Inspection on 20/04/05 for The Belfry

This inspection was carried out on 20th April 2005.

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

Other inspections for this house

The Belfry 05/03/08

The Belfry 29/05/07

The Belfry 01/06/06

The Belfry 31/12/05

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 The Belfry Dowsett Lane Ramsden Heath Billericay, Essex CM11 1HX Lead Inspector Ron Reeves Unannounced 20th April 2005 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 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. The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service The Belfry Address Dowsett Lane, Ramsden Heath Billericay Essex CM11 1HX 01268 710116 01268 710367 Telephone number Fax number Email 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 CRH 12 Category(ies) of OP registration, with number of places The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: The home may accommodate 12 persons of either sex who only fall within the category of old age. Date of last inspection 19th OCTOBER 2004 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, most with 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. The garden is easily accessible for residents and offers a shaded canopy over the seating area. The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on 20th April 2005 and lasted 8.00 hours. The inspection process included discussions with the manager, two staff and four service user managers. A random sample of bedrooms were inspected together with the bathrooms and toilets, communal areas and garden. Thirty seven of the thirty eight national minimum standards were inspected on this occasion. What the service does well: What has improved since the last inspection? The home has met the vast majority of requirements arising from the previous inspection. Improvements were noted in care planning and staff training including promoting NVQ training. The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 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 standard(s) 1,3,4 and 5 The home operates a thorough pre-admission process. The manager ensures the home can meet individual needs. Written information provided for prospective residents and the policy of encouraging as many visits as possible before making a decision is excellent practice. EVIDENCE: The home has an appropriate Statement of Purpose and Service Users Guide. Pre-admission assessments are carried out by the manager, who confirms in writing whether the home can meet the prospective residents needs. All admissions are subject to a four week trial period. Records of three residents examined contained detailed assessments. Staff spoken with demonstrated a sound knowledge of the residentd needs.No Visitors attended the home during the inspection, however residents spoken with said the home looks after them very well and that their relatives can visit at any time. The home does not offer intermediate care. The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 Page 9 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 standard(s) 7,10 Care plans seen were comprehensive with clear instructions for staff to meet residents’ needs although daily records require improvement.The health needs of the residents are well met with evidence of good multi-disciplinary working taking place. EVIDENCE: Improvements were noted to the home’s care planning system which now reflects all aspects of residents needs and information provided for staff on meeting the identified needs is now comprehensive,although daily records need to be more detailed. Risk assessments were in place where appropriate and any restrictions placed on residents are recorded, but there was no evidence of service users involvement. The manager stated she has discussed the issue of using sensors in residents bedrooms at night with the service users and their families who agreed to the use as a safety measure. Daily records were brief and did not reflect the welfare of the residents, how they spend their day and the progress of the care plan. Improvements were discussed with the manager. All residents spoken with expressed their satisfaction with the care provided by the home and that staff treat them in a respectful way ensuring their privacy and dignity. Medication administration procedures were well managed and there was evidence that residents health care needs were being met. The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 Page 10 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 standard(s) 12 and 15 Daily routines were seen to be flexible to meet residents needs. The home provides social activities which are enjoyed by the service users. The range and quality of food provided was to a very good standard and provided a well balanced diet that met individual needs. EVIDENCE: Residents spoken with said the daily routines of the home were flexible to meet their needs. The home has a daily programme of activities, care staff spoken with confirmed that they organise the activities on a daily basis and record activities in each residents’s care plan. Residents’ hobbies and past times are recorded in their assessment. Residents were heard taking part in a sing-a-long during the afternoon. Staff said they had time to sit and talk to residents on a one-to-one basis. The manager informed that residents’ meetings are held on a regular basis. Minutes of the last meeting held on 7th April 2005 evidenced residents involvement in decision making. Visitors were welcome at anytime, although none visited during the inspection. Residents confirmed that they could see who they liked when they liked. Menus were found to contain a wide range of meals provided which appeared balanced and nourishing. The meal of the day was well presented and in good portions. Residents were particularly complimentary regarding the food provided. The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 Page 11 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 standard(s) 16 and 18 The home has satisfactory procedures in place for dealing with complaints. Appropriate policies, procedures and staff training regarding protection of service users from abuse are in place . EVIDENCE: The home has a detailed complaints procedure. One complaint has been received by the home since the last inspection which has been responded to by the home. The manager informed that residents are registered to vote by their families and all have chosen postal votes. The home’s policies and procedures regarding protection of vulnerable adults were updated on 12th November 2004. Eight staff have attended training for Protection of Vulnerable Adults. The complaints procedure and details regarding local advocacy services are displayed in the home. The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 Page 12 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 standard(s) 19,24-26 The home has made the improvements required by the previous inspection report and now provides a comfortable well-furnished and well maintained accommodation for the residents. EVIDENCE: The home provides a comfortable, clean and well-furnished accommodation for theresidents. The home has recently been assessed by an occupational therapist and was rated as “highly satisfactory”. Shortfalls identified at the previous inspection have been addressed. These include the fitting of window restrictors. The advice of the fire brigade has been sought regarding the door locks to bedroom doors which can now be opened from the outside by a magnetic door release. However, consideration should be given to enlarging the locking device on the inside of the door to make it easier for residents to open and lock. The bedroom with the obscure glass has been transformed into the office. The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,30 The home benefits from a core group of experienced and well trained staff. Staffing levels were appropriate to meet residents needs. EVIDENCE: Service users spoken with said the staff were “very nice and very helpful”. Throughout the day it was noted that there was a good relationship between staff and residents which generated a relaxed and comfortable atmosphere. The home’s staffing rota indicated three care staff on duty during the day. The home employs a cook who also works as a carer. The hours were not clearly identified when she was working as a cook. The home has staff shortages which resulted in approximately six shifts per week being covered by agency staff and by some of the home’s staff working long shifts although not working excessive hours. The manager was requested to submit an amended staff rota to the commission fully detailing staff on duty and hours worked by the cook. Staff recruitment files inspected contained all the information required apart from one which only included one reference. This member of staff has worked in the home for many years and was recruited by the previous owner. Staff training has improved and staff are supported to undertake NVQ training. Induction training to TOPSS standards has been introduced, but foundation training to TOPSS is yet to be introduced. The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,37and38 It was evident that the manager was easily approachable and very supportive. She has managed to address the vast majority of outstanding issues detailed in the previous report. The home has been slow in implementing a formal system to review the performance of the home .Satisfactory procedures were in place to ensure the health and safety of the home. EVIDENCE: The registered manager has an RMN Qualification and has worked previously for a number of years with older people in a nursing home. She has commenced training at NVQ level 4. Staff and service users felt the manager was easily approachable and supportive. Regular staff and service users meetings are held. The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 Page 15 The home still has not produced a quality assurance system. Detailed discussion took place with the manager regarding the format and content required. Relatives of all the service users in the home have undertaken enduring power of attorney. The home does not look after any service users money. Both the manager and deputy have attended training in supervisory supervision and have started staff supervision but this needs to be regularised. The manager frequently works alongside care staff and therefore staff receive regular ongoing supervision. Safety certificates were seen for services and equipment. Regular safety checks are made for the fire alarms, emergency lighting and fire exits. Fire drills are held regularly and record names of staff attending. Records should show the actual time of the fire drill. The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 Page 16 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x 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 x COMPLAINTS AND PROTECTION 3 3 3 3 3 2 2 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 2 2 3 3 The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 Page 17 YES Are there any outstanding requirements from the last inspection? 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 OP3 Regulation OP24 Requirement A quality assurance system is required to be implemented that includes consultations, and demonstrates review. This is a repeat requirement. Records must be kept for the protection of service users and as identified within the report. This includes staff roster and information on service users . Home must ensure that staff employed in the home received (i) traininig appropriate to the work they are to perform. This includes providing foundation training to TOPSS standards. Records must be kept for the protection of service users and as identified within the report. This includes staff roster and information on service users. Timescale for action 31/05/05 2. 27 17(i) With immediate effect With immediate effect 3. 36 18(9)(c) 4. 5. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 Page 18 No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard OP36 OP27 OP31 OP28 OP38 OP7 OP24 Good Practice Recommendations All staff should be provided with supervision at least six time each year. Staff should not work long days/double shifts The registered manager should achieve NVQ4 by 2005 50 of care staff to achieve NVQ Level 2 by 2005 The record of fire drills should include the time the drill took place. Service users daily records should fully reflect the welfare of the service user, how they spend their day and the progress of the care plan. Handles to bedroom doors should be made larger to ensure that service users with little grip can easily open the doors. The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 Page 19 Commission for Social Care Inspection 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 The Belfry 156 I06 S38149 Belfry V222383 200405 Stage 4.doc Version 1.20 Page 20 - 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. 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