportunity to show that they did keep the records required by law up to date. They were not supplied. Another agreement was made following a telephone call from Mr Simpson that they would be bought to the CSCI office on the 18th December however they were not provided on that date. These records have not been available on previous inspections and an immediate requirement was made on 7th July 2006 that they be kept at the home and be available for inspection at all times. What the service does well: The home is overall a comfortable and pleasant environment for people to live in. It is in a village location and has access to some local facilities which are important to people. One person living at the home said that their family member had been enabled to remain a part of their care delivery which was of great importance to them and their relative. This helps relatives to keep involved with the care of their Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 6 family and helps to give re-assurance and comfort to the person living at the home. Staff seen worked well with the people living at the home in keeping a family like atmosphere. People were respectful and good humoured and on the day of the visit were celebrating one persons birthday with a party. Relatives were welcome to visit and had a good relationship with the owner. The home has pets which help many people to feel at home. One person living at the home said they had been enabled to carry on with interests they had before coming into the home which was of great importance to them. What has improved since the last inspection? What they could do better: Care plans and assessments must be fully completed and regularly reviewed, so that they reflect the changing needs of the people using the service. On the inspection visit no care plans were available to be seen, so it is not possible to tell whether they have been reviewed or how well they reflect the needs of the people at the home. This was a requirement at a previous inspection but has not been achieved. Care plans should identify the persons support needs and how they are to be met. They also help to identify goals of the care given. Records were not available to detail how well the home is achieving standards for National Vocational Qualifications for staff. National Vocational qualifications are an assessment of the staff members skills and competency in their working role, and should help to demonstrate the staffs ability to care for people at the home. This was a requirement at a previous inspection but has not been achieved. Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 7 No evidence was available of new staff receiving structured induction training within the first six months of appointment. This was a requirement at a previous inspection but has not been achieved. The home must be clean, with particular reference to the first floor bathroom. This is so that people can live in an attractive end hygienic environment. The Registered Providers must make sure that all records are available at all times for inspection in the care home by any authorised person. This is so that it is clear records required by law are in use and being kept up to date. This was a requirement at a previous inspection but has not been achieved. The registered providers must make sure that the home is fully protected against fire and fire drills and tests are kept up to date. The fire escape remains in poor repair and a potential slip hazard. This was a requirement at a previous inspection but has not been achieved. A full recruitment process must be followed for all staff. These includes taking up references, criminal records bureau checks and other evidence to confirm the person is suitable to be working with potentially vulnerable people. Initial assessments of peoples needs should be written, dated, and have the details of where completed on them. This is so that it is clear when they were completed and how the person completing the assessment made sure that the home could meet the persons needs. Initial assessments of peoples needs should include their mental health needs including memory loss. Initial assessments of peoples needs should include if their needs match the registration categories of the home. This is so that the home is sure they are not admitting people they are not able to care for. The home owner should have records available of people’s interests and social histories. This helps with the planning of activities and helps with an understanding of peoples chosen lifestyles. The home owner should let people know what is on the menu so that they can choose what to eat. The homes management should implement a food management system for the safe handling and recording of foods, as advised by the Environmental Health Officer. This helps to protect people living at the home from poor food hygiene practices. A system for recording and reviewing complaints or concerns that people may have raised should be provided. This will help with ensuring any concerns are investigated impartially and in a systematic way Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 8 There are no ongoing written plans of maintenance, and no plans for the areas of décor partly finished or not yet started. 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. Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 9 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 Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6, Quality in this outcome area is adequate. The home provides some information about the home to help people judge whether they want to move there. People are assessed before a decision is made about whether the home is the right place for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The owner confirmed that the home had a statement of purpose and service user guide, but this has not been updated and this needs to be done to ensure the information contained is an accurate reflection of what services the home has to offer. People should be given this information to help them make a decision about whether the home is the right place for them. It should also give them information about their rights and a copy of the homes complaints procedure. We talked to the owner on this visit about needs the home was not able to meet. The owner said that although there are some people with memory loss at the home, it is understood that if they deteriorate the home will no longer be able to look after them, and they will need to move to a home more capable of specialising in people with memory loss. This information needs to be Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 11 placed in the homes statement of purpose and service user guide. This is so that people can make a decision about the home in the knowledge of what may happen in the case of their future deterioration. We talked to the owner on how the most recent admission had come to the home. Records for this admission were not available on this visit, but were seen at the last inspection, and no new people have been admitted since then. All documentation must be kept on the premises so that is available to staff and for reference. Mrs Simpson said that she had assessed the person when they had visited the home with their relative and see the accommodation available. Assessments are important as they make sure that the home can meet the persons needs before a decision is made to move in. She said that following an admission, a full medication review is held with the GP and that care plans are completed. At this time consideration is also given as to whether any environmental adaptation is needed for the person. This might mean providing different lighting for people with eyesight difficulties or a grab rail to make sure someone could move about safely. Assessments (seen on the last inspection) did not always make clear the mental health needs of those intending to use the service. For example several people seen at that time had a level of memory loss, for which the home is not registered or designed. This had not always been recorded. There was no evidence of how the service had taken into account peoples mental health needs when inviting them to live at the home, and the owner confirmed that no changes have been made since the last inspection when these were seen. The service must ensure that they do not accept people into the home that is outside of the registration of the home for; example people with mental health needs, or accept people that they are unable to care for. Bessmount House does not provide Intermediate Care, which is a specialist programme of rehabilitation aimed at returning someone to their own home. Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. People living at the home have their health and personal care needs met, however plans to support progress and record peoples preferences in how their care is to be delivered were not available. This judgement has been made using available evidence including a visit to this service. EVIDENCE: When we visited the home, no care plans were available for us to look at. Care plans are a written record of the support each person needs and how they wish their care to be delivered. The owner stated that the care plans were at their other accommodation being updated. However this had also been the case on two previous inspections, on one of which an immediate requirement was issued that all records be maintained at the home. Care plans are important as they allow for goals to be set in improving care and help staff to provide consistency. Following the inspection an agreement was made that a sample of care plans and a number of other records also not available would be delivered to the Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 13 CSCI office in Ashburton within two days following site visit. Plans were not delivered by this or by a second agreed date. It has therefore not been possible to judge fully whether these plans are being maintained appropriately or how well they reflect peoples changing aspirations and the support they require. The owner stated that care staff dont look at the care plans, but know what peoples needs are because it is a small home and the staff communicate well any changes. Any daily changes will be recorded in the daily log/record for each person. We looked at this log and it did contain some information which could be cross referenced with the homes accident book. This helped to show that some records are being maintained. The owner stated that in January the home will be appointing a new manager, who will be dealing with updating all the care plans and putting them on a computerised system. They will also be having a new office. People we spoke to on the visit felt they were well cared for. They said that staff looked after them well and that when they were unwell General Practitioners were called to see them. A person spoken to said that their relative was able to continue being a part of their care package and care delivery which was of great importance to them both. This is good practice. Discussion was held with the owner on the care needs of people living at the home who have some memory loss. No particular environmental or social adaptations are made for these people currently, and as care plans were not available it was not clear what arrangements are made to record their social and personal history or the effects of the memory loss on the individual and how their needs are best met. This might mean that as people lose the ability to communicate their wishes and needs as their memory loss progresses they may not be able to make staff understand what they need. The medication practices seen including storage and administration were satisfactory. Medication records are kept, which help to ensure that a full audit can be carried out on medications received into the home, given to people living there and returned or destroyed if no longer needed. This means medication can be administered safely. A relative spoken to referred to the home as “A lifeline”, providing long term care for one relative and respite for another. They experienced the home as being supportive and said that their relatives felt ‘at home’. Staff seen supporting people living at the home had a good rapport and were respectful. People were being treated well by staff. Bessmount House DS0000003652.V355971.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): 12, 13, 14, 15. Quality in this outcome area is good. People living at the home experience a lifestyle that is flexible and enables them to continue with interests. Friends and family contacts are encouraged. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion was held with the owner on activities and daily life at Bessmount House. The owner confirmed that there was a visiting activities organiser each Monday afternoon who provided games, quizzes, reminiscence and Bingo. People living at the home are supported to go to Church and attend local clubs such as the Women’s institute. Communion is also provided in house for people who do not wish to go out. The owner confirmed that also trips out are provided and on the day of the site visit one person living at the home was celebrating their birthday with a party. In the evening local bell ringers were coming to the home for a festive evening. Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 15 The home aims to operate as a family unit and there are dogs and other animals which the people living at the home are said to get great enjoyment from. As no care plans were available it was not possible to judge the way in which the home plans to meet individual needs, or how activities are provided to meet the support needs of people with memory loss or sensory impairments who are accommodated. A person living at the home said they felt enabled to continue doing things that they had enjoyed doing before they came into the home. Other people spoken to said that they were able to stay in bed for as long as they wish in the morning, and had good contacts with family and friends. A relative who visited confirmed that she bakes cakes for the home, the money for which goes towards a local hospice. The home has recently obtained an electric wheelchair for people to use. The owner feels this will help to improve their access to the local area. Meals at the home are cooked by the care staff on duty, which means meals are home cooked but cooking has to be fitted in between care duties. No menu plan was available to detail how meals are planned or what choices are available. People living at the home said that if they didn’t like a particular meal than an alternative would be provided. No evidence was available to show the homes management has responded to the requirements of the Environmental Health department in providing a safe system for the handling of food. This could put people at risk from unsafe food practices. Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is adequate. The complaints systems at the home need development to ensure people can be confident that complaints will be addressed in a consistent fashion. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure was displayed in the hallway of the home. Discussion with the owner indicated that no complaints have been received since the last Inspection. There was no system in place that could be seen for recording and reviewing complaints or concerns that people may have raised, however the owner said that minor issues would be recorded in the daily logs. Some staff at the home have not yet received training in adult protection or are due updates. Staff spoken to were aware of the homes adult protection policy and procedure and felt confident that they would know what to do if a disclosure was made to them. They also felt clear about what constituted abuse. A clear understanding of and training in abuse prevention helps to protect people living at the home from poor or abusive practices. Bessmount House DS0000003652.V355971.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, 20, 21, 22, 23, 24, 25, 26. Quality in this outcome area is adequate. Bessmount House is a comfortable place to live. Attention is required to some décor, cleanliness and safety issues. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has seven single bedrooms and two double bedrooms, all except one have en-suite toilet facilities. All the bedrooms are connected to a call bell system and have telephone and television points. There is a quiet sitting room and a lounge-dining room, which means people can have a choice of where to sit. There is a bathroom/toilet on each floor. A chair lift provides access to the first floor, so people with some limited mobility can be cared for. At the back of the house is an enclosed patio garden. A tour was made of all areas of the home. Most of the home seen was clean, warm, well decorated and comfortable. Attention was required to some areas to make sure that people can live in a well maintained and homely environment that is safe and well maintained. Some of these areas remain Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 18 outstanding from the last inspection. For example the decoration in the entrance hallway and cleanliness in the bathroom. Peoples individual bedrooms were clean and comfortably furnished and contained pieces of their own furniture, pictures and possessions. This helps people to feel at home. There were no ongoing records of maintenance available or plans for the future development of the home. Mrs Simpson stated she had plans for completing the works needed, but had no dates set. She also described plans for expansion of the home. Some areas of the home continue to present risks to people living there, and no environmental risk assessments were available to identify and minimise any of the risks identified. A fire risk assessment had been completed by an external provider, but was not available during the inspection The fire escape was slippery and would present risks to people having to use it in a hurry. This has been previously identified but not addressed. Bessmount House DS0000003652.V355971.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, 30 Quality in this outcome area is poor. Staff seen were competent and confident in dealing with people, but recruitment practices put people living at the home potentially at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No staff recruitment records or training records were available or seen at this inspection. The owner stated that nothing had changed since the last inspection however discussion indicated that recruitment practices were not suitable to protect people living at the home from being cared for by people who may be unsuitable to work with vulnerable adults. As an example the owner stated that a new staff member was due to start working at the home within a few days of the inspection. Their references were said to be “in the post”, they had only a criminal records bureau check from their previous employer and no Protection of Vulnerable adults check had been undertaken. A new criminal records bureau check should be taken up on each appointment to ensure that the check is as up to date as possible. The protection of vulnerable adults check helps to identify people who have been deemed not suitable to be working with vulnerable adults. One other staff member, currently working at the home also had no new Criminal records bureau check and ‘verbal references’ which had not been recorded. No information was available on the Induction or foundation training that they had been given since commencing work. These practices do not protect people living at the home from potentially being cared for by people Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 20 who may be unsuitable to work with vulnerable adults, and do not ensure that staff training is given in a consistent and thorough way. No staff training or supervision records were available for us to see on the visit. At the last two previous inspections, as on this one, the owners stated these tasks shad been delegated to a private company who had failed to provide the agreed documentation or support. The staff seen on duty were confident and clearly had a good relationship with the people they were caring for. People spoken to said that the staff cared for them well. Bessmount House DS0000003652.V355971.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, 36, 38. Quality in this outcome area is poor. Significant gaps in management systems or unavailable information places people living at the home at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager of the home, Mr Simpson was not available on the day of the site visit, but Mrs Simpson was at the home and assisted in the Inspection. A quality assurance system has been introduced since the last inspection. Mrs Simpson said that people living at the home are consulted regularly about the home and whether it is meeting their needs. Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 22 Mrs Simpson stated that the home does not manage any money for people living at the home, and has supported people in accessing solicitors or other advocacy support. Staff supervision has not yet commenced, despite this being a requirement at previous inspections. No progress has been made in this area, however the owner stated that it was their intention this would be dealt with by a new manger when they start in January. Portable electrical appliances were last tested in July 2007. Many environmental checks and health and safety checks due to be done monthly according to the owners own assessments were last done in July 2007. The home has also not started on the requirements of the environmental health officer and fire precautionary works remain outstanding. These place people at the home at risk. The owner stated that a fire drill was last done’ a few weeks ago’ but no records could be found to evidence this. Staff spoken to said that they had received fire training and could correctly identify fire procedures, where call points were and where extinguishers were sited. There was no fire risk assessment available during the inspection, but a copy was provided subsequently. Staff training in Health and safety is variable with only two staff having a first aid qualification according to Mrs Simpson. Staff have watched a DVD on Infection control, and all have food hygiene certificates. Moving and handling training information was not available, neither were servicing records of equipment. The owner stated that work is being done with a relative who is qualified physiotherapist to look at the moving and handling needs of one person, and guidelines will be drawn up. No safe working practices risk assessments could be found. These help to identify risks to staff in their work and how these can be minimised. Bessmount House DS0000003652.V355971.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 2 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 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 2 17 x 18 2 2 2 3 3 3 3 2 2 STAFFING Standard No Score 27 2 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x N/A 1 x 1 Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 14,115,11 7,1aSch 3 Requirement Timescale for action 21/02/08 2. OP28 18,1ac19, 5b Care plans and assessments must be fully completed and regularly reviewed, so that they reflect the changing needs of the people using the service. Previous timescale 12/10/07 not met A minimum ratio of 50 01/01/08 members of care staff, excluding the Registered Manager, must be qualified to NVQ Level 2 or above by 2008. Timescale carried over from previous inspection site visit 01/01/08 as date not passed. The Registered Providers must provide new staff with structured induction training within the first six months of appointment and ensure that it meets with the required standards. Previous time scales of 30/05/07, 01/10/07 were not met The Registered Providers must keep records as evidence of any DS0000003652.V355971.R01.S.doc 3. OP30 18,1 21/01/08 4. OP30 18,1 21/01/08 Bessmount House Version 5.2 Page 25 induction training undertaken by staff. Previous time scales of 30/05/07 and 01/10/07 were not met 5 OP26 23 2 (d) The home must be clean, with particular reference to the first floor bathroom. Previous timescale 01/10/07 not met. The Registered Providers must ensure that all records referred to in this regulation are available at all times for inspection in the care home by any person authorised by the Commission to enter and inspect the home. This was an Immediate Requirement at the time of a previous inspection, and was not complied with at the last inspection. The registered providers must ensure that the fire escape is kept in good order and a potential slip hazard removed. Previous time scale of 01/10/07 was not met 8 OP29 19 A full recruitment process must be followed for all staff. This include taking up references, criminal records bureau checks and other evidence to confirm the person is suitable to be working with potentially vulnerable people. 21/01/08 21/01/08 6 OP37 17,3b 21/01/08 7 OP38 23, 4 21/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 26 No. 1. 2. 3. 4. 5. 6. Refer to Standard OP3 OP3 OP3 OP14 OP15 OP15 Good Practice Recommendations Initial assessments of peoples needs should be written, dated, and have the details of where completed on them Initial assessments of peoples needs should include their mental health needs including memory loss. Initial assessments of peoples needs should include if their needs match the registration categories of the home. Record activities and interests that people participate in. Let people know what is on the menu so that they can choose what to eat. Implement a food management system for the safe handling and recording of foods, as advised by the Environmental Health Officers last visit to the home. Develop a system for recording and reviewing complaints or concerns that people may have raised. There were no ongoing written plans of maintenance 7. 8. OP16 OP19 Bessmount House DS0000003652.V355971.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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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