Inspection on 15/09/08 for The Belmont

This inspection was carried out on 15th September 2008.

CSCI 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 14/09/09

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 27/11/2008.

CARE HOMES FOR OLDER PEOPLE The Belmont Schools Hill Cheadle Stockport Cheshire SK8 1JE Lead Inspector Geraldine Blow Unannounced Inspection 15th September 2008 09:30 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.V371683.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 Belmont DS0000060734.V371683.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.V371683.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. 28th September 2007 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 £465 per week. The Belmont DS0000060734.V371683.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 Commission for Social Care Inspection (CSCI) 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. Staff and some people living at the home were sent comment cards. At the time of this visit, nine comment cards from people living at the home and four staff comment cards had been received by CSCI. Some of their comments have been included in the body of this report. This visit was unannounced, which means that the manager and staff were not told that we would be visiting. This visit forms part of the overall inspection process and took place on Monday, 15 September 2008. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS). This report is an overview of what the inspector found during the inspection. As part of the visit we (the commission) spent time examining relevant documents and files. We also spent time talking with the deputy manager, the manager, the area manager, several people living at the home and members of staff. A tour of the building was undertaken. Feedback was given to the manager and the area manager during the course of this visit and on conclusion of the visit. What the service does well: Before a prospective person is admitted to the home a pre-assessment of their needs is undertaken to make sure that the person’s needs can be met. People who were living at the home were complimentary about the staff. One person said “the staff are marvellous”, another person said “the staff are very good and I have everything I need”. The Belmont DS0000060734.V371683.R01.S.doc Version 5.2 Page 6 Visitors are welcome in the home at any time and can visit in the peoples own room or in any of the shared areas of the home. The menus seen evidenced that a choice of meals is available and people spoken to during this visit confirmed this. Systems are in place to support people to raise any concerns they have and all of the returned comment cards from people living at the home indicated that they knew how to make a complaint. What has improved since the last inspection? What they could do better: The manager has been in post for two and half years but has not submitted an application to CSCI for registration. To ensure the home is managed in the best interest of the people living there an application for registration must be submitted as a matter of some urgency. Some areas of the medication administration and the care planning process need some improvements to ensure that all the personal, health care needs and personal preferences of people are met. It is also recommended that the plans of care are further developed on a more person centred approach and contain more details of people’s personal needs and preferences. Some improvements are needed to the recruitment procedure to ensure that the people living at the home are fully protected. To ensure a fair recruitment process it is recommended that a set interview format is used and notes are taken during the interview process. As detailed in the last inspection report it is important that all staff employed receive appropriate training to meet the needs of people living there. There were some shortfalls in that not all staff had received training in, for example, first aid, infection control, and training in Safeguarding Adults to ensure that the people are protected from potential abuse or harm. Some areas of the home were not clean and well maintained. The Belmont DS0000060734.V371683.R01.S.doc Version 5.2 Page 7 Only limited activities are provided and it is recommended that a programme of social activities is made available and that people are supported to go on trips out of the home. 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 Belmont DS0000060734.V371683.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.V371683.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to make sure that people’s needs are assessed before admission. EVIDENCE: The deputy and the manager both confirmed that prospective person to be admitted to the home and/or their relatives are encouraged to visit the home before making a decision to move in. All the returned comment cards from people living at the home stated that they had received enough information about the home before moving in. A documented pre-admission assessment form is in use to ensure peoples assessed needs can be met prior to admission. One of the files looked at contained the home’s own pre admission assessment. The manager confirmed The Belmont DS0000060734.V371683.R01.S.doc Version 5.2 Page 10 that the other two people were admitted on an emergency basis so the preadmission assessment had not been able to be completed. All of the files looked at during this visit contained a care manager assessment. The process of assessment was also confirmed in the completed AQAA. An intermediate care service is not provided at The Belmont. The Belmont DS0000060734.V371683.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): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some shortfalls were identified in ensuring that the health care needs of people living at the home were being met. EVIDENCE: A sample of care plans were seen and three people were case tracked. The care files examined all contained a plan of care and were organised and easy to use. The deputy manager confirmed that random audits of the care plans are undertaken and any shortfalls are discussed with the carer. However she stated that the process is not formally documented. To ensure any shortfalls are identified and addressed it is recommended that a formal care plan audit is implemented. The Belmont DS0000060734.V371683.R01.S.doc Version 5.2 Page 12 There was a ‘short summary of ‘resident’s everyday care needs’, which clearly stated ‘to be updated each week’. None of the assessments seen had been updated weekly. Of the three files looked at the last update was in December 2007, February 2008 and March 2008. It is recommended that assessment updates are undertaken as stated on the assessment forms. Not all of peoples identified care needs had been incorporated into the care plan. For example, one care file identified that the person had short term memory loss and was very forgetful. Another file identified that the person had a tendency to wander and was disoriented. A care plan had not been implemented to address these specific care needs. To ensure that the health and welfare of people living at the home are fully met, a detailed plan of care must be implemented for each identified care need. Some parts of the care plans contained person centred information. For example one file detailed that the person liked her breakfast in her room between 8.30 and 9am. However other plans were vague and did not give specific details of how care needs or personal preferences could be met. For example, in relation to hygiene needs the care plan only stated the number of staff required and did not give any details of exactly what help was needed to maintain personal hygiene or any details of the persons personal preferences. It is recommended that that all care plans are developed using a person centred approach and contain sufficient detail for staff to meet all of the persons identified needs and personal preferences. Some risk assessments had been included in the care files e.g., nutrition, moving/handling, falls, general risks and skin care (Waterlows). It was of some concern that one moving and handling risk assessment stated that the person must be supervised at all times and there was no evidence that this was happening. A daily care plan review was completed for each person. However some entries were vague and repetitive. In some of the reviews concerns had been documented and not followed up. From discussions with the manager it was clear that the reports did not always accurately reflect the care given over a 24-hour period. A recommendation has been made. People living at the home who were spoken to stated that they felt they were well looked after and staff helped them when they needed assistance. Information received in the returned comment cards from people living at the home identified that they did receive the care and support needed and staff do listen and act on what they say. The records regarding medication were examined. It was day one of week one of the recording. There were no gaps in the recording of medication and medication had been signed into the home. The Belmont DS0000060734.V371683.R01.S.doc Version 5.2 Page 13 The manager and deputy manager both confirmed that only care staff who had received appropriate training have the responsibility for administering medication. Surplus, unwanted or expired medicines were appropriately documented and stored while waiting to be picked up by the pharmacy. It was noted that some medication with a limited life, for example, eye drops, did not have the date of opening documented to ensure out of date medication is not given to residents. A recommendation has been made. The manager confirmed that a copy of the GP’s original prescription is not kept in the home. It is recommended that there is a copy of the GP’s original prescription so that the medication received into the home can be checked against medication prescribed. The manager confirmed that at the time of this visit there was no formal system of auditing medication. To ensure that residents are receiving medication as prescribed by the GP, medication should be accounted for at all times by means of an audit trail. The last recorded drug fridge temperature was dated 4/10/07. To ensure that medication is kept at the correct temperature there should be a daily recording. During a tour of the building it was noted that in one shower room there was a bath/shower list on display that contained the names of people living at the home. This does not promote dignity and the area manager removed it. In addition some of the written terminology in one of the care plans did not fully promote that persons dignity. This was discussed with the manager during the visit. However staff spoken to confirmed that privacy and dignity was respected during day-to-day interactions and people are encouraged to exercise choice in their daily lives. The Belmont DS0000060734.V371683.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): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Limited activities are provided and people are able to maintain contact with family and friends. EVIDENCE: An activities book is kept where staff record what activities have taken place and who has participated. From the records it appears that one activity has taken place on a monthly basis. The deputy manager stated that she has responsibility for organising activities and due to time constraints only limited activities can be provided. Activities include birthday parties, bingo, quizzes and one of the care staff regularly sings for the residents. She either undertakes this in her own time or as part of her paid shift as a carer. When asked, the deputy manager confirmed that unless relatives take people out or they are able to go in the garden residents do not go out of the home. It is recommended that more social activities are made available for people and trips out of the home are facilitated. The Belmont DS0000060734.V371683.R01.S.doc Version 5.2 Page 15 To ensure that the activities provided are what the people living at the home want to do hobbies and interests are recorded on admission and there is a daily living and social activities care plan. The manager confirmed that some people receive visits from various religious denominations. The manager stated that specific religious or cultural needs would be assessed pre-admission. A copy of the menus was seen, which were varied and nutritionally balanced, although the deputy 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. The majority of comment cards from people living at the home stated that they usually liked the food. One person spoken to said that the food was “very good”. All the people spoken to said there was enough food and another person said there is always a good choice of meals. People living at the home and staff spoken to confirmed that there is open visiting and visitors are made welcome. One person said visitors can come and go when they like and are made welcome when they do come. The Belmont DS0000060734.V371683.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): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure protected people living at the home. To ensure that people are protected from potential abuse, staff must receive appropriate training. EVIDENCE: Since the last inspection visit a new complaint recording system has been implemented. There was a complaint policy all of the returned comment cards from people living at the home, indicated that they knew what to do if they had a complaint. One person spoken to said she knew how to make a complaint but had never wanted to. CSCI has not received any complaints since the last inspection visit. There was a Whistle Blowing policy and a policy relating to the Protection of Vulnerable Adults. However the policy did not accurately reflect the procedure to follow if an allegation of abuse was made. In addition, a copy of the local ‘No Secrets Guidance’ was not available for staff to access. The manager stated that 22 care staff were employed and apart from herself and the deputy only 3 members of care staff had attended safeguarding adults training. No in house training had been cascaded to staff and no further dates The Belmont DS0000060734.V371683.R01.S.doc Version 5.2 Page 17 for training had been arranged. This lack of staff training has the potential to put people at risk. No allegations of abuse have been made since the last inception visit. The Belmont DS0000060734.V371683.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): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available 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. Some radiators were unprotected and there were no risk assessments in place. This has the potential to put people at risk and must be addressed. There were no window restrictors in a first floor bathroom and toilet. This has the potential to put people at risk and was discussed with the manager and the The Belmont DS0000060734.V371683.R01.S.doc Version 5.2 Page 19 area manager. It was later confirmed that restrictors had been fitted to both windows. Bedrooms were seen to be personalised. Some areas of the home were not well maintained or clean. For example, several bedroom armchairs were seen to be dirty and stained. One chair had a dirty and split pressure cushion in place and some chairs in one dining room was split and dirty. The headboard in one bedroom was seen to be extremely loose and in another room the window could not be opened. Wheelchairs were dirty and encrusted with food and it was unclear if one bath was dirty or just heavily stained. Bathrooms and shower rooms had a collection of communal toiletries and in one shower room paint was peeling of the wall in the toilet area and the tiles in the shower area. 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. A number of fire exit doors led directly off the corridors and two peoples bedrooms. The doors on the first floor opened out onto metal stairs. The doors were not alarmed and could be easily pushed opened. It was of concern that a person could easily open the door and could then be at risk of falling down the meal stairs. To ensure the safety of the people living at the home advice from the local fire authority in relation to the fire exit doors must be sought and any required action taken. It was noted that a number of care plans were kept on the shelf on the ground floor corridor. These were easily accessible to anybody passing by. This does not protect peoples personal information and is in breach of the Data Protection Act 1984. All personal information of the people living at the home must be kept securely in the home. The Belmont DS0000060734.V371683.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): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all staff had received appropriate training and the recruitment procedure did not full protect people. . EVIDENCE: At the time of this visit 34 people were accommodated and the manager confirmed that there are usually five staff, in addition to the manager on duty, until 7.45pm and then there are three staff on night duty. The majority of comments, received from staff in the comment cards, indicated that there is usually enough staff on duty. The manager stated that 22 care staff are employed. Thirteen staff have successfully completed NVQ Level 2 or above and 6 staff are currently working towards NVQ Level 2. A sample of two 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.V371683.R01.S.doc Version 5.2 Page 21 Some short falls were seen. For example, one file did not have a photograph or proof of identity. The same file did not have a competed application form and the addresses of referees had not been completed. Both files did not have a full employment history, even though the application form asked for it to be detailed as from leaving school. It was noticed that one reference was not obtained from the applicant’s last employer, as documented on the application form. The manager was able to explain the reasons why but there was no written evidence of this. A recommendation has been made. 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. In addition, in the files looked at, there was no evidence that a set interview format had been used or that notes were taken. It is recommended that a set interview format is used and notes are taken during the interview process. Evidence was seen of Protection of Vulnerable Adults (POVA) and Criminal Record Bureau (CRB) checks. There was evidence of a basic induction, however the manager stated that it was in the process of being updated inline with Skills for Care. A staff training matix was available for inspection. From looking at the matrix and talking to the manager it was evident that there were gaps in training. There was no evidence of First Aid, Infection Control, Food Hygiene and, as already referenced in this report, limited Safeguarding Adults training. The manager confirmed that the training programme for care staff relied on the training events offered to care homes by the City Council Adult Social Care Service. Members of staff were nominated for a range of core training events. If the home were offered places on these events then staff would attend. 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. It is further recommended that staff competence should be assessed in applying the skills and knowledge gained through training events. The Belmont DS0000060734.V371683.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): 31,33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available 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: The manager has been in post for two and half years but has not submitted an application to CSCI for registration. To ensure the home is managed in the best interests of the residents living there an application for registration must be submitted as a matter of some urgency. The manager confirmed that quality assurance questionnaires had been left in the main reception for the people living at the home, relatives and visiting The Belmont DS0000060734.V371683.R01.S.doc Version 5.2 Page 23 professionals to access. The manager stated that a small number had been returned but they could not be found on the day of this visit. As detailed in the previous report there was no evidence that any returned questionnaires had been analysed or that the results had initiated an action pr development plan. It is recommended that an effective quality assurance monitoring system, based on seeking people’s views, is developed and implemented and that any information received is collated and made available for people to see. The manager stated that meetings for the people living at the home were held approximately every 3 months. The last meeting was June 2008 although the minutes could not be found on the day of this visit. Minutes of staff meetings held in May and June 2008 were available. The manager confirmed that she did not hold relatives’ meeting but did encourage relatives to raise any concerns they may have. Financial procedures for handling peoples monies were discussed and it is recommended that the policies and procedures relating to finances are reviewed and updated to clearly set out the systems to be followed. Secure facilities were provided for the safekeeping of money and valuables and receipts retained for any purchases made on behalf of residents. The manager confirmed that, on occasions, staff do purchase items on behalf of a resident. However, there was no record of agreement that people had given their permission for staff to make purchases on their behalf. It is recommended that written agreements be developed between people and the home setting out permission for the staff to purchase personal items for that person and the receipt be signed by the person purchasing items. The records for peoples finances were not seen during this visit, as manager had come to the home direct from a training day and did not have the keys to where this information is kept. 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.V371683.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 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 2 x 2 x x 2 The Belmont DS0000060734.V371683.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 OP7 Regulation 15 (1) Requirement To ensure that the health and welfare of people living at the home are fully met, a detailed plan of care must be implemented for each identified care need. To ensure people are protected from abuse all staff must receive Safeguarding Adults training. Radiators within the home must be assessed for the risk they present to the people who use the service and appropriate action taken to make sure that any risk is minimised. Personal information relating to people living at the home must be kept in a secure place. To ensure the safety of people living at the home, advice from the local fire authority in relation to the fire exit doors must be sought and any appropriate action taken. Timescale for action 20/10/08 2. OP18 13 (6) 20/10/08 3. OP19 13 (4) (c) 20/10/08 4. OP19 17 (1) (b) 20/10/08 5. OP19 23 4 (a) (c) (b) 18/09/08 The Belmont DS0000060734.V371683.R01.S.doc Version 5.2 Page 26 6. OP29 19 and schedule 2 9 All staff files must include all the details listed in Schedule 2 to ensure the recruitment procedure protects residents. To ensure that The Belmont is managed in the best interest of the people living there an application for the manager to register with CSCI must be submitted. 20/10/08 7. OP31 01/11/08 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 1. It is recommended that peoples care plans are developed on a person centred approach and contain sufficient detail for staff to meet all that persons identified needs and personal preferences. 2. It is recommended that all assessments are reviewed and updated as stated on the assessment forms. 3. To ensure any shortfalls are identified and addressed it is recommended that a formal care plan audit is implemented. 4. It is recommended that the daily care reports are written in sufficient detail to accurately reflect the care given over a 24 hour period. 1. It is recommended that there is a copy of the GP’s original prescription so that the medication received into the can be checked against medication prescribed. 2. To ensure people are receiving medication as prescribed by the GP medication should be accounted for at all times by means of an audit trail. 3. To ensure that out of date medication is not being The Belmont DS0000060734.V371683.R01.S.doc Version 5.2 Page 27 2. OP9 given to people the date of opening should be recorded on medication with a limited life. 4. There should be a daily drug fridge temperature recording to ensure that medication is stored at the correct temperature. 3. 4. OP10 OP12 Peoples privacy and dignity should be promoted at all times. It is recommended that more social activities are made available for people living at the home and trips out of the home are facilitated. 1. To ensure that people are not put at potentional risk it is recommended that the policy relating to Safeguarding Adults is reviewed and updated to accurately reflect the procure to be followed in the event of an allegation of abuse being made. 2. It is recommend that a copy of the local guidance ‘No Secrets Guidance’ be kept in the home for all staff to access. 6. OP19 1. It is recommended the dirty and stained armchairs in some peoples bedrooms are thoroughly cleaned or replaced. 2. It is recommended that the chipped and peeling deocr in the ground floor shower room is removed and the room be re-decorated/tiled. 7. OP26 3. Sluice doors when not in use should be kept shut. To ensure that the risk of cross infection is minimised: 1. Communal toilettes should not be used. 8. OP29 2. Wheelchairs should be thoroughly cleaned. 1. It is recommended that a set interview format is used and notes are taken during the interview process. 2. It is recommended that written evidence be maintained that the original documentation has been seen, the date and by whom. 3. It is recommended that if a reference is not obtained by the applicant’s last/current employer, as detailed on the application form, the reason is clearly recorded. The Belmont DS0000060734.V371683.R01.S.doc Version 5.2 Page 28 5. OP18 9. OP30 1. 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 those skills, knowledge and awareness. 2. Staff competence should be assessed in applying the skills and knowledge gained through training events. It is recommended that an effective quality assurance monitoring system, based on seeking people’s views, is developed and implemented and that any information received in collated and made available for people to see. 1. It is recommended that the policies and procedures relating to finances are reviewed and updated to clearly set out the systems to be followed. 2. It is recommended that written agreements be developed between people and the home setting out permission for the staff to purchase personal items for that person and the receipt be signed by the person purchasing items. 10. OP33 11. OP35 The Belmont DS0000060734.V371683.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 The Belmont DS0000060734.V371683.R01.S.doc Version 5.2 Page 30 - 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!