Inspection on 01/06/06 for The Belfry

This inspection was carried out on 1st June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Belfry 05/03/08

The Belfry 29/05/07

The Belfry 31/12/05

The Belfry 20/04/05

The Belfry 19/10/04

The Belfry 11/05/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Belfry (The) The Belfry Dowsetts Lane Ramsden Heath Billericay Essex CM11 1HX Lead Inspector Pauline Marshall Unannounced Inspection 1st June 2006 9:55 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 Belfry (The) DS0000038149.V290871.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. Belfry (The) DS0000038149.V290871.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Belfry (The) Address The Belfry Dowsetts Lane Ramsden Heath Billericay Essex CM11 1HX 01268 710116 01268 710367 thrbelfrynch@aol.com 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) Cloverform Limited Miss Deborah Reynolds Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Belfry (The) DS0000038149.V290871.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Number of service users for whom care shall be provided shall not exceed 12. (Total number not to exceed 12). Personal care to be provided to no more than twelve service users over the age of 65 years. (Total number not to exceed 12). 31st December 2005 Date of last inspection Brief Description of the Service: The Belfry is a detached family style residence situated in a residential area of the village of Ramsden Heath, close to the village shops and post office. A bus route to Billericay passes close by, although access by public transport is limited. There is parking available for up to six vehicles at the front of the property. The Belfry provides residential care for twelve residents in single rooms, all but one have en suite facilities. Bedrooms are located on two floors and accessible by use of the homes shaft lift. The home offers a lounge and dining area. An assisted bathroom is available on the ground floor and there is a separate small room for use by the hairdresser for hair washing. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplies them with up to date information on the home. Fees are £526.00 per week and there are additional charges for hairdressing, chiropodist and newspapers. The garden is easily accessible for residents and offers a shaded canopy over the seating area. Belfry (The) DS0000038149.V290871.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that lasted for five hours and fortyfive minutes. The process included a tour of the premises, a random selection of resident and staff files and discussions with residents, staff, a district nurse and a visiting relative. As part of this inspection surveys have been sent to six residents, two relatives, and three General Practitioners to obtain their views on the service the home provides. Four residents’ surveys were returned and all were positive in their comments, saying how sympathetic and willing staff was and that the home is clean and fresh. Of the three surveys sent to relatives one only was returned and this was positive about the service that the home provided. No other surveys were returned to the Commission. Twenty-nine of the thirty-eight standards were inspected. What the service does well: What has improved since the last inspection? The recording of the daily notes has greatly improved and they now include more details. The manager has looked at the reviewing process and now reviews care plans and risk assessments on a monthly basis or more frequently if required. New furniture and carpets have been purchased. The quality assurance system has been implemented and residents and relatives’ views sought through questionnaires. The manager is currently working on a training plan. Belfry (The) DS0000038149.V290871.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Belfry (The) DS0000038149.V290871.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belfry (The) DS0000038149.V290871.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4, 6 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Copies of the contracts/statement of terms and conditions are not kept on individual care files. The home carries out a thorough pre-admission assessment of needs and provides prospective residents with sufficient information to enable them to make an informed choice. EVIDENCE: The home prepares a written contract/statement of terms and conditions, for each resident. On the day of the inspection a copy of individual residents contract was not on the care files sampled. The manager said that the homes administrator now works from home and copies of the contracts were stored there. Each resident should have a copy of their contract/statement of terms and conditions on their individual care files. The home carries out a full pre-admission assessment and invites prospective residents to visit the home on as many occasions as they feel necessary to Belfry (The) DS0000038149.V290871.R01.S.doc Version 5.1 Page 9 assist them to decide if the home meets their needs. The admission process includes a four-week trial period. The care files examined contained full preadmission assessments and evidence of visits. The Belfry does not provide intermediate care. Belfry (The) DS0000038149.V290871.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, 9, 10 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The homes care planning process ensures that residents health, personal and social care needs are met. Medication policy and practices are good. Residents feel treated with repect and their right to privacy is upheld. EVIDENCE: Daily records and risk assessments were detailed and care plans gave clear instructions on staff intervention. Health care records were complete and included GPs notes on the file. Care plans and risk assessments are now reviewed on a monthly basis and more often if required. PRN protocols were in the care plan and the manager said she would place a copy with the MARS sheets. Belfry (The) DS0000038149.V290871.R01.S.doc Version 5.1 Page 11 Residents spoken with said that they are feel they are treated with respect. One resident commented on how her right to privacy was always upheld. A visiting relative confirmed that staff were always respectful to the residents. Belfry (The) DS0000038149.V290871.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, 15 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Residents experience a lifestyle that matches their needs, they are encouraged to maintain contact with family and friends and have choice and control over their lives. Residents receive a wholesome appealing balanced diet in spacious pleasing surroundings. There are areas of concern around food storage practices. EVIDENCE: The home offers residents a range of activities that include, bingo, board games, aerobics, manicures, wine evenings, gardening, pub lunches, shopping trips and trips to the park. Residents spoken with confirmed that entertainment offered at the home was good and on the day of the inspection a birthday party was being held and the entertainment was two country and western singers. Relatives were invited and were present at the event. Residents spoken with confirmed that they had contact with their family and said that they enjoyed trips out in the local community. Belfry (The) DS0000038149.V290871.R01.S.doc Version 5.1 Page 13 Residents meetings take place regularly and notes of these are kept, topics discussed at a recent meeting included: summer outings, garden activities, clothes shop, videos, staff, bedrooms, food and miscellaneous items. The menus offer a choice of meals and residents spoken with said that they were able to have an alternative to what was on the menu if they wished. Residents stated that the food was excellent and that meals are home cooked with plenty of fresh vegetables and that the service was good. Mealtimes are flexible to meet residents’ needs. The dining area includes a large table that seats nine residents and extends if further seating is required. Three residents currently choose to take their meals elsewhere. Fresh foods had been frozen and had expired their sell by date; they were not labelled with the date of freezing. All food must be used by its sell by date. Belfry (The) DS0000038149.V290871.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, 17, 18 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Complaints are dealt with effectively and good records kept and all issues raised are taken seriously by the home. Residents’ legal rights are protected. Residents’ are protected from abuse. EVIDENCE: The homes complaint procedure was clearly displayed in the home and contained within the homes brochure. There was one complaint that had been made at the time of the last inspection, this was investigated by the home using their procedure and was partially upheld. Residents are encouraged to use the postal voting services. The home does not deal with residents’ finances. The home has a clear procedure for dealing with adult abuse and follows the guidelines as laid out in the Essex County Council Adult Protection Procedure. All staff have received adult protection training. Belfry (The) DS0000038149.V290871.R01.S.doc Version 5.1 Page 15 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): 19, 20, 24, 25, 26 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Residents generally live in a safe well-maintained environment with sufficient communal facilities that are clean, pleasant and hygienic. EVIDENCE: The home is comfortable, well furnished and decorated to a good standard; bedrooms are personalised with residents’ own items. All bedrooms have ensuite except one, which has a toilet with washing facilities opposite it. Each bedroom contains a full-length mirror. Bedrooms are fitted with window restrictors and all doors have a locking device that can be opened from the outside using a magnetic door release in an emergency. The home has a chairlift and a passenger lift to enable access to the first floor. There are two lounges and one conservatory where residents said they often received their visitors. Belfry (The) DS0000038149.V290871.R01.S.doc Version 5.1 Page 16 The home was clean and hygienic. The garden was tidy and has a seating area. Belfry (The) DS0000038149.V290871.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, 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Staff are well trained, competent and supplied in sufficient quantities to meet residents needs. The homes recruitment practice supports and protects residents. EVIDENCE: The duty rota showed adequate staffing as agreed with the previous registering authority and highlighted the person in charge of each shift. There were several long days/double shifts shown on the rota, staff members spoken with said they wanted to work these shifts. Five care staff have completed NVQ2 or above and the manager is making enquiries to various providers with regard to NVQ for the over 25’s. Three staff files were examined and the most recently employed staff have all the required documentation. The files examined showed evidence of in house induction and the manager said that she is awaiting a pack from Regis training on the new common induction standards. Staff training includes all the mandatory requirements and many specialist subjects including epilepsy, osteoporosis, reminiscing, Parkinson’s, dementia, equality and diversity and healthy eating and nutrition. Belfry (The) DS0000038149.V290871.R01.S.doc Version 5.1 Page 18 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, 33, 35, 36, 38 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. The home is well managed and run in the best interests of the residents and their financial interests are safeguarded. The health, safety and welfare of the residents is generally promoted and protected; however the storage of a bed in the upstairs bathroom may present a risk to resident’s safety. Staff supervision is not carried out on a regular basis. EVIDENCE: The manager is a qualified nurse and is half way through completion of the Registered Managers Award and expects to complete by the end of 2006. The home has produced a quality assurance system and undertakes its own audits as part of the process. Surveys of residents, relatives and staff have Belfry (The) DS0000038149.V290871.R01.S.doc Version 5.1 Page 19 been undertaken and the manager is in the process of compiling a report on its findings, a copy will be sent to the CSCI on completion. The home does not handle any residents’ finances; either the resident or their relatives look after these. The manager and the administrator have attended supervision training and the manager said that she intends to roll this out to her senior staff. Formal supervisions have not taken place regularly, however the manager said that she works alongside staff on a regular basis and informal supervision takes place frequently. Supervision sessions must take place at least six times a year and the outcomes recorded. There was a disused bed stored in the first floor bathroom, the staff member stated that this was awaiting removal and that the bathroom was not in use. It was advised that the door be kept locked whilst the bed is stored there to ensure residents safety. All safety certificates were examined and were up to date and fire drills and checks are regularly undertaken and results are recorded. Belfry (The) DS0000038149.V290871.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 2 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 X X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Belfry (The) DS0000038149.V290871.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38 Regulation 13 (4) (a) Requirement The registered person shall ensure that all parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety. This refers to the bed stored in the upstairs bathroom The registered person shall supply a copy of the contract/terms and conditions to each resident. The registered person shall provide wholesome and nutritious food. This refers to foods being used by their sell by date. The registered person shall ensure that persons working at the home are appropriately supervised. Timescale for action 31/07/06 2. OP2 5 (2) 31/07/06 3. OP15 16 (2) (i) 31/07/06 4. OP36 18 (2) 31/07/06 Belfry (The) DS0000038149.V290871.R01.S.doc Version 5.1 Page 22 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 Belfry (The) DS0000038149.V290871.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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. Extracts may not be used or reproduced without the express permission of CSCI Belfry (The) DS0000038149.V290871.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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