Inspection on 20/07/07 for Bessmount House

This inspection was carried out on 20th July 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 12/12/07

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 Andrea East Unannounced Inspection 10:00 20th and 23rd July 2007 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.V338451.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.V338451.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.V338451.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2006 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 current 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.V338451.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was carried out over two days. We examined a range of documents including staff and peoples individual files, policies, procedures and the homes service users guide. People were spoken too in the homes lounge and in private rooms and members of staff were also spoken with. The homes owners were present on the second day of the inspection visit. Feedback about the home was also received by post in survey questionnaires provided by the Commission and in discussion with visitors to the home. This report also refers to information obtained at previous inspection visits to the home. What the service does well: The home had a system of assessment for people planning to come into the home. People had an opportunity to visit the home and discuss their needs before coming into the home. Peoples, needs were also discussed with relatives and advocates, as some people were unable to say how they wished to be cared for. The home provided a good standard of care for people using the service. People said “they really look after me” “I know they will do what ever is best for me”. Medication administration systems in the home were good. Medication was stored safely and administered safely by staff, who knew the medication policy and procedures well. People were encouraged and supported in enjoying activities inside and outside of the home. People joined in an activities afternoon and going out of the home shopping or to church with staff, relatives or friends. Relatives and visitors were welcomed into the home. People enjoyed the meals served in the home and the home offered a choice in meals and snacks served in the home. People were able to raise any concerns with staff and the owners and that those concerns would be listened to and acted upon. People said that the staff and owners provided a “ kind and caring” service and that they treated everyone with the “respect they deserve”. The home had a good recruitment system, to enable them to check that all documents were in place, before starting a new member of staff at the home. Bessmount House DS0000003652.V338451.R01.S.doc Version 5.2 Page 6 This ensured that no new staff employed in the home, were unsuitable to work with vulnerable people. What has improved since the last inspection? What they could do better: The storage and administration of documentation could be improved. For example: assessments and care plans were not always fully completed, clear, reviewed, dated or signed for everyone coming into the home. All documentation was not kept on the premises so that is available to staff and to inspectors for inspection. Poor assessments means that the home can not ensure that the service does 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. Care plans and assessments had not been reviewed or updated consistently. This did not give the staff the consistent information they needed to care for people safely and peoples changing needs. Management system in the home in several areas needed to be improved. Examples were: The management system for the safe handling and recording of foods had not yet been implemented. Fire safety management systems had not been implemented. In the event of a fire this placed the people living at the home and the staff at risk. There was no system in place for recording and reviewing complaints or concerns that people may have raised. Not recording issues and concerns means that the owners are unable to identify patterns or trends that may indicate poor service or poor care. The upstairs large communal bathroom was dirty. There were no written routines for staff cleaning duties. Staff said that the peoples care needs came first so that sometimes cleaning was not always completed. There was no process or system for making sure that this rubbish was removed on a routine regular basis. This collection of rubbish gave the outside of the home an unsanitary appearance. Bessmount House DS0000003652.V338451.R01.S.doc Version 5.2 Page 7 Induction and supervision records for staff were not well completed. No staff had any level of NVQ training accept the owner who acts as the manager. This falls well below the required standard for staff training and had been raised at the previous inspection. Staff skills and experiences gained from previous employment needs to be sustained to maintain good working practices and safe affective care for the people using the service. 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.V338451.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 Bessmount House DS0000003652.V338451.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The people using the service were confidant that their care needs had been assessed and that their needs could be met, right from the start of their stay in the home. The services provided did not include intermediate care EVIDENCE: People living at the home, said that they had an opportunity to visit the home and discuss their needs before coming into the home. Some of peoples needs had also been discussed with relatives and advocates, as some people were unable to say how they wished to be cared for. Written assessments were not always fully completed for everyone coming into the home. Staff spoken to relied on information recorded in diaries and information passed on in informal discussions between staff, the owners and Bessmount House DS0000003652.V338451.R01.S.doc Version 5.2 Page 10 the people coming into the home. Written ongoing assessments would make the peoples needs much clearer to all staff and to the people using the service. On the first day of the inspection assessments were not available, as the owners had taken them from the premises. The owners said that they had been removed to update them. All documentation should be kept on the premises so that is available to staff and to inspectors for inspection. On the second day of the inspection assessments were examined. It was not always clear when and where these assessments had been completed. Assessments should be dated and should say where they were completed. Assessments did not always make clear the mental health needs of those intending to use the service. For example several people had a level of memory loss. 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. 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 DS0000003652.V338451.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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People using the service had their health, personal and social care needs met and this was set out in an individualised plan of care. Individuals were involved in decisions about their lives, and did play an active role in planning the care and support they received. People were treated with dignity and respect and their privacy was upheld EVIDENCE: On the first day of the inspection the care plans and assessments were not in the home. On the second day of the inspection the owners brought files into the home, which held care plans and assessments. Assessments and care plans showed peoples care needs and how the homes staff should care for peoples needs. Members of staff were able to describe peoples’ individual needs and preferences in detail. Members of Staff were observed assisting people and they asked people what way worked best for Bessmount House DS0000003652.V338451.R01.S.doc Version 5.2 Page 12 them, when caring for them. Staff used diaries and communication books to share information about peoples needs. These books also held information on Health Professionals visits and the day- to- day life in the home. Surveys returned to the Commission said that people using the service felt well cared for and, that staff called in Health Professionals when needed. Care plans and assessments had not been reviewed or updated consistently since the last inspection. Documents appeared to have been extended and updated for a short period and then not reviewed for months. Care plans and assessments must be kept on the premises so that members of staff have access to all the information they need, to care for people, as they wish to be cared for. This is particularly important for members of staff who may have been away form the home, on holiday and for new staff that do have up to date knowledge about the home. Care plans and assessments must also be regularly (minimally monthly) reviewed and updated to reflect peoples changing needs. This would ensure that members of staff are made fully aware of peoples needs and how best to meet those needs. Medication administration systems in the home were good. Medication was stored safely and administered by staff who knew the medication policy and procedures well. People said that staff dealt with their medication safely and reliably. Medication records examined were well maintained. Bessmount House DS0000003652.V338451.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People’ s lifestyle in the home met their expectations and satisfied their needs. People who used the services were able to make choices about their life style, and were supported to develop their life skills. Social, educational, cultural and recreational activities met individual’s expectations. People enjoyed an appealing, varied diet, at a time that suited them, with support from staff. EVIDENCE: Staff said that people were encouraged and supported in enjoying activities inside and outside of the home. This included most people joining in an activities afternoon and going out of the home shopping or to church with staff, relatives or friends. The things people had participated in and enjoyed was not always recorded so that it was not clear how people had been offered the choice to enjoy things that interested them. Bessmount House DS0000003652.V338451.R01.S.doc Version 5.2 Page 14 Surveys consistently said that relatives and visitors were welcomed into the home. One person’s relative said that the staff and owners welcomed them at any time. They said that they had an opportunity to share in the events planned in the home such as meals and how care was provided. Members of Staff were observed preparing and serving the main meal of the day. Staff said that the home did not employ one person as a cook, so that care staff were caring and cooking. In such a small home, this appeared to work well as staff cooked individual meals based on peoples’ choices. For example; one person said they preferred a lighter meal and staff accommodated this without hesitation and working together to make sure everyone ate food at a time that suited them. Members of staff, spoken with, were able to describe peoples’ preferences, special diets, meal sizes and favourite snacks and drinks. People said that they could eat where they wanted to and although they were not always aware of what was on the menu, felt that they did have a choice in meals and snacks served in the home. Making sure that people are aware of what is on the menu gives them the opportunity to make an informed choice about what they eat. Staff said that the management system for the safe handling and recording of foods had not yet been implemented. A management system for food handling had been highlighted at the Environmental Health Officers last visit to the home. (see management section of this report). Bessmount House DS0000003652.V338451.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who used the service were able to express their concerns, and complaints and suggestions from those using the service, relatives or other visitors to the home were treated seriously. People were protected from abuse, and had their rights protected. EVIDENCE: People said that they felt able to raise any concerns with staff and the owners and that those concerns would be listened to and acted upon. A complaints procedure was displayed in the entrance of the home and staff said that they were aware of complaints and adult protection procedures. Surveys said that people were aware of the homes complaints procedure and new who to speak to if they had any concerns. There was no system in place for recording and reviewing complaints or concerns that people may have raised. Not recording issues and concerns means that the owners are unable to identify patterns or trends that may indicate poor service or poor care. It would also show how the home deal with concerns and the progress the home may have made in some areas. Bessmount House DS0000003652.V338451.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People lived in an adequately maintained house, which offered a range of facilities and was on the whole comfortable, clean and safe. EVIDENCE: People’s individual rooms were personalised with their own possessions such as photographs, items of furniture and ornaments. Surveys said that the home was generally clean and tidy and that the people living and working at the home enjoyed it’s “homely atmosphere”. Parts of the home are in need of redecoration and cleaning. For example inside the entrance to the home and the doorway needs decorating. This was also highlighted at the previous inspection. There were no ongoing written plans of maintenance. Staff said that repairs were completed as and when needed and receipts for work and maintenance Bessmount House DS0000003652.V338451.R01.S.doc Version 5.2 Page 17 checks were stored at the home. A written plan for repair shows the progress the home has made in redecorating and maintenance and is way to ensure that areas of the home are continually refreshed and kept in good repair. The upstairs large communal bathroom was dirty. There were no written routines for staff cleaning duties. Staff said that the peoples care needs came first so that sometimes cleaning was not always completed. All areas of the home must be clean. The outside area to the rear of the property was cluttered and had rubbish bags that had not been removed for some time. The owner said that they removed the rubbish. There was no process or system for making sure that this rubbish was removed on a routine regular basis. This collection of rubbish gave the outside of the home an unsanitary appearance. Peoples individual rooms do not have locks fitted, so that they can lock them for privacy. The owner said that people had been asked if they wanted locks on their doors and this had been recorded. This was only the case for those people living at the home at the time of the last inspection. This practice had not been continued for new people entering the home. People must have the opportunity to have locks fitted to their private rooms to ensure their privacy. Bessmount House DS0000003652.V338451.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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The people using the service, were supported by Staff, who were trained, skilled and competent. Staff had been subject to rigours recruitment checks EVIDENCE: Surveys said that the staff and owners were kind and caring and that they treated everyone with the “respect they deserve”. Surveys consistently said that staff had the right skills and experience to look after people properly. Staff were observed assisting people around the home and helping with medication and meals. Members of Staff were described as “kind” and did not rush people, explaining what they were doing and sharing information about the days events. One relative said the staff and owners were “wonderful”. We examined staff files, which had a range of documents in, including application forms and contracts of employment, police checks and references for new staff, that had been consistently completed. The owners had developed clear processes, to enable them to check that all documents were in place, before starting a new member of staff at the home. Staff said that they had received training and induction into the home. Staff training records had not been consistently updated so that it was difficult to Bessmount House DS0000003652.V338451.R01.S.doc Version 5.2 Page 19 see what staff had received training in key areas such as manual handling, infection control, adult protection. Induction and supervision records for staff were not well completed. The owner said that a private firm had been commissioned to provide support in these areas but had failed to provide the agreed documents. This was also raised at the last inspection when the same reason was given for not having an indepth induction that met national standards. No staff had any level of NVQ training accept the owner who acts as the manager. This falls well below the required standard for staff training and had been raised at the previous inspection. Staff skills and experiences gained from previous employment needs to be sustained to maintain good working practices and safe, affective care for the people using the service. Bessmount House DS0000003652.V338451.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): Quality in this outcome area was poor This judgement has been made using available evidence including a visit to this service. People lived in a poorly managed home, with few management systems in place to keep people safe. The staff team and owners, worked together to respect and protect peoples’ rights. EVIDENCE: Throughout the inspection visit several shortfalls in management were identified, which puts people at risk. The management of fire safety was poor. Devon and Somerset Fire and rescue service had highlighted in writing, in April 2007, several areas of concern that had not be addressed. For example: the home did not have a fire risk assessment that had been reviewed and updated, no fire safety management policy, telling staff what to do in the event of a fire, had been devised and escape routes and exits were unsafe. The fire escape was in poor repair and a Bessmount House DS0000003652.V338451.R01.S.doc Version 5.2 Page 21 potential slip hazard. In addition portable appliance testing had not been carried out. On the 8th of August 2007 (after the inspection site visit) the Commission received written confirmation that portable appliance testing and repair to a fire door had taken place. Management routines for recording information had not been consistently maintained and were not always on the premises. This had been highlighted at previous inspections, as an immediate requirement. That had improved and at this visit returned to poor practice. For example; Documents appeared to have been extended and updated for a short period and then not reviewed for months. The management system for the safe handling and recording of foods had not been implemented. A management system for food handling had been highlighted at the Environmental Health Officers last visit to the home. There were no ongoing written plans of maintenance or cleaning for the home so that areas of the home had not been cleaned and were in need of redecoration. For example the rear of the property cluttered with rubbish, and a dirty bathroom. Staff training for was not monitored or recorded and staff training fell well below the standard required. For example no staff having National Vocational Qualification in Care training, staff induction and supervision not being carried out in a formal organised and recorded way. This had been highlighted at a previous inspection and a timescale for National Vocational Qualification in Care training agreed as 01/01/08. No action had been taken to start to address this. One member of staff, was due to start at the home, who had an National Vocational Qualification in care. The home had did not have an ongoing quality assurance systems that seeks the views of the people using the service and monitors the quality of care. The owners said that they had employed outside agencies that had failed to meet their requirements and agreed commitments, which had led to several things, such as fire safety and staff training and supervision, not being addressed. The owners were aware that it is their responsibility to address issues in the home and to keep staff and people living at the home safe. The owners and staff team clearly had a desire to provide good care that respected people. People said that they felt valued and respected. Good management systems that planned for the needs of the people living in the home, would support staff and owners to care for people safely. Bessmount House DS0000003652.V338451.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 x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 2 x x x x x x 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 2 2 2 Bessmount House DS0000003652.V338451.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 OP7 Regulation 14,115,11 7,1aSch 3 Requirement Timescale for action 12/10/07 2. 3. OP26 OP28 23 2 (d) 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 time-scales of 18/12/06 Had been met and this is a return to poor practice. The home must be clean 01/10/07 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 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 scale of 30/05/07 was not met The Registered Providers must keep records as evidence of any induction training undertaken by staff. DS0000003652.V338451.R01.S.doc 4. OP30 18,1 01/10/07 5. OP30 18,1 01/10/07 Bessmount House Version 5.2 Page 24 6 OP33 24 Previous time scale of 30/05/07 was not met An effective quality assurance system must be developed to establish the residents’ level of satisfaction with the care services they receive in the home. This must also be extended to all visitors to the home including health and social care professionals, to establish their level of satisfaction with the care services being provided in the home. The results of all the surveys undertaken must be published and available to prospective service users and the Commission Previous time scale of 31/03/07 was not met. 01/10/07 7 OP37 17,3b 8 OP38 23, 4 The Registered Providers must 01/10/07 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 the last inspection and has been re raised at this visit. The registered providers must 01/10/07 ensure that after consultation with the fire authority they: take adequate precautions against the risk of fire, provide adequate means of escape, plans for evacuation for all persons in the home, make arrangements for detecting, extinguishing and giving warning of fires. Bessmount House DS0000003652.V338451.R01.S.doc Version 5.2 Page 25 This relates to the homes lack of fire risk assessment that had been reviewed and updated, no fire safety management policy, telling staff what to do in the event of a fire, and escape routes and exits were unsafe. The fire escape was in poor repair and a potential slip hazard. 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 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 Develop a system for making sure that bags of rubbish from the outside of the premises are removed on a routine regular basis. Develop an ongoing system so that People have the opportunity to have locks fitted to their private rooms to ensure their privacy. 7 8 9 10 OP16 OP19 OP20 OP23 Bessmount House DS0000003652.V338451.R01.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Bessmount House DS0000003652.V338451.R01.S.doc Version 5.2 Page 27 - 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!