Inspection on 31/12/05 for The Belfry

This inspection was carried out on 31st December 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 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 Helen Laker Announced Inspection 13th December 2005 11:00 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.V273218.R01.S.doc Version 5.0 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.V273218.R01.S.doc Version 5.0 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.V273218.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Personal care to be provided to no more than twelve service users over the age of 65 years. (Total number not to exceed 12). Number of service users for whom care shall be provided shall not exceed 12. (Total number not to exceed 12). Date of last inspection 20th April 2005 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. Belfry (The) DS0000038149.V273218.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on 13th December 2005 and lasted 4 hours. The inspection process included discussions with the manager, two staff and two service users. A random sample of bedrooms were inspected together with the bathrooms and toilets, communal areas and garden. Twenty six of the thirty eight national minimum standards were inspected on this occasion. Five requirements and three recommendations are detailed in this report. What the service does well: What has improved since the last inspection? 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.V273218.R01.S.doc Version 5.0 Page 6 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.V273218.R01.S.doc Version 5.0 Page 7 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): 2,3,6 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. Service user reviews were not evidenced. EVIDENCE: Each service user has a written contract/statement of terms and conditions with the home. Minor amendments were discussed with the manager. 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. Discussion with the manager highlighted that service user reviews required more prominence. Records of two residents examined contained detailed pre admission assessments. Intermediate care is not offered at The Belfry. Belfry (The) DS0000038149.V273218.R01.S.doc Version 5.0 Page 8 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): 7,8,9,11 Care plans seen were comprehensive with clear instructions for staff to meet residents’ needs although daily records require improvement in some areas. The health needs of the residents are well met with evidence of good multidisciplinary working taking place. EVIDENCE: Two service user care files were examined. These were noted in places to still require more detail and the manager advised the inspector that this was being addressed. Care notes were written daily. Risk assessments have previously been identified to require more detail and reference to care plans. Service users’ health care needs are fully met at The Belfry and records of visits kept. The registered manager advised previously that one service user had been admitted with a pressure sore and the care offered by staff at The Belfry meant this was now healed. Service users are protected by the home’s policies and procedures for dealing with medicines. Based on daily care notes, discussion and policy and procedures available, service users personal wishes and a recent death at the home are considered handled sensitively and with dignity respected. Belfry (The) DS0000038149.V273218.R01.S.doc Version 5.0 Page 9 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): 13,14 Daily routines were previously seen to be flexible and to meet residents needs. Service users choices are considered. EVIDENCE: Service users at the Belfry are encouraged to maintain contact with family / friends / representatives and the local community as they wish. The home operates an open visiting system. The inspector was informed that choices with things such as rising times and clothing and daily routines were encouraged. Room sensors are fitted and service user consent and relative agreement was seen for two service users Belfry (The) DS0000038149.V273218.R01.S.doc Version 5.0 Page 10 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 The home has satisfactory procedures in place for dealing with complaints. Appropriate policies, procedures and staff training regarding protection of service users from abuse and protecting their legal rights are in place. EVIDENCE: Since the last inspection one complaint has been made to the Commission for Social Care Inspection and passed to the person registered to investigate. It was under investigation at the time of this inspection. The complaints procedure was clearly displayed in the home. The manager stated that postal voting was encouraged and that either the service user or their relatives dealt with finances. Belfry (The) DS0000038149.V273218.R01.S.doc Version 5.0 Page 11 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): 20,21,22,23 The home has made improvements required by previous inspection reports and now provides a comfortable well-furnished and well maintained accommodation for the residents. EVIDENCE: The home provides a comfortable, clean well-furnished accommodation for the residents. The home has been assessed by an occupational therapist and was rated as “highly satisfactory”. Shortfalls identified at previous inspections 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. Consideration has been given to enlarging the locking device on the inside of the door to make it easier for residents to open and lock. All but one bedroom has its own ensuite toilet and washbasin. There is one assisted bathroom and a separate toilet and hairwashing basin on the ground floor, and a separate bathroom and toilet on the first floor. Belfry (The) DS0000038149.V273218.R01.S.doc Version 5.0 Page 12 The home meets the standards for bedrooms of pre-existing care homes before March 31st 2002 and rooms were seen to be suitably personalised and furnished to individual service users tastes. Belfry (The) DS0000038149.V273218.R01.S.doc Version 5.0 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 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 The home benefits from a core group of experienced and well trained staff. Staffing levels were currently appropriate to meet residents’ needs. Recruitment procedures have in place safeguards to ensure service users safety EVIDENCE: Minimum staffing levels agreed with the previous registering authority remain with appropriate additional hours for domestic/cooking and administration tasks. Copies of the current weeks rota and the previous weeks rota indicated some limited long day/double shifts but not at levels which would pose a risk to staff and or service users, many shifts previously have only included 2 care staff on duty. On some occasions the cook was also doing care work sufficient ancillary staff should be employed at all times. The issue of The Belfry not meeting minimum agreed staffing levels has been identified in previous inspections The registered manager was advised that adequate staffing must be in place to meet service user needs at all times. The files for two staff employed recently were sampled. All had comprehensive documentation. No records were available in relation to agency staff or volunteers with the exception of a list of some names and some Criminal Records Bureau check numbers. This was discussed with the manager at the time of inspection. A training matrix is available for mandatory and additional training. The registered manager advised that training is either recent, or updates are imminent, for all staff. The registered manager advised that a Foundation training/induction programme is still to be introduced. Belfry (The) DS0000038149.V273218.R01.S.doc Version 5.0 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 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): 32,33,34,35,36,37,38 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 previous reports. The home has been slow in implementing a formal system to review the performance of the home this is currently under review. Satisfactory procedures were in place to ensure the health and safety of the home. EVIDENCE: Interaction observed between the manager and service users indicated she was approachable and receptive to service users needs. The home had made efforts to produce a quality monitoring system. Advice was reiterated on making the system relevant, including service user and relatives views, linking it to the annual development, business and training plans, as well as to monitoring of, for example care plans or premises safety checks. The Belfry does not look after any monies for service users. Belfry (The) DS0000038149.V273218.R01.S.doc Version 5.0 Page 15 The two staff records sampled indicated that induction formats for the first six weeks of employment are available. The registered manager confirmed that these meet TOPSS standards. The registered manager advised that a Foundation training/induction programme is still to be introduced. 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. Records were sampled and found satisfactory: A number have been mentioned in this report. Safety certificates were available for inspection. Fire drills are undertaken monthly, the time of which should is now being recorded. Records of weekly checks of fire alarm and emergency lighting were being maintained. Concerns regarding the safety of the unrestricted upstairs windows and the bedroom door locks are already noted in this report, as requiring immediate action. Belfry (The) DS0000038149.V273218.R01.S.doc Version 5.0 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. 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 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X X 3 3 3 3 X X X STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 2 3 3 2 3 3 Belfry (The) DS0000038149.V273218.R01.S.doc Version 5.0 Page 17 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 OP3 Regulation 14 (2) (a) Requirement The registered person shall ensure that the assessment of the service users needs is kept under review. A quality assurance system is required to be implemented that includes consultations, and demonstrates review of service users and their care. (This is a repeat requirement.) The Registered Person must ensure that staff are suitably trained to meet the increased and varying care needs of service users, including the updating of care plans and the completion of risk assessments, which should be reviewed on a monthly basis and detail reference to care plans. The registered person must ensure that all staff employed at the home receive training for the work undertaken. It is recommended this meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims DS0000038149.V273218.R01.S.doc Version 5.0 Timescale for action 31/01/06 2 OP7 18(1)14(2) & 15 31/01/06 3 OP30 12(1) & 18(1) 31/01/06 Belfry (The) Page 18 4 OP33 Reg 26 5 OP36 18(1) & (2) 19(1) of the home and meet the changing needs of service users. The Registered Provider must 31/01/06 ensure that effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure the success in meeting the aims and objectives and the Statement of Purpose of the home. This with particular reference to the implementation of quality auditing processes. 31/01/06 The registered person must ensure that the employment policies and procedures adopted by the home and it’s induction, training and supervision arrangements are put into practice. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP2 OP9 Good Practice Recommendations Contracts should be updated to show the CSCI as the regulatory body not the NCSC Risk assessments should be reviewed on a monthly basis reference to care plans. Staff rotas should denote and highlight the person in charge of each shift and all staff irrespective of role and task. 3 OP27 Belfry (The) DS0000038149.V273218.R01.S.doc Version 5.0 Page 19 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.V273218.R01.S.doc Version 5.0 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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