Inspection on 29/05/07 for The Belfry

This inspection was carried out on 29th May 2007.

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 01/06/06

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 Ray Finney Key Unannounced Inspection 29th May 2007 09:00 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.V341708.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. Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belfry (The) Address The Belfry Dowsetts Lane Ramsden Heath Billericay Essex CM11 1HX 01268 710116 01268 710367 thebelfryrch@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.V341708.R01.S.doc Version 5.2 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). 1st June 2006 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 and parking is permitted in the surrounding roads. There is an accessible garden to the rear of the property with a shaded seating area. The Belfry provides care for twelve older people in single rooms; all but one of the rooms have en suite facilities. Bedrooms are located on two floors and accessible by lift or stairs. The home has a communal lounge and dining area. There is an assisted bathroom on the ground floor and a separate small room used by the hairdresser for hair washing. Information about the home may be obtained from the manager. The home charges between £470.00 and £566.00 per week with additional charges for chiropody or hairdressing services and for personal items such as newspapers and sweets. This information was provided to us in May 2007. Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as menus, staff rotas, care plans and staff files. Two completed surveys were received from the relatives of people living in the home. A visit to the home took place on 29th May 2007; this included a tour of the premises, discussions with the manager and members of staff and conversations with people living in the home. Observations of how members of staff interact and communicate with people living in the home have also been taken into account. On the day of the inspector’s visit the atmosphere in the home was relaxed and welcoming and the inspector was given every assistance from the manager and members of staff. What the service does well: What has improved since the last inspection? What they could do better: The programme of activities is not well developed and some of the people living in the home do not get enough stimulation to ensure they have a interesting and fulfilled lifestyle. Staffing levels are adequate to provide for people’s care needs. However, as there are few activities taking place, if people living in the home are to benefit Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 Page 6 from a stimulating and fulfilled lifestyle then staffing levels need to be recalculated to take this into consideration. Although overall people living in the home enjoy the food, they would benefit from having a wider variety of fresh fruit and vegetables. The unused upstairs bathroom means people do not have a choice of where they wish to have personal care carried out. Only one usable bathroom is not adequate for the number of people living in the home. Further thought needs to go into renovating the upstairs bathroom that is not currently used to provide either a second bathroom or shower. 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. Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 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.V341708.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (standard 6 is not applicable). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People choosing to live at The Belfry can be confident their needs will be assessed before admission. EVIDENCE: Pre-admission assessments are carried out by the manager and senior carer. The manager is able to demonstrate a good awareness of the assessment process. A sample of three people’s records examined all contain an assessment of needs. The pre-admission assessments cover a wide range of areas including sleeping, personal hygiene/dressing, mobilisation, eating & drinking, elimination, vision, hearing dentures, orientation, communication, social contacts & daily routine, and personal history. As previously reported, anyone wishing to move to The Belfry can visit the home as many times as they like to help them decide if the home meets their needs and the admission process includes a four-week trial period. Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals can be confident that their personal and healthcare needs will be met in The Belfry. Overall there are appropriate systems in place that make sure the administration of medication is safe for people living in the home. People can be confident that they will be treated with respect and dignity. EVIDENCE: The records of three people living in the home were examined. Each contains a ‘Long Term Need Assessment and Care Plan’. Areas covered in the care plans include sleeping, routines, personal cleansing, personal dressing, eating & drinking, breathing, mobility, elimination and observations such as how the person presents in terms of mood. Care plans contain sufficient detail to ensure staff are able to provide appropriate care. Keyworkers meet monthly with people they support and make a brief report in the care plan and records examined contain evidence of regular review of the care plans. Daily reports are brief but relevant to what is happening in the person’s life. Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 Page 10 The home continues to meet people’s individual healthcare needs. Care plans examined contain evidence of input from healthcare professionals including records of doctor’s notes and details of district nurse’s visits. Records also contain evidence of other visiting professionals including optician visits, wheelchair services, continence advisory service and Occupational Therapy. One person spoken with said they are “well cared for”. A variety of tools are used to assess people’s needs and risks associated with their care. Records examined contain risk assessments using the Strasbourg Dependency test to assess help required and the Barthel Scale to assess mental awareness. Records also contain assessments of emotional well-being, nutritional risk assessments, pressure care risk assessments and manual handling risk assessments. The home’s processes around the storage and administration of medication were examined. At the time of this inspection visit there was no one in the home with the capacity to take control of their own medication. The senior carer described the monitored dose system that the home uses. A tour of the premises showed that medication is stored securely in a locked metal drug trolley, although any item needing to be kept at a controlled temperature such as creams or eye drops are kept in the refrigerator in the kitchen. There was a discussion with the senior carer about the need to ensure there is no cross contamination and any medication should be kept in a closed container if they are to be stored in the fridge. Observations of the administration of lunchtime medication indicate that staff follow good practices around the handling of medication, including ensuring people take their medication with a drink. Records examined confirm that details of prescribed medication are recorded in care plans. Medicines Administration Record (MAR) sheets were examined and found to be completed appropriately. The home’s approach will ensure that people living in the home are well protected by the procedures around the handling and storage of medication. Observations of interactions between staff and people living in the home show that people are treated with dignity and respect. Staff are courteous when talking to people and knock on doors before entering rooms. People spoken with made positive comments about the way they are treated. One relative commented, “the home treats people with kindness and respect and is good at getting to know each individual person”. Records examined contain details of people’s wishes about how they like personal care to be carried out. Staff spoken with explained about how two people who have had strokes and need to be fed want to maintain their dignity Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 Page 11 by not using the dining room and prefer to eat where they are not observed by other people living in the home. Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall The Belfry provides people who live there with variety and choice, although their lifestyle would be better if there was more stimulation in their daily lives. People living in the home benefit from maintaining contact with family and friends. Overall people living in the home are provided with a varied diet that they enjoy, although it could be improved by increasing the amount of fresh ingredients used. EVIDENCE: The senior carer said that music, singing and quizzes are the main activities enjoyed by people in the home; staff also organize ‘armchair aerobics’ to help keep people supple. However, on the day of the inspection visit the main activity that was observed was watching television and one person said they enjoy reading. Comments from relatives include “It would be good if my relative had more stimulation in the form of activities. My relative is not used to sitting still all day in the same place which is what happens because there is nothing else to do.” Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 Page 13 Records indicate that some musical entertainers visited recently and have been rebooked to return later in the year. One of the rooms is fitted with a hairdressers sink so that it is easier for people to have their hair styled. People spoken with enjoyed having their hair done. Most of the people living in the home are very elderly and some said they like to rest and aren’t very active. Overall it was observed that people are not well stimulated and some spent much of the time sleeping in chairs in the lounge. One relative commented that they are “disappointed at the level of stimulation and activities at the home”. There is not a wide variety of planned regular activities available. Staff spoken with said that most people have family that visit regularly; this was confirmed by people spoken with. There is a smaller quiet area just off the main lounge with doors that can be closed so that people can entertain visitors in private but not necessarily in their own rooms. One person said that the family had visited the previous day bringing a great-grandchild, which brought them a great deal of pleasure. The manager said that relatives are involved in people’s lives and help them to make choices. Details of advocacy services and contact details for Age Concern are displayed on the dining room wall. People spoken with said they choose what they want to do. A tour of the premises confirmed that people living in The Belfry are surrounded by personal items such as photographs and ornaments; people are happy with their accommodation. One person spoken with chose to spend time in their room rather than in the communal lounge. Menus examined show that a variety of food is offered and there is a whiteboard in the dining room where the day’s lunch is written. Every day there is one main meal available at lunchtime and an alternative will be prepared for anyone who does not wish to have the main meal. People spoken with after they had finished lunch were complimentary about the food. One said it was ‘lovely’ and another was very enthusiastic about the meal. One relative said, “the food is also very good”. As previously reported, people needing assistance to eat are supported discretely. Food storage and preparation areas were examined on a tour of the premises. The cook was able to demonstrate a very good awareness of appropriate practices for handling, storing and preparing food. Opened foods were appropriately labelled. The cook said that they don’t use wide variety of fruit because most people in the home are unable to eat harder fruits like apples, but they do use soft fruits like bananas. One person said they had lovely strawberries and cream the Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 Page 14 previous day. In the main frozen vegetables are used. Overall the food offered is good and those spoken with said they enjoy their meals. However, people’s diet would benefit if they were offered a greater variety of fresh vegetables and perhaps stewed fresh fruit. Belfry (The) DS0000038149.V341708.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): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a clear and understandable complaint procedure that ensures that they are listened to. The home’s practices and procedures ensure the protection of the people who live there. EVIDENCE: The home’s complaints procedure was examined and found to be clear and simple. There is a complaints log in place but no complaints have been documented in the past year. A discussion with the manager confirms that the home has not had any complaints and that minor concerns are usually dealt with as and when they arise. The process would benefit from documenting minor concerns and how they are resolved so that people living in the home and their relatives can be assured that their opinions are acted upon. People living in the home continue to be protected by staff who have had training to help them recognise signs of abuse and to understand their responsibilities about reporting any concerns they may have. Staff receive inhouse Protection of Vulnerable Adults training using the Essex Vulnerable Adults Protection Committee training pack and are given the accompanying booklet. Staff files examined contain evidence that staff have had Protection of Vulnerable Adults training and Criminal Record Bureau (CRB) enhanced checks have been carried out. Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 Page 16 A tour of the premises shows that all rooms have lockable cupboards for the safe storage of valuables. The manager explained that the home does not handle people’s finances. This is dealt with either by families or legal representatives and the home invoices them for any expenditure such as hairdressing or personal items. Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall people living in The Belfry benefit from a safe and well-maintained environment that is clean and pleasant. However, improvements to bathrooms and signage would enhance people’s lifestyle. EVIDENCE: A tour of the premises confirmed that The Belfry is homely and clean throughout and is maintained to a reasonably good standard. The furnishings are domestic in nature, which adds to the homely feel. The grounds are tidy and well looked after. There is a large screen television in the lounge so that people with poorer vision are better able to see it. Records examined show that more people living in the home have changing elderly needs and some are becoming more confused and forgetful. The home has taken measures to ensure they can continue to support people, including dementia training for staff. However, Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 Page 18 improvements could be made to the environment to address people’s changing needs. Bedroom doors have room numbers on but better signage such as pictures that are relevant to the individual on the door of their own room and clear signs on bathrooms and toilets would help those who are becoming confused. There are two bathrooms in the home. The manager said that the downstairs bathroom is the one that is used by everyone living in the home. This bathroom contains an assisted bath, but as it is getting quite old the manager said that funding has been agreed to have it replaced. There is also a shower in this bathroom, but the manager said that this is not generally used, possibly because people don’t like the step down into it. Although the upstairs bathroom is in working order, it is not used and there are items such as continence products stored there. There was a discussion with the manager about how to improve the bathing facilities so that there are two fully functional bathrooms or shower rooms as required for the number of people living in the home. The manager said they are considering future developments and will look at ways to make the upstairs bathroom better for the people living there. A tour of the premises confirmed that people living at The Belfry can expect the home to be clean, pleasant and hygienic. The laundry room contains appropriate equipment with an industrial washer and separate tumble dryer. There are hand-washing facilities and the floor is tiled. Staff spoken with have completed distance learning infection control training and people living there can be confident that staff are aware of the importance of infection control. The kitchen is well maintained and kept clean. Overall home clean throughout with no offensive odours, although the flooring in one bedroom is being replaced because issues around continence are beginning to have an effect on the freshness of the room. Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the home has a competent staff team, who are provided with some training. However, for people in the home to benefit from a well qualified staff team, the training programme should be improved. Staffing levels should be sufficient to ensure people receive sufficient stimulation to have a good lifestyle. The home’s recruitment procedure provides the safeguards to ensure that appropriate staff are employed. EVIDENCE: On the day of the inspection visit it was observed that staffing levels were appropriate for what was going on. The manager said that staffing levels are calculated according to the dependency levels of people in the home. Rotas examined and show two staff at night and two per shift plus the manager and cook during the day. This was observed to be an adequate level on the day. However, as previously reported (see evidence for standard 12), there were few activities taking place and if people living in the home are to benefit from a stimulating and fulfilled lifestyle, staffing levels would need to be recalculated to take this into consideration. One relative commented, “there is very little stimulation of their minds or encouragement to pursue hobbies because there are not enough staff”. Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 Page 20 The manager confirmed that four out of a total of thirteen staff currently have a National Vocational Qualification at level 2 or above and a further two people are working towards the award. Although this is below the National Minimum Standard recommendation of 50 , the manager said they are looking at ways of accessing NVQ awards for other staff. The Belfry has an appropriate process in place for the recruitment of staff. Two out of a sample of three staff personnel records examined contain evidence of appropriate recruitment documentation including an application form containing an employment history with no gaps, personal identification, health questionnaire and two written references. One of the files only contained one written reference, although a recruitment checklist said two have been received. Enhanced Criminal Records Bureau (CRB) checks are carried out. Records examined contain evidence that staff are given the General Social Care Council code of conduct. The recruitment process in place is basically sound but the manager needs to tighten up on ensuring all documentation is in place for all members of staff. New staff now receive induction training using the Skills for Care induction package and evidence was available that a senior carer has had training in the Common Induction Standards. The home’s training planner and a sample of three staff files were examined. Training that has taken place during the last year includes fire training, reminiscing, understanding diabetes and NVQ. Staff spoken with said that training is good and they were particularly pleased with recent distance learning packages that they have completed in infection control and dementia awareness. Some staff have also completed the distance learning medication training package. Certificates were examined for an in-house course in ‘Legal Aspects of Moving & Handling’ but there is no evidence of staff having done any practical Manual Handling training. Manager said a member of staff who is a trained Occupational Therapist is delivering manual handling training. Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Belfry is well run by a competent management team and people living there can be confident that the home is run in their best interests. There are health and safety systems in place to ensure the welfare of both individuals and staff. EVIDENCE: The manager has a nursing qualification and is in the process of completing the NVQ level 4 Registered Manager’s Award. The completion of the award has been delayed due to some difficulties with the training providers but the manager has now re-started and is confident that the award will be completed. The manager is able to demonstrate a good awareness of her responsibilities Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 Page 22 in running the home and is continually looking at ways to improve what they do. There have been improvements to the Quality Assurance system since the last inspection. A comprehensive self-audit of the National Minimum Standards was carried out by the manager as part of the Quality Assurance system. The audit document includes a list of planned improvements for the coming year. The home seeks the views of people living there through residents meetings. Records examined show that a recent residents meeting took place in April 2007. No one living in The Belfry has the capacity to manage their own finances because of increasing elderly needs or poor memory. The home does not manage anyone’s finances; this is done either by relatives or legal representatives. The manager explained that an invoice is sent for reimbursement of any expenditure for personal items such as hairdressing, toiletries or newspapers. Since the last inspection visit the process for carrying out staff supervisions has improved. Records examined contain evidence of more regular supervision. Records examined indicate the home carries out appropriate maintenance checks. Checks were carried out on gas installations and new gas boilers were installed in November 2006. Fire equipment was last checked in April 2007, electrical testing in September 2006, maintenance on the lift in April 2007 and hoists in February 2007. A maintenance book is kept for minor repairs and general maintenance such as replacing light bulbs. The cook explained how they deal with maintaining hygiene around the storage and preparation of food. Fridge temperatures are taken regularly and recorded in a temperature book. There was a routine visit from the Environmental Health officer in June 2006. They have implemented the use of the ‘Safer Food Better Business’ package produced by environmental health. Anything relevant to ensuring good infection control is documented here. This includes procedures around storage and preparation of food such as maintenance, replacement and cleaning of kitchen equipment. Opened food is clearly labelled with the date it must be used by. Products such as bread that have been stored in the freezer are labelled with the date they are removed for use. Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X 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 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP12 Regulation 16(2)(n) Requirement People living in the home should have a range of social and recreational activities that will provide stimulation and improve their lifestyle. People living in the home should have access to appropriate bathing facilities. In particular improvements to the upstairs bathroom are needed. This should be addressed as a matter of priority. Staff need practical training in Manual Handling techniques so that people living in the home are protected when having their care needs met. Timescale for action 31/08/07 2. OP21 23(2)(j) 30/09/07 3. OP30 18(1)(a) (c)(i) 30/09/07 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. Refer to Standard OP15 Good Practice Recommendations A wider variety of fresh fruit and vegetables would ensure DS0000038149.V341708.R01.S.doc Version 5.2 Page 25 Belfry (The) 2. 3. OP19 OP28 people living in the home have a healthier diet. Pictures and signs on bedroom doors and shared facilities such as bathrooms would help people who are becoming confused to be less disorientated. More staff obtaining NVQ awards would ensure people are being cared for by a well qualified staff team who have a sound knowledge of good practices. Belfry (The) DS0000038149.V341708.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Belfry (The) DS0000038149.V341708.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. 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