Inspection on 25/07/07 for The Bell Memorial Home

This inspection was carried out on 25th July 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 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 Bell Memorial Home 10/05/06

The Bell Memorial Home 29/11/05

The Bell Memorial Home 24/06/05

The Bell Memorial Home 04/11/04

The Bell Memorial Home 22/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Bell Memorial Home 164 South Street Lancing West Sussex BN15 8AU Lead Inspector June Hough Key Unannounced Inspection 25th July 2007 10:45 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 The Bell Memorial Home DS0000014768.V343306.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. The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Bell Memorial Home Address 164 South Street Lancing West Sussex BN15 8AU 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) 01903 752020 maureen.bellmemorial@ntlbusiness.com The Bell Memorial Home Mrs Maureen Condick Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 46 male and/or female service users over 65 years of age in the category of old age, not falling within any other category may be admitted/ accommodated. 10th May 2006 Date of last inspection Brief Description of the Service: The Bell Memorial Home is a detached building which is set back off the main road, close to local shops, amenities and the sea front in Lancing. The home offers care and support to service users but is not registered to provide nursing care. The Bell Memorial Home is registered to provide accommodation for 46 service users in the category OP (Old age, not falling within any other category). The home offers separate sitting and dining rooms and additional areas where activities take place. A smoking and hairdressing room is provided on the ground floor. Twelve rooms provide en suite facilities. There is a wellmaintained garden at the rear of the home. The registered manager is Mrs. Condick and the responsible individual for the home is Mrs. Gillian Rodway. The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection was carried out by June Hough Regulatory Inspector on 24th July 2007 from 10:45 hrs to 17:40 hrs. The registered person had completed an annual quality assurance assessment (AQAA) and information from this plus feedback given on resident’s surveys and evidence from previous inspections has been used for the planning of this inspection. Further evidence for this inspection report was gained during the inspection visit when speaking with the registered manager, deputy manager, three care staff and ten residents. A variety of records were reviewed including resident’s assessments and care plans, medication administration records, accidents and complaint logs and staff files for newly appointed staff. Residents were seen in their bedrooms and in the communal areas. Current fees are £400.00 to £440.00 per week. What the service does well: From the six surveys completed and returned from the residents all gave positive feedback on the home. Residents spoken with during the inspection all praised the care staff for their care and attention saying they are looked after very well. The home works with other health professionals to ensure that the residents receive good healthcare services. The home has its own training centre and is committed to providing the staff with regular training. The home has achieved a target of 75 of care staff having obtained the National Vocational Qualifications in Care at level 2 or 3. The residents are encouraged and supported to make choices about how they are looked after and what they do during the day. Residents are supported and encouraged to express their views about the home through resident’s surveys, meetings, suggestion box and regular The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 6 contact with the registered manager. Feedback is followed up and acted upon as necessary. A programme of activities is provided taking into account resident’s interests and wishes. Residents have a choice of nutritious home cooked food. What has improved since the last inspection? What they could do better: The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 7 The format used for recording risks to residents must be consistent and give clear direction to staff on the actions needed to manage and minimise risks. 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. The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are only admitted to the home following a full needs assessment to ensure the home is able to meet their needs. The home does not provide intermediate care. EVIDENCE: Three resident’s files examined showed that a needs assessment was carried out prior to residents moving into the home that is sufficient for the home to determine if they can meet the person’s needs. The registered or deputy manager carries out assessments either by visiting the prospective resident or inviting them to visit the home. The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 10 Funded residents also have a needs assessment completed by Social Services. The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met as care plans, and assessments give evidence that care is well planned and carried out. The medication procedures and practice in the home ensure residents are protected from harm. Residents feel they are treated with respect and their privacy and dignity is upheld. EVIDENCE: Four care plans were read and three contained current and detailed information regarding the support needs of each resident. The plans contained The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 12 personal care routines, healthcare needs and risk assessments and all had been reviewed and updated on a monthly basis. As part of case tracking it was noted that one resident’s care plan required updating in order to reflect all the care needs of the resident. Risk assessments in relation to moving and handling and falls are undertaken but there was inconsistency in the format used to document this information and identifying the action needed by staff to manage and minimise risks for residents. A review of risk assessments was therefore advised. Incidents of falls are monitored and audited monthly. Since the last inspection the home had implemented a life history (my life before you knew me) for residents that was now included in care notes. The staff on duty were aware of the information contained in the care plans and had a good knowledge of the individual needs of residents. In order to ensure that the healthcare needs of the residents are met other health care professionals are involved in their care, including district nurses, local doctors, continence and palliative care nurses. Specialist equipment is provided when needed via the district nurse. The home has a good supply of pressure relieving mattresses and cushions. Residents have access to healthcare services via their GP and a chiropodist and optician visit the home when needed. Medication is safely stored and staff have attended medication training that is updated each year. Medication administration records were accurate and a head carer has been assigned to check the records on a monthly basis. Residents said they felt the staff treated them with respect and upheld their right to privacy. Staff were observed knocking on doors to resident’s private accommodation before entering and speaking to residents in a caring and respectful manner. Since the last inspection the home has registered with the Liverpool Care Pathway as part of a pilot scheme for using the assessment tool for care of the dying. The registered manager confirmed that the tool has been used in the home and provides a thorough assessment of the needs of the dying resident ensuring they get the appropriate care in their last days of life. The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 13 The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities and entertainment is provided and residents can choose if they want to take part. Residents are supported to maintain contact with family and friends of their choice. Residents are offered a varied choice of nutritious and home cooked food. EVIDENCE: Since the last inspection an activity co-ordinator has been employed who works three mornings per week. There is a daily choice of activities and the programme of activities is displayed in areas around the home. When the activity co-ordinator is not working a member of the care staff is allocated to organise and run the activities. However this depends on the workload as priority is given to looking after the care needs of residents. Resident surveys completed showed that the home arranges activities that suit the resident’s interests. The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 15 Some residents chose to participate in the activities where others chose not to take part. Menus show that residents are offered a variety of fresh home cooked meals. Residents have the choice of a cooked breakfast three days per week. The chef discusses the menus with residents taking into account their likes and dislikes in food. Residents said the food was generally very good and it was nicely cooked and well presented with a good choice. Feedback from a recent food survey showed that residents favoured a light evening meal of soup, sandwiches and a dessert. The home has an open policy for visitors although they are advised to avoid mealtimes wherever possible. The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are informed how to make a complaint and the home is responsive to any complaints raised. Staff are aware of adult protection issues and have received training to ensure residents are protected from harm. EVIDENCE: A complaints procedure is in place and displayed in the main hall of the home. Residents are also given a copy of the procedure when moving into the home. Resident surveys completed showed that residents were aware of the procedure and understood how and to whom they should raise any concerns or make a formal complaint. Residents spoken with said they would not hesitate to speak to the manager or deputy manager should they have any concerns. The complaint log was seen and one formal complaint was recorded since the last inspection. The registered person confirmed that any concern or complaint that is resolved immediately is not recorded in the log but documented in the resident’s daily records. It was advised that all complaints be recorded giving The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 17 the nature of the complaint/concern, the investigations, actions and outcomes to ensure compliance with the home’s complaint procedures. Staff training records showed that staff attend training on the Protection of Vulnerable Adults (POVA). Staff spoken with were aware of the whistle blowing policy and their responsibilities in reporting any incidents or allegations of abuse. The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable, clean and fresh environment. EVIDENCE: A tour of the premises took place and all areas of the home were fresh and clean. Residents are able to furnish and decorate their rooms with their own personal belongings and small items of furniture. Residents expressed their satisfaction with their bedrooms and said all areas of the home were always kept clean and fresh. Laundry facilities in the home are suitable for the size and number of residents and washing machines meet the disinfectant standards. The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 19 Staff have training on infection control and protective clothing is worn when needed. There is an annual maintenance programme for the home that includes further refurbishment. It was noted that some areas of the home would benefit from re-painting. New table and chairs have been purchased for the north dining room and nonslip floor covering fitted to some corridors. One bathroom was in the process of being refurbished to offer an additional assisted bath. The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a caring and well-trained care team. Resident’s needs are met by the number and skill mix of staff. Recruitment procedures and practices within the home ensure residents are protected from harm. EVIDENCE: There was sufficient numbers of staff on duty to meet the needs of the current residents. Staff rotas show that staffing numbers are maintained between seven to eight care staff during the day until 4pm when there are five to six care staff working until 10pm. There is four care staff on duty at night. Staff spoken with felt there was sufficient levels of staff on duty to be able to give the residents the time and care they needed. Many of the staff have worked in the home for a number of years and at present the home did not use agency staff. Residents spoken with said staff were generally available when needed and spoke highly of the staff saying they were kind and caring. The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 21 Three staff files were read for newly appointed staff. All files contained all the relevant documentation and evidence that all the appropriate checks were carried out prior to staff working in the home. The home is committed to training the staff and has its own training and assessment centre. 75 of the care staff have achieved a national vocational qualification in care at level 2 or 3. All new members of staff have induction training within the first twelve weeks of employment and complete the Skills for Care induction programme. The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run by an experienced and qualified manager. Residents are encouraged to make their views known about the home and their feedback is acted upon as necessary. Staff are supported and supervised. The health and safety and welfare of residents and staff is protected. EVIDENCE: The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 23 The registered manager is a qualified registered nurse and has gained her Registered Managers Award (RMA). She has many years experience of working in a care setting. Both the residents and staff said the manager was approachable and was available to all who wished to speak with her. There is an annual quality assurance system in place that involves residents, relatives and health professionals surveys. Residents are supported and encouraged to give their views of the home and the services provided by way of surveys, suggestion box, and regular resident meetings. Residents are supported to continue to handle their own money where able. For those residents unable to deal with their own finances, relatives or an advocate takes responsibility. Staff spoken with confirmed that they received regular formal staff supervision that was kept on file. All equipment and systems in the home are serviced and maintained to ensure the safety of residents and staff. Accidents and incidents are recorded and reported to the appropriate authorities. The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 24 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 X X 3 The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations A review of the format used for recording risks to residents in relation to moving and handling and falls. The Bell Memorial Home DS0000014768.V343306.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 - 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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