Inspection on 10/11/05 for The Belmont

This inspection was carried out on 10th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Belmont 14/09/09

The Belmont 15/09/08

The Belmont 28/09/07

The Belmont 27/02/07

The Belmont 23/05/06

The Belmont 07/06/05

The Belmont 19/10/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Belmont Schools Hill Cheadle Stockport Cheshire SK8 1JE Lead Inspector Kath Oldham Announced Inspection 10th November 2005 08:15 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 The Belmont DS0000060734.V250136.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. The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Belmont Address Schools Hill Cheadle Stockport Cheshire SK8 1JE 0161 428 7375 0161 428 7374 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) The Belmont Care Homes Ltd Janet McManus Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. Maximum number of service users - 40. Service users to include up to 40 OP. A minimum of 10 bedrooms must be refurbished in line with the National Minimim Standard by 1st September 2004. A minimum of a further 10 bedrooms must be refurbished in line with the National Minimum Standard by 1st December 2004. All bedrooms must be refurbished in line with the National Minimum Standard by 1st June 2005. All radiators throughout the home must be covered or provide guaranteed low temperature surfaces by 1st September 2004. Bathrooms and toilets must be refurbished by 1st December 2004 Date of last inspection 7th June 2005 Brief Description of the Service: The Belmont is a large, two-storey house set in its own extensive grounds. In the past, the home belonged to the Kendal Milne family, although its history extends further back. The home provides a service to 40 older people. The home has four lounge areas and two dining rooms on the ground floor. Stairs and a passenger lift are available to enable service users to access the upper floors. The home is situated near to the village of Cheadle and is well placed for access to a large retail-shopping outlet. The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place on 10th November 2005, commencing just after 8.00am. The inspection looked at how the home had developed from the previous inspections and whether the requirements and recommendations of that inspection had been addressed. Time was spent on the inspection examining records, in conversation with service users, observing staff practice and routines, and a partial inspection of the premises. The pharmacy inspector accompanied the inspector and undertook a thorough evaluation of the recording, storage and administration of medication to service users. Comments are also made in this report in relation to these findings. The inspection identified that a number of requirements and recommendations of past inspections had been fully addressed by the home. In addition, some had been partially achieved. Verbal feedback of the findings of the inspection was given to the manager, during and at the end of the inspection. What the service does well: Staff feel they provide a good quality of care at the home and that service users are well cared for. Activities within the home were reported to be encouraged and a full time activities co-ordinator arranges trips out of the home, in addition to arranging for entertainers to come to the home. Service users are able to bring with them articles of furniture and furnishings to personalise their bedrooms. Service users are able to share their views and opinions on the quality of care and how the home is run in the periodic residents’ meetings, which are undertaken by the activities co-,ordinator. Staff were patient, friendly and sensitive and spent time with individual residents. Service users said “nothing is too much trouble” for the staff. The manager continues to keep in touch with changes in care practices and routines. The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Staff need to be familiar with what constitutes abuse and the process which must be followed if an allegation of abuse comes to light. A number of radiators need to be guarded to promote the safety of service users in the home. A lot have been done, however there is a need that the work should be finished. The care planning process needs to be developed to include the needs of service users and how these needs are met. The routine practice of staff wedging open fire doors must be discontinued, as this compromises the safety of service users and staff. A number of requirements in relation to fire safety must be addressed with immediate effect to promote safety in the home. The medication administration, storage and record keeping needs to be developed to satisfy regulations. There are requirements outstanding from past inspections that must be addressed fully by the home. The home needs to produce an annual development plan based on a systematic cycle of planning, action and review. A training plan is in place which indicates the dates of the planned staff training. The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 7 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 Belmont DS0000060734.V250136.R01.S.doc Version 5.0 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 Belmont DS0000060734.V250136.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed as part of this inspection and are reported on the inspection undertaken in June 2005. EVIDENCE: The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 & 9 Systems are in place to ensure, as far as possible, service users’ maintain good health. Care plans did not fully indicate service users’ needs. Medication procedures do not comply with regulations. EVIDENCE: Examination of a sample of care files identified, in some instances, that very few care needs were recorded. Service users spoken to said they received the care they need. One service user said they would like “more showers and baths please”. Others commented that they did not always receive the personal care that they need before retiring to bed. This was fed back to the manager and she intends to look further into these matters. The lack of recorded care needs does not assist to evidence the actual care provided to service users. Service users use the opportunity of the residents’ meetings to discuss any areas where they feel there could be some improvements to the care and running of the home. This is in addition to daily contact with specific staff. The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 11 The daily recordings contained minimal information in relation to the care and support provided to service users. Staff recorded their own perceptions of how service users were feeling. Each service user’s file inspected contained a care plan. However, the detail needs to be developed and attention taken to ensure that the needs of service users are recorded. The administration, storage and record keeping of medication was thoroughly evaluated by the pharmacy inspector. Examination of the medication administration records found that on occasions where a variable dose of medication was prescribed the actual dose administered was not normally recorded. The home is therefore not maintaining accurate records of medication administration. Printed dosage information had been amended by hand. The amendment was not dated and therefore it was not possible to determine the actual dosage of medication administered throughout the period of the record. Items of medication were prescribed, “as directed”; this does not provide staff members with adequate dosing information to ensure that medication is administered correctly. Medication administration details had been handwritten. These transcribed details had not been signed or dated or validated by an additional member of staff. Staff members were recording the non-administration of medication by the use of the code “F” representing “other – please define”. Frequently, there was no reason defined for the use of this code. Medication labels were not checked prior to administration and records were signed prior to rather than immediately following administration. Medication was prepared into medicine pots that were then taken to another floor and administered concurrently. This practice carries a significant risk of medication being administered to the incorrect service user and therefore must cease immediately. Staff members were removing items of prescribed medication from their dispensed containers and putting them into an inappropriately labelled and unsealed compliance aid for staff to administer from. This extra step in the administration process greatly increases the risk of medication error. Service users were self-administering items of medication. Appropriate risk assessments had not been completed. A number of items of medication had not been administered as prescribed The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 12 The temperature of the medication refrigerator is monitored and recorded daily, however a maximum/minimum thermometer is not used. The medication storage areas identified an amount of excess stock and medication that had exceeded their expiry dates. Medication is stored in two medication trolleys, a walk-in cupboard and a number of wall mounted cupboards in a downstairs office. One of the trolleys is stored in an area off the office that also contains a number of hot water pipes. This area is too warm to store medication. Prior to medication ordering, staff members are failing to check the current stock, to ensure that items are ordered only when they are needed. The date of opening had not been recorded for a number of items, which have a limited shelf life once opened. Prescribed eye drops that had an inner container and an outer box were labelled on the inner container only. Medication is administered by senior carers who have received basic training in the handling and administration of medication. There is no formal assessment of carer competency in medication administration. A controlled drug was returned to the supplying pharmacy. The medication was recorded as returned in the controlled drug register and signed by a single staff member. The home manager later witnessed the entry. The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 15 Service users have a flexible lifestyle in the home and receive an appropriate diet. EVIDENCE: A record is kept of service users’ meals so, if necessary, an evaluation can be made of the nutritional content. The manager said that this record could be used in conjunction with other records if, for example, a service user is losing weight. Staff were observed asking service users what they wanted to eat for their meals, with choices being provided to the main meal of the day. Service users said they enjoyed the food, which was hot and attractively presented. One service user said she liked small portions and that these were provided for her. A six-week menu is in place, which detailed choices for each mealtime. A varied breakfast menu is available with service users, on occasions, choosing to have a cooked breakfast, cereals or toast. A residents’ meeting held in October 2005 identified the “roast meats are too tough to eat”. A mealtime was shared on the inspection and again, comments were made that the roast meat was tough. Staff stated that this was unusual since the home has changed the butcher who was providing quality produce. The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 14 Service users are able to take part in activity at the home, which ranges from afternoons out for pub lunches, canal trips and day trips to Blackpool and Southport. Regular trips to lunch are arranged and to the Trafford Centre. Comments were varied about the frequency of activity with some service users and representatives saying there was enough to occupy them and others commenting they “could do with more to occupy the residents and more outings”. Activities in the home included quizzes, videos and birthday parties. Service users said they had a celebration tea at Halloween with staff’s children coming to the home dressed up. Photographs of the event were taken; service users commented they “had a lot of fun”. The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Complaints and adult protection procedures were in place but recording of incidents was poor. EVIDENCE: A complaints record is in place and details one written complaint. The comments and complaints from service users and their representatives is an integral part of a home’s quality assurance and should assist in the development of the home. The recording of comments and complaints needs to be further developed. Service users stated that they discussed their comments and complaints as they arise, and they are usually addressed by the home. The home has a procedure for responding to allegations of abuse. A number of staff have attended in-house training on the subject to increase staff’s awareness of adult protection. The manager and deputy have attended local authority training and are to research obtaining this additional training for staff. The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 & 26 The environment was not fully maintained to ensure the safety of service users. The bedrooms and communal areas were clean. EVIDENCE: The safety of the service users was compromised by the practice of wedging open fire doors. Radiators in the home need to be guarded or have low surface temperatures to safeguard service users. It was reported that a large number had been completed and that priority had been given to those that are placed, for example, near service users’ beds or chairs. It was estimated that possibly 12 further radiators need attention. The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 17 Since the last inspection a number of bedrooms have been repainted and they look clean and fresh. Carpets have also been replaced in a number of bedrooms. The majority of service users had brought personal possessions and furnishings with them. One service user said that they had “everything that they need” in their bedroom. It is the registered person’s plan to totally refurbish the whole of the building, paying particular attention to the bedrooms, bathrooms and toilets. In addition, an extension is to be undertaken to the side of the home which, once completed, will provide additional bedroom and living accommodation. A new shower room has been installed and two of the bathrooms have been redecorated which improves the feel of the room. A number of toilets are not used as they are too small for service users who use mobility aids. The furniture and furnishings in service users’ bedrooms continues to need repair and replacement. It was the manager’s understanding that all furniture in the home will be replaced in the major refurbishment. The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 18 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 The number of staff on duty during the day and in the evening was not sufficient to meet residents’ needs. Staff training is in place to assist in the provision of care and to safeguard residents. EVIDENCE: Examination of the staff duty rosters identified there were insufficient numbers of staff on duty to meet the needs of service users. Comments indicated that, on occasions, service users have to wait long periods of time to receive assistance. Information provided for inspection showed there were a maximum of five staff on duty and, on occasions, only four staff to provide personal care for the residents. Service users said that there are times when there are not enough staff on duty. Staff have received updates to their training in care related work. Proposals are in place for staff to attend additional training. Staff said they felt that The Belmont was a good place to work; they worked hard and well together as a team for the needs of service users. A number of staff have obtained NVQ Level 2 qualifications and a number were in the process of completing the training. The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35, 36 & 38 The management are approachable and focus on meeting the needs of service users. Some health and safety issues in the home need to be addressed. EVIDENCE: The maintenance man has the responsibility of carrying out the routine tests and checks to fire safety equipment. Examination of the records of the checks to the means of escape, emergency lighting and fire alarm identified the checks had been conducted routinely. The emergency lighting in the home needs some attention and is awaiting the contractor to attend to the deficient units. This should be chased up by the home to ensure that in the case of an emergency the home is illuminated sufficiently. The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 20 A record is kept of identified faults in the home that are given to the maintenance man for repair or to make contact with a contractor for attention. A number of bedroom doors continue to be wedged, propped or kept open, this increases the risk to service users and staff. A fire risk assessment for the building was not in place, which needs to be produced in line with Fire Safety Regulations. The policy and procedures to inform staff, visitors and service users of what to do in the case of a fire needs to be updated to reflect actual practice in an emergency situation. Some of the fire doors in the house are not closing sufficiently into the rebate to act as a barrier in the event of fire. Further doors are closing very quickly and are heavy which may result in service users experiencing difficulty when mobilising in and out of bedrooms. A service user said they had to wait for staff as she didn’t have the strength to open the door and when she could, it closed so quickly behind her she was frightened of being injured. It was reported that all staff had received fire drill training or practice in the previous six months. Staff spoken to on this matter were able to describe the procedures to be adopted in the event of fire. Five fire drill training exercises had been undertaken since June 2005. A record is maintained of any accidents, incidents or occurrences experienced by service users. Examination of the accident book identified the record to be completed in line with procedures. Staff meetings are arranged periodically, with a record kept of the discussion topics; this provides an opportunity for staff to have their say in how the home and the care of service users is developed. Monthly visits are undertaken by the registered person or their representative in line with regulations and a report is compiled of the areas evaluated. Copies of these reports are kept on file. The records do not include all aspects of the regulations and need to be amended to record this. The visit undertaken, as part of the regulations, is to ensure that the registered person is aware of how the home is running and the regulations clearly stipulate what must be included and recorded about these visits. Staff receive supervision from their line manager which assists in their personal development. Records are kept of the supervision sessions and include aspects of practice, the philosophy of care and staff career development needs. A record is maintained of financial transactions and purchases made on behalf of service users, of those seen all were clearly recorded with the actual purchase made and the balance. All records were signed. The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 21 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 X X X X 2 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 2 2 X 2 The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 22 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 OP7 Regulation 15 Requirement The registered person must develop the care plans, ensuring all areas of residents needs and interventions are detailed. (Previous timescale of 31/07/05 not met). The registered person must develop the staff team and provide direction and supervision in what should be recorded within the daily reports. The registered person must ensure that where a variable dose of medication is prescribed, for example, one or two tablets to be taken, an accurate record is made of the actual dosage of each medication administered. The registered person must ensure that when staff members record the non-administration of medication, they do so using the codes specified on the resident’s medication administration records, and an additional explanation for nonadministration is recorded if required. Timescale for action 31/12/05 2 OP7 15 31/01/06 3 OP9 13 (2) 14/11/05 4 OP9 13 14/11/05 The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 23 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. 5 Standard OP9 Regulation 13 Requirement The registered person must ensure that care home staff administer medication as per a recommended medication administration procedure. The registered person must ensure that medication administration records are completed contemporaneously. The registered person must ensure that medication is only administered to residents from containers, which have been dispensed by a pharmacist or dispensing doctor and that the medication is administered as prescribed. The registered person must ensure that residents who wish to manage their own medication are assessed as to their ability to do so, before medication is provided to them. Assessments must then be repeated on a regular basis. The registered person must ensure that all medication is administered to residents as prescribed. The registered person must ensure that medicines in the custody of the home are stored securely and at a temperature that does not exceed 25oC. DS0000060734.V250136.R01.S.doc Timescale for action 14/11/05 6 OP9 13 14/11/05 7 OP9 13 12/12/05 8 OP9 13 14/11/05 9 OP9 13 12/12/05 The Belmont Version 5.0 Page 24 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. 10 Standard OP9 Regulation 13 Requirement The registered person must ensure that medication in the custody of the home is stored securely and is not accessible to unauthorised persons. The registered person must ensure that all items of medication which have exceeded their expiry dates, do not belong to current residents or are not labelled with prescribed directions are returned to the supplying pharmacy. In no instance should this medication be kept as “stock” or reused for a resident for whom it was not prescribed. The registered person must ensure that that the expiry dates of medicines stored within the home are checked on a regular basis. The registered person must ensure that the receipt, administration and disposal of controlled drugs are recorded accurately and contemporaneously in a Controlled Drugs register. Timescale for action 14/11/05 11 OP9 13 28/11/05 12 OP9 13 14/11/05 The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 25 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. 13 Standard OP16 Regulation Sch 4 Requirement The registered person must further develop recording in the complaints book to detail all aspects of the complaint, the investigation and outcome. (Previous timescale of 31/08/05 not met). The registered person must cease the practice of wedging bedroom doors open. (Previous timescale of 07/06/05 not met). The registered person must redecorate all bathrooms and toilets. (Previous timescales of 01/09/04 & 30/09/05 not met). The registered person must increase the number of staff on duty to ensure that service users receive the care and attention they need in a timely manner. The registered person must fit covers to all the radiators in the home. (Previous timescales of 30/11/04 & 31/08/05 not met). The registered person must replace the furniture, i.e., drawers, cupboards and wardrobes, where identified at the time of inspection. (Previous timescales of 30/11/04 & 31/08/05 not met). Timescale for action 31/12/05 14 OP19 23 10/11/05 15 OP21 23(1)(2) 31/12/05 16 OP22 12(1) 20/12/05 17 OP23 16(1)(2) 13(c) 16(1)(2) 31/12/05 18 OP23 31/12/05 The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 26 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. 19 Standard OP31 Regulation 26 Requirement The registered person must, as part of the Reg 26 visit and subsequent report, interview, with their consent and in private, service users, their representatives and persons working in the home in order to form an opinion of the standard of care provided. (Previous timescales of 30/11/04 & 31/08/05 not met). The registered person must introduce an annual development plan for the care home, based on a systematic cycle of planning, action and review. (Previous timescales of 30/11/04 & 31/08/05 not met). The registered person must arrange for the replacement or repair of the emergency lighting in the home and arrange for the production of a fire risk assessment, which is forwarded to the fire authority for agreement. Timescale for action 30/11/05 20 OP33 10(1) 12(1)24 31/12/05 21 OP38 23(4) 30/11/05 The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 27 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. 22 Standard OP38 Regulation 23(4) Requirement The registered person must review the effectiveness of all doors within the home, ensuring they close into their rebate sufficiently to act as a barrier in the event of a fire and service users are able to mobilise independently without fear of being hurt by the doors’ strength. The registered person must amend the fire safety policy to reflect actual practice for an emergency situation. Timescale for action 30/11/05 23 OP38 23(4) 30/11/05 The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 28 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 OP7 OP7 Good Practice Recommendations The registered person should arrange for staff to have training in risk assessments and how to identify risk for individual residents. The registered person should further develop the staff team to enable them to complete the daily/night reports in sufficient detail to give an indication of how service users have spent their day. The registered person should ensure that if the prescriber amends the dosage of medication, the current record is discontinued and a new record is commenced. The registered person should ensure that the directions of medication prescribed as ‘as directed’ are clarified with the resident’s General Practitioner and the prescriptions altered accordingly. The registered person should ensure that handwritten medication details on the medication administration records are signed and dated and an additional member of staff validates the details. The registered person should ensure that the temperature of the medicines refrigerator is monitored daily using a maximum/minimum thermometer and the temperature is maintained between 2-8°C. The registered person should ensure that stocks of medication are rotated regularly and that stock is checked each month prior to medication ordering to prevent the build up of excess medication. The registered person should ensure that the date of opening is recorded on all items which have a limited shelf life once opened, to ensure that the health of residents is not put at risk by the administration of expired medication. The registered person should liaise with the supplying pharmacist to ensure that all medication received by the home is labelled on both the inner container and the outer box. 3 4 OP9 OP9 5 OP9 6 OP9 7 OP9 8 OP9 9 OP9 The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 10 11 Refer to Standard OP9 OP15 Good Practice Recommendations The registered person should ensure that the competency of carers with responsibility for medication administration is assessed regularly on a formal basis. The registered person should ensure the cook has access to a safely functioning food mixer. The Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Belmont DS0000060734.V250136.R01.S.doc Version 5.0 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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