Inspection on 14/09/09 for The Belmont

This inspection was carried out on 14th September 2009.

CQC found this care home to be providing an Adequate service.

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 Belmont 15/09/08

The Belmont 28/09/07

The Belmont 27/02/07

The Belmont 23/05/06

The Belmont 10/11/05

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 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE The Belmont Schools Hill Cheadle Stockport Cheshire SK8 1JE Lead Inspector Geraldine Blow Key Unannounced Inspection 14th September 2009 09:30 DS0000060734.V377470.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Belmont DS0000060734.V377470.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Belmont DS0000060734.V377470.R01.S.doc Version 5.2 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.V377470.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 40 service users to include: *up to 40 service users in the category of OP (Old age not falling within any other category). The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 2. Date of last inspection Brief Description of the Service: The Belmont is a three storey detached property set within its own grounds, near to the village of Cheadle. The home is registered to provide care for up to 40 older people. There are three lounge areas and two dining rooms. Bedroom accommodation is provided on two floors and office space occupies the third floor. The fees for staying at the home were reported to be between £340 and £495 per week. The Belmont DS0000060734.V377470.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This report is based on information gathered by the Care Quality Commission (CQC) during the unannounced visit on the 14 September 2009 and supporting information received in the Annual Quality Assurance Assessment (AQAA) submitted by the manager prior to this visit. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. This visit was unannounced, which means that the manger and staff were not told that we would be visiting. The visit took place on Monday 14 September 2009. This report is an overview of what the inspector found during the visit. References to we or us in this report represent the CQC. Some people living at the home were sent comment cards so that we could get their views on how the home is run. At the time of writing this report we had not received any completed comment cards. As part of the visit we spent time examining relevant documents and files. We also spent time talking with several people living at the home and some members of staff. We also walked round the home and looked at the communal areas and some bedrooms. Feedback was given to the manager and the area manager during the course of the visit. What the service does well: People have an assessment of their needs before being admitted to the home to make sure that all of their needs can be met and people are encouraged to come and visit the home before making a decision to move in. People spoken to were complementary about the food provided and they confirmed that they always get a choice of meals. Staff said that people can have drinks and snacks whenever they want. The Belmont DS0000060734.V377470.R01.S.doc Version 5.2 Page 6 Everybody spoken to said that visitors can visit whenever they like and that they are always made welcome. What has improved since the last inspection? What they could do better: The recruitment procedure must be improved to ensure that all the necessary safety checks are undertaken on staff before they are employed. This is to ensure people living at the home are placed at risk To ensure a fair and consistent interview it is recommended that a set interview format is used and notes are taken during the interview process. The policy relating to safeguarding adults should be updated to reflect the correct procedure to follow if an allegation of abuse is made. The Belmont DS0000060734.V377470.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Belmont DS0000060734.V377470.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 Belmont DS0000060734.V377470.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There were systems in place to make sure that peoples needs are assessed before admission to ensure their care needs can be met. EVIDENCE: The completed AQAA identified and the manager confirmed that admissions to the home are made after a pre admission assessment of the persons needs has been undertaken, to ensure that those needs can be met. In addition to the homes own assessment they also receive information from the care managers assessment of the placing authority. Evidence was seen of the assessments undertaken by the manager on the care files looked at during this visit. The Belmont DS0000060734.V377470.R01.S.doc Version 5.2 Page 10 However it was noted that the homes own pre assessment document did not include an assessment of peoples specific religious or cultural needs. To ensure that all peoples assessed needs can be met it is recommended that the pre admission assessment is reviewed and updated to include as assessment of any specific religious or cultural needs. The manager stated that people who are thinking about moving into the home and or their relatives are encouraged to visit, have a look round, meet staff and other people living at the home. This was supported by information received in the completed AQAA. The manager confirmed that people are given a Service User Guide on admission to the home and the Statement of Purpose is available on request. The Belmont does not provide an intermediate care service. The Belmont DS0000060734.V377470.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not all of the care plans were detailed enough to make sure that peoples needs would be met at all times. EVIDENCE: Since the last inspection the manager had reviewed and rewritten all of the individual plans of care. The care plans were much improved since the last inspection visit. The care plans seen contained details of peoples care needs, personal choices and preferences. For example the file looked at identified that the lady preferred to wear trousers and liked to have her hair set once a week. The plans of care set out how the persons identified needs should be met by the staff delivering the care. However it was noted that some plans of care had not The Belmont DS0000060734.V377470.R01.S.doc Version 5.2 Page 12 been updated to include information about that person. For example the bath and shower record identified that the person was ‘very frightened’ when having a shower. This had not been included in the care plan so it was not clear how staff would meet this need. One person had a catheter and the care plan relating to this was vague. It did not contain details of how to specifically care for the catheter or any signs or symptoms that staff should be aware of. The manager said that some staff had attended catheter care training and it was her intention to speak to the district nurses for advice in further developing the care plan for catheter care. Appropriate risk assessments had been undertaken to ensure that any identified risks are minimised. The risk assessments were seen to be reviewed on a monthly basis. However we were informed that the risk assessment relating to the use of bedrails were undertaken by the district nurses as they order the bedrails and copies of the assessment are not kept in the home. Also there was no reference in the care file to bedrails being used. Following this visit the manager confirmed that she has now undertaken her own risk assessment that includes the risk of entrapment and not just the risk of falling out of bed. These risk assessments were not seen by us. Since the last inspection visit the manager had started to audit care plans. Formal audits were undertaken on a random basis every three months. However the audit was not detailed and did not provide an audit trail or evidence of action taken when shortfalls were identified. For example it was seen that the audit identified that some details needed updating but there was no reference to what these details were or if they had been updated. Prior to this visit we had received information that some people were being transported in wheelchairs without footplates being in place. This would have the potential to put people at risk, although during the visit people were observed to have footplates in situ when in wheelchairs. We saw the care plan for a person who required a wheelchair for transfers and it did not include the need to use of footplates. It was discussed with the manager that to avoid any unnecessary risk, unless a risk assessment suggest otherwise footplates should be in place when people are being transported in wheelchairs. A daily record is completed for each person. However some entries were vague and repetitive. From discussions with the manager it was clear that the reports did not always accurately reflect the care given over a 24-hour period. Also one record repeatedly stated that the person was ‘washed and dressed by the night staff’. When asked the manager stated that the person liked to get up early. This personal preference was not included in the plan of care. To ensure people go to bed and get up at their preferred times it is recommended that this information is included in the care plan. The Belmont DS0000060734.V377470.R01.S.doc Version 5.2 Page 13 Evidence was seen that people were registered with a local General Practitioner (GP) and there were arrangements in place to access to other health care professionals if needed. We looked at the way they manage peoples medication. We were informed that the GP’s original prescription comes to the home for checking before it is sent to the pharmacy for dispensing. On the day of this visit it was day one of week one on the record sheets. We saw that they kept a record of medication received into the home and a system of recording the return of unused medication. The senior carer told us that any medication that has not been used is always returned to the pharmacy so they do not have stocks of medication. As recommended in the last inspection report daily drug fridge temperature are now being taken to ensure that medication is being stored at the correct temperature. Also for medication with a limited life, for example eye drops, the date of opening is now being recorded to ensure that out of date medication is not being given to people. Since the last inspection visit a monthly audit of medication is now undertaken. It was noted that the audit did not include a tablet count for medication that was supplied in box’s or bottles rather than in the blister packs. To ensure that people receive medication as intended it is recommended that this be included in the audit. Staff told us that they have good relationships with people living at the home and staff are careful to respect peoples privacy and dignity. During the visit we saw that staff were kind and patient with people. People spoken to during the visit were complimentary about the staff and the care received. One person said ‘the staff are very nice . The Belmont DS0000060734.V377470.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Activities are provided and people are able to maintain contact with family and friends. EVIDENCE: There is a personal profile that is completed when people move into the home. The profile includes information regarding social interests, cultural and religious beliefs. The deputy manager has the responsibility for organising social activities. A record is kept of the activities provided and who attends them. Some of the activities included a summer fare, outside entertainers such as dancers and singers. On the day of this visit there was a singer performing. All the people spoken to thoroughly enjoyed the afternoon’s entertainment. The Belmont DS0000060734.V377470.R01.S.doc Version 5.2 Page 15 The manager said in addition to the large group activities they also do 1:1 activities such as nail painting, staff sitting chatting to people or afternoon tea in the garden. However none of this had been recorded. People living at the home told us there were not enough activities and they would like more. One person said that they never went out of the home and she would love to go out. Also some staff told us they felt that there were not enough activities. One staff member said it was great to se how much everybody enjoyed the signing and it would be nice if it happened more often. The manager confirmed that they had a mini bus and once it was insured they would be able to take people out on trips. The manager confirmed that they were not yet ready for the digital TV switchover but were aware that it must be done before 4 November 2009. A copy of the menus was seen, which were varied and nutritionally balanced, although the manager stated that they were currently under review. The menus evidenced that a choice of meals is available and people spoken to during this visit confirmed this. During this visit we observed people having their evening meal and there were several different meals served. People spoken to were complimentary about the quality and quantity of food provided. People living at the home and staff spoken to confirmed that visitors are made welcome and can visit whenever they like. Staff spoken to said, that where possible, people are encouraged to make choices around their day to day living. The manager has obtained some information booklets on the Deprivation of Liberty (DoLS), which came into force on 1 April 2009 and forms part of the Mental Capacity Act. These booklets are in the main reception for people to access. She said it was her intention to access training for all staff to attend. The Belmont DS0000060734.V377470.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to raise concerns and their views are listened to. EVIDENCE: There is a complaints procedure, which is on display in the main entrance and the manager confirmed that it is included in and the Service User Guide which people are given when they move into the home. The procedure needs updating as it reflects the name and address of the previous registering body. There was a record of complaints and concerns made which included a conclusion. The manager said she makes herself available for people to talk to or raise any concerns they may have. There was a Whistle Blowing policy and a policy relating to Safeguarding Adults. However the policy did not accurately reflect the correct procedure to follow if an allegation of abuse was made. This does have the potential to put people at risk. We were told there was a copy of the Stockport No Secrets Guidance. However it was discussed with the manager that there was an updated version of this document available and should be obtained. The Belmont DS0000060734.V377470.R01.S.doc Version 5.2 Page 17 Evidence was seen that just under half of the staff had attended safeguarding adults training and the manager said she was in the process of arranging further training for staff. At the time of this visit there was an allegation of abuse that was currently being investigated. The Belmont DS0000060734.V377470.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements were needed to the cleanliness and maintenance of some areas of the home to provide a safe, comfortable environment for the people who live there. EVIDENCE: During this visit a tour of the building was undertaken which included the shared areas and some peoples bedrooms. The Belmont DS0000060734.V377470.R01.S.doc Version 5.2 Page 19 At the last inspection visit some radiators were unprotected and there were no risk assessments in place. The manager confirmed that some radiators were still unguarded but made assurances that risk assessments were in place for these. Bedrooms were seen to be personalised. Some areas of the home were not well maintained or clean. For example, some of the paintwork was chipped and marked especially round the door frames and skirting boards on the corridors. Some bedrooms and corridors were in need of redecoration as the wall paper was marked and dirty. Several bedrooms smelt unpleasant and in one room the carpet was heavily stained and the en-suite door would not close. Comments from staff on the cleanliness of the home varied. One staff member said that it had improved but another member of staff said it could be improved. Both sluice doors were found to be wide open. This has the potential to put people at risk. When not in use it is recommended that sluice doors are kept shut. Since the last inspection visit the care plans are not on public display and are now kept in cupboards. There were policies and procedures relating to infection control and to reduce the risk of cross infection people who required the use of the hoist had their own slings. It was noticed that a trolley containing personal protective (PPE) equipment for example pads, gloves, wipes and aprons were stored on the corridor and first thing in the morning similar equipment was left on a ledge at the top of the stairs on the first floor. We were told this was so staff could easily access them. The trolley could be a potential trip hazard for people living at the home and this practice gives and institutional feel. The Belmont DS0000060734.V377470.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The recruitment procedure and practice did not full protect people living at the home. EVIDENCE: At the time of this visit 29 people were accommodated. From looking at the staff rota and observing staffing levels during the visit there appeared to be sufficient staff employed. The manager stated that 21 care staff are employed. Fourteen staff have successfully completed National Vocational Qualification (NVQ) Level 2 or above and five staff were due to commence NVQ Level 3. A sample of three staff files for people who had been recruited since the last inspection visit were looked at to see whether the required documentation was in place and if the necessary checks had been made. The Belmont DS0000060734.V377470.R01.S.doc Version 5.2 Page 21 Some short falls were seen. For example, in two files both references were obtained from personal addresses so the authenticity of last employer reference could not be verified. One of the referees only had a personal mobile number so again the authenticity could not be checked. The employment history was not clear in two of the files. In one file there was conflicting information on the application form regarding employment history and in another file the history was not complete. Two of the files did not have a contract or terms and conditions of employment. In addition, in the files looked at, there was no evidence that an interview had taken place. The files looked at contained some photocopied documents and there was no evidence that the original documents had been seen. It is recommended that all photocopied documents are signed and dated to indicate that the original has been seen. These shortfalls were discussed at length with the manager and the area manager. Two days following the visit the manager phoned us to confirm that she had clarified people’s employment history and made checks regarding the references. Evidence was seen of Criminal Record Bureau (CRB) disclosure checks being obtained before a person is employed to work in the home. There was evidence of induction and the AQAA identified that they were registered with Skills for Care. The manager confirmed this. A staff training matix was available for inspection. There was evidence of training relating to Moving and Handling, Fire Safety, Safeguarding Adults and NVQ training. There were gaps relating to First Aid, Infection Control and Food Hygiene, DOL’s and the Mental Capacity Act. Evidence was seen that some staff had attended training on catheter care and diabetes but this had not yet been recorded. Staff spoken to all said that the manager was supportive and encouraging where training was concerned. The Belmont DS0000060734.V377470.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not all areas of the home are managed in the best interests of the people living there. EVIDENCE: At the time of this visit the manager had submitted her application for registration with us and it was currently being processed. The Belmont DS0000060734.V377470.R01.S.doc Version 5.2 Page 23 As already mentioned in this report there was some concerns about the management of the recruitment and selection process in the home as its shortfalls do not fully protect people. There was a policy and procedure folder and evidence that they had been reviewed. The folder was kept in the main office so that staff could easily access it. There was a quality assurance policy and a quality assurance file. People living at the home are given a comment card on an annual basis and staff sit with them to complete the cards. It was discussed with the manager that this was perhaps not the most objective way to obtain information. Relatives and visiting professionals are also sent an annual comment card to obtain their view of the service being provided. The manager was in the process of collecting the comment cards and then she said it was her intention to analyse the received information and produce an action plan based on the results. The manager stated that they no longer hold any money on behalf of people. The information provided in the AQAA demonstrated that the home’s maintenance certificates and records were up to date. Fire safety checks were looked at and found to be up to date. The Belmont DS0000060734.V377470.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 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X N/A X X 3 The Belmont DS0000060734.V377470.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. 1. Standard OP29 Regulation 19 and schedule 2 Requirement All staff files must include all the details listed in Schedule 2 to ensure the recruitment procedure protects the people living at the home, with particular reference to checking the authenticity of references and their employment history. Timescale for action 12/10/09 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 OP3 Good Practice Recommendations To ensure that all peoples assessed needs can be met it is recommended that the pre admission assessment is reviewed and updated to include an assessment of any specific religious or cultural needs. It is recommended that the individual plan of care is updated to reflect any changes in care needs and it is recommended that people’s preferred getting up and DS0000060734.V377470.R01.S.doc Version 5.2 Page 26 2. OP7 The Belmont 3. 4. 5. 6. OP7 OP12 OP16 OP18 7. OP19 8. 9. OP29 OP30 retiring times are included in the care plan. It is recommended that the daily care reports are written in sufficient detail to accurately reflect the care given over a 24 hour period. It is recommended that the 1:1 activities are recorded as well as the large group activities. It is recommended that the complaint procedure be updated to reflect the name and address of the current registering body. To ensure that people are not put at potential risk it is recommended that the policy relating to Safeguarding Adults is reviewed and updated to accurately reflect the correct procure to be followed in the event of an allegation of abuse being made. It is also recommend that the updated local safeguarding guidance is obtained and be available for all staff to access. It is recommended the use of the trolley containing PPE is stopped and people have their own supply in their bedrooms. Also sluice doors when not in use should be kept shut. It is recommended that when people are employed they are issued with a contract or terms and conditions of employment. To ensure the staff employed receive appropriate training to meet the needs of the people living at the home it is recommended that an action plan based on individual staff training needs is developed to provide staff with the skills, knowledge and awareness appropriate to their role. The Belmont DS0000060734.V377470.R01.S.doc Version 5.2 Page 27 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. The Belmont DS0000060734.V377470.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!