Inspection on 26/01/06 for Belmont Lodge Care Centre

This inspection was carried out on 26th January 2006.

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

Belmont Lodge Care Centre 20/12/07

Belmont Lodge Care Centre 15/09/06

Belmont Lodge Care Centre 27/07/05

Belmont Lodge Care Centre 20/12/04

Belmont Lodge Care Centre 28/06/04

Belmont Lodge Care Centre 11/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Belmont Lodge 392/396 Fencepiece Road Chigwell Essex IG7 5DY Lead Inspector Sharon Thomas Unannounced Inspection 23rd January 2006 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 Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 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. Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Belmont Lodge Address 392/396 Fencepiece Road Chigwell Essex IG7 5DY 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) 020 8500 5222 020 8559 8100 Diomark Care Limited Manager post vacant Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, age 65 years and over, who require care by reason of old age (not to exceed 46 persons) 27th July 2005 Date of last inspection Brief Description of the Service: Belmont Lodge is a large detached house located in a residential area in Chigwell. The home is registered to provide residential care to 46 older people (i.e. over the age of 65), with varying degrees of dependency. Residents are accommodated in 36 single rooms and 5 double rooms. The home has several lounges and a dining room. The home provides facilities, aids and adaptations that enabled staff to deliver quality care. The home promotes the rights of service users and provides care with privacy and dignity. Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 26 January 2006, and took 5.5 hours. Fifteen of the thirty-eight National Minimum Standards were inspected: eight were met, and seven were nearly met. For the purpose of this report the individuals living in the home spoken with on the day stated that they would prefer to be called residents. The inspection process included: discussions with the acting manager, two members of staff, and the cook. The tour of the premises included observation of four bedrooms, the bathrooms and toilets, the communal areas, the kitchen and the laundry. There was an opportunity to spend a considerable period of time observing the care being provided by the staff. The inspection included the examination of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). The CSCI has received two complaints since the previous inspection, the details of which may be found below. The home was warm clean and tidy. The residents spoke highly of the care that they receive in Belmont Lodge and spoke highly of the efforts of the staff. The home has had difficulty in recruiting to the manager’s post and the acting manager confirmed that the recruitment process is ongoing. The home has a number of residents who appear to have dementia, it is confirmed that a re-assessment of these residents has been completed by the home and the CSCI has received an application applying to vary the registration to residential care with specific beds for dementia. What the service does well: The residents living in Belmont Lodge benefit from an established and knowledgeable staff group who gave sensitive and professional care. The staff have an in-depth knowledge regarding the needs of the individual residents in their care. Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 Page 6 Relatives and visitors are welcomed into the home and residents felt that the home done everything possible to make sure that their relationships were maintained. The environment in the home was considered safe and well maintained. The home had a warm and homely feeling. The residents spoken with on the day reported that they felt “warm and comfortable” and “at home”. The recruitment process used in the home ensures that staff that are recruited to the home have had appropriate checks to ensure the safety of the residents. What has improved since the last inspection? What they could do better: The home needs to continue to develop the care plans and ensure that all aspects of care are recorded. The risk assessments do not contain all aspects of risk identified in other professional assessments. The care plans did not contain information regarding the oral health care of residents. The home did not provide or offer appropriate regular exercise to the residents to enhance or promote their current health. The home did not maintain accurate records relating to the administration of controlled drug medications. Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 Page 7 The home did not meet the standard in relation to the provision of activities or the pursuit of leisure activities. The home did not accurately record all complaints that are made. The home did not, in one instance, report the issue to the CSCI as required by the regulations. 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. Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 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 Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The home has an appropriate pre-admission process that ensures that the home has assessed the needs of the prospective resident. EVIDENCE: Two of the three care plans examined were those of the newest admission into the home. These residents were both self-funding and their files contained the home’s pre-admission assessment. There was evidence that the resident and their family were involved in the care planning process. The home had used its own pre-admission assessments, which were comprehensive and contained an appropriate assessment of need. Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 10. The care planning systems have improved but need further development to ensure that staff are provided with adequate information to enable to meet the residents’ needs. The home’s system of the administration of medication remains unsafe, and has the potential of placing residents at risk. The staff have a sensitive and caring approach toward residents and treat them with respect. EVIDENCE: The three care plans examined on the day indicated that the care planning system has improved since the previous inspection. The care plans contained detailed and comprehensive information on the needs of the residents. One of the care plans had a comprehensive risk assessment relating to falls, pressure care and continence. Two care plans contained a risk assessment document, however, these did not provide adequate information relating to risks identified in professional assessments. The care plans were reviewed on a monthly basis and there was evidence that residents and relatives were involved in the process. Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 Page 11 The health care needs of the residents were, on the whole well recorded. The care plans contained information of health issues, pressure care issues and continence issues. The needs of residents with personal care needs are well documented and where an individual is able to self-care this is recorded and encouraged by staff. The care plans contained assessments that enhance the staff’s ability to deliver appropriate care. There was evidence from the records that referrals are made to GP’s, district nurses and other health care professionals. The home continued to receive support from local health care agencies with continence, dementia and pressure care issues. The care plans did not provide adequate information with regard to the oral health of residents. The home does not provide adequate exercise for the residents living there. NMS: 9 was not fully inspected. The standard was revisited to ensure that the requirements of the previous inspection had been addressed. The records of the administration of medication were examined and were found to be accurate and well maintained. The records of controlled drugs were examined and one entry had not been witnessed. The numbers of individual tablets for one particular resident were not accurate and a number of tablets were missing. This concern was discussed with the acting manager and he confirmed that he would undertake an investigation with the staff on duty at the time that the errors were noted. Two of the residents and one relative spoken with commended the staff with regard to the treatment they received in Belmont Lodge. The residents stated that their privacy and dignity was maintained in a variety of ways, including the way staff provided personal care, toileting issues, respect for visitors, and the provision of private areas in the home that enabled residents to see visitors in private. Observation of staff during the inspection indicated that staff were friendly, considerate and respectful toward residents. The relative spoken with stated that staff are “wonderful” and treated her mother “with a great deal of respect”. Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 14. Belmont Lodge is not meeting the social and recreational preferences of the residents with regard to activities provided in the home. The home provides the residents with flexibility and choice with regard to their daily lives. The home encourages contact with families, friends and the local community. EVIDENCE: Discussion with the acting manager, residents and a visiting relative indicated that the residents’ individual choices with regard to activities were not fully addressed. The manager and relative confirmed that there was not an appropriate programme of activity. The manager stated that the home had identified a carer to undertake the role of activity co-ordinator. This issue was discussed and it was agreed that the home had not been provided in an appropriate manner for some time. There were no social activities evident on the day and residents were observed sitting in the communal areas without stimulation apart from the television. The care plans did identify resident’s social and leisure preferences. The relative spoken with expressed concern regarding the lack of social stimulation and felt that the gap would have a “detrimental affect to my mothers well being”. Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 Page 13 The manager confirmed that the home does not act as appointee for any of the residents living there. The residents spoken with on the day were not aware of the advocacy service, as this information was not displayed in the home. The manager confirmed that arrangements for residents to bring in possessions were discussed prior to admission, and records of possessions were available. Routines observed in the home were flexible and overall residents’ individual choices were addressed. Staff encouraged residents to leave the home with relatives and friends. The relative spoken with confirmed that she was welcomed into the home and staff encouraged and supported the relationship with her mother. Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &. 18 Overall the complaint system in the home is satisfactory and enables residents, relatives and staff to make a complaint. Belmont Lodge has a clear and robust system in place that ensures the protection of its residents in the event of an allegation of abuse. EVIDENCE: The commission had received two complaints since the previous inspection comprising: • • Poor care practice, lack of appropriate recording, lack of response to change in need. Inappropriate behaviour of staff member – currently under investigation. The home had a complaint policy and procedure in place that detailed timescales for response and the contact details of the CSCI. The second complaint regarding staff was not recorded in the home’s complaint log. The home had also failed to contact the CSCI with details of the second complaint which was eventually referred by the complainant to the inspector at the CSCI. The home had a clear and comprehensive Protection of Vulnerable Adult (POVA) policy available to staff. The home has formal guidelines to advise staff on the procedure to take in the event of an allegation of abuse being made. Belmont Lodge has a Whistle blowing policy available to staff to help them to Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 Page 15 bring up any issue that they have concerns about, without repercussions. The home had no allegations of abuse since the previous inspection visit. Evidence seen on the day confirmed that the home had a planned programme of training for staff on the issue of the Protection of Vulnerable Adults, all staff currently working in the home have received this training. On discussion with the manager it was noted that the current training time provided on this issue was all provided internally and that senior staff in the home may benefit form receiving further external training to enhance their knowledge. The manager was able to discuss the procedure both he and the staff would follow in the event of an allegation of abuse being made. Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were inspected – please see previous report. EVIDENCE: Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29. Staffing levels (number and competence) meet the needs of current residents. There is a stable and loyal staff team, which ensure consisitency in the delivery of care. The recruitment procedure in the home was robust and ensured the safety and protection of the residents. EVIDENCE: The staff rota examined reflected that the home was providing the agreed levels of staff. The home had an appropriate number of day care and night care staff and additional numbers were on duty during busy periods. Records confirmed that of the 22 staff currently employed 6 members of staff in the home had achieved the NVQ Level 2 qualification while 10 members of staff were undertaking the NVQ Level 2. The manager provided evidence that the home is securing places with a new provider on the NVQ Level 2 for the remaining staff. The staff personnel file of the only new recruit to the home was examined on the day. This contained all of the information needed to ensure the safety of residents through the recruitment process. They contained a POVA first/Criminal Reference Bureau check, three references, a photograph of the member of staff and personal ID. Staff had received a contract of employment and a copy of the General Social Care Council Code of Conduct for staff. Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 Page 18 Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 & 35. Belmont Lodge does not currently have a permanent manager in post. Overall the resident’s financial interests are safeguarded in the home. EVIDENCE: The acting manager confirmed that the home continues to positively recruit to the manager’s post. A number of candidates have been interviewed but have not fully fitted the criteria of the job description. The personal allowances of five residents were inspected. The allowance of one of the residents was found to be £5 over the record. The other four residents personal allowances were accurate and up to date. The records of resident expenditure were examined and were also found accurate and up to date. Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 Page 20 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 2 X X X Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 Page 21 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 15 (1) (2) Timescale for action The registered person must 31/03/06 ensure that care plans include all relevant and up to date information. The care plans must contain an up to date and detailed risk assessment that identifies all aspects of risk. This is a repeat requirement and was initially identified in December 2004. The registered person must 31/03/06 ensure that care plans contain information for staff regarding the resident’s oral healthcare needs. The registered person must 27/01/06 ensure that the records regarding the administration of medication are accurate and up to date. This is a repeat requirement and was initially identified in December 2004. The registered person must 31/03/06 ensure that service users are consulted with prior to any changes that impact upon their care and quality of life. The registered person must ensure that service users are enabled to DS0000017768.V280916.R01.S.doc Version 5.1 Page 22 Requirement 2 OP8 15 (1) (2) 3. OP9 17 (1a) Sch 3 4. OP12 16 (2) 12(2) Belmont Lodge 5. OP12 6. OP16 7. OP31 8. OP38 make decisions regarding the care that they receive, regarding their health and welfare. This requirement was not inspected and therefore is carried over. 12 (1) (a) The registered person must ensure that residents are provided with a formal and relevant programme of activity. Residents’ needs with regard to leisure interests must be identified and addressed as a matter of urgency. This is a repeat requirement. 7,9,19,37, The registered person must Schedule1 ensure that all complaints form residents, relatives, staff or others are recorded. The home must report any incidents or complaints to the CSCI. 12 (1) (a) The registered person must ensure that the home has a permanent manager. This is a repeat requirement. 13 (4) (a) The registered person must (c) ensure that the hot water temperatures are recorded on a weekly basis. 31/03/06 27/01/06 31/03/06 27/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Belmont Lodge DS0000017768.V280916.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 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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