Inspection on 23/05/06 for The Belmont

This inspection was carried out on 23rd May 2006.

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 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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Belmont Schools Hill Cheadle Stockport Cheshire SK8 1JE Lead Inspector Kath Oldham Unannounced Inspection 23rd May 2006 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.V293283.R01.S.doc Version 5.1 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.V293283.R01.S.doc Version 5.1 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.V293283.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. 10th November 2005 Date of last inspection 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 home has a statement of purpose and service user guide which were reported to be given to prospective service users or their families when they visit the home to look round. The fees for staying at the home were reported to be between £337 and £450 per week. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was unannounced and took place over two days, on 23rd and 24th May 2006, commencing at 8:15am. The visit was used to monitor the requirements and recommendations of past inspections, examine records and to spend time in conversation with service users. Comment cards were given out for service users, relatives and visitors. Health care professionals visiting the home were spoken with and comment cards were sent to the doctors and district nurses who visit the home. Comments received on the site visit and in comment cards are contained within this report. The case files of four service users were looked at in detail, looking at their experiences in the home from their time of admission to the present day. Breakfast and lunch were taken at the home with service users and a partial inspection of the premises was undertaken. The inspector spoke with service users and several members of staff who were on duty. The deputy manager was on duty during the visit and verbal feedback was given to her on conclusion of the visit. The registered person attended the home on the first day of the inspection and spent some time with the inspector. What the service does well: The activities arranged outside of the home were reported by service users to be very much enjoyed and they were looking forward to a planned barge trip in the week after the visit. The home’s manager is currently on sick leave. She has a number of years’ experience and holds a NVQ level 4 and the registered manager’s award. The manager continues to keep in touch with changes in care practices and routines. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The manager has been off sick for a period in excess of six weeks and the management arrangements at the home are inadequate. Staff appear unhappy with the current management arrangements and feel that confidentiality is not maintained, they are not treated equally in relation to duty rosters and areas in the home that they are allocated to work in. The storage of medication needs to be improved to safeguard service users. Medication training provided to staff is not sufficient to enable them to have the correct knowledge when administering medication to service users. As reported on previous inspections, the routine practice of staff wedging open fire doors must be discontinued, as this compromises the safety of service users and staff. The care plans need development to reflect the actual care needs of service users. They need to be reviewed at least monthly or more frequently and these reviews must be recorded and include the service users and/or their relatives. Staff need to receive supervision at least six times a year to further develop their skills. The records must be dated with the date and year they were completed and must be maintained accurately. There are number of service users who need to be mobilised by using a hoist. The home has one electric and a manual hoist. The number and the type of hoists available in the home needs to be reviewed and the appropriate type and number provided to assist in the transfer of service users. The routine in the mornings needs to be reviewed and amended so service users are not waiting indefinitely for care, attention and meals. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 Page 7 Staff need moving and handling training and need to be more vigilant when assisting service users to minimise the risk of cuts and abrasions. The communication and advice service from health care professionals needs to be developed to further enhance the quality of health care to service users. The assessment of service users who have bed rails fitted to their beds needs to be undertaken again and reviewed in line with health and safety guidelines, ensuring this is the appropriate and safest method for service users. Staff need to be familiar with what constitutes abuse and the process which must be followed if an allegation of abuse comes to light. There are requirements outstanding from past inspections that must be addressed fully by 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 Belmont DS0000060734.V293283.R01.S.doc Version 5.1 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.V293283.R01.S.doc Version 5.1 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): 1,2 & 3. (Standard 6 was not applicable) Quality in this outcome area is good. Service users’ needs are assessed prior to them being accommodated at the home. This judgement has been made using available evidence, including a visit to this service.” EVIDENCE: The deputy said that the service user guide and statement of purpose were contained in each of the service users’ bedrooms. The bedrooms inspected did not have them, except in a vacant bedroom. One service user said they told her lots of things when she first came into the home and gave her some papers but she was not sure what they were. The care files did not indicate whether a service user guide had been given to service users. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 Page 10 A contract for service users who are funded by the local authority is in place, in addition to a terms and conditions of residency for service users, some of which were not signed. Two service users indicated that they had received a contract and they received enough information about the home before they moved in so they could decide if it was the right place for them. It was the practice of the home that service users were assessed prior to their admission. Assessments were obtained from social workers and health professionals if they had been involved in the admission. Examination of four care files showed that a pre-admission assessment had been completed. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. The care planning and care delivery was not sufficient to meet the health, personal and social care needs of the service users. Medication procedures and practices were not completely safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of the care plans identified that not all care needs of service users were identified, so is was not always possible to determine whether their health and social care needs were met. Staff described particular service users’ care needs, which were not recorded in the files examined. An evaluation of the care plans identified them not to be reflective of the care needs. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 Page 12 Staff indicated that they were not always told about particular care needs service users have and that they are asked to care for service users outside of their area of expertise. Risk assessments for the prevention of falls were not always in place and where they were, they had not been reviewed for some time. Service users who had bed rails fitted had a record of this on file, however the assessment was from 2004. There was no indication, in the main, who had been involved in the decision to have these fitted or that this had been reviewed. Two service users’ file did not indicate that they needed assisted feeding. Staff said the service users needed some support. A further service user who had some mental health needs did not have this detailed or how staff should support this service user. There were not always details on the care file that service users’ care needs had been reviewed. One staff member said that they had been asked to quickly review the care plans before they were given to the inspector. The care plans that had been reviewed, in the main, had not been dated and did not detail their effectiveness. One service user said they always received the care and support they need, another indicated that they usually get the right level of care. The majority of service users have their breakfast in their bedroom, with two service users having breakfast in the dining room. Staff get service users up then take breakfasts up to their rooms. Once service users have eaten, staff then assist with washing and dressing. This routine takes the whole of the morning, with the last service user being assisted with washing and dressing at 11:35am. The service user needed assistance and had continence difficulties and had the commencement of what could be pressure areas. This routine in the morning compromises service users’ health and dignity. Service users said they do not always get assistance when they need it. Some service users are not able to articulate what they want or have to be patient for staff assistance. One relative commented that the “standard of care has deteriated due to shortage of staff since new ownership”. Examination of the daily reports identified that some had been completed in detail, with staff taking time and thought in the words they used to describe how a service user had presented. Other entries were inappropriate or did not detail how service users had spent their day. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 Page 13 One service user had a pressure sore, which the deputy said she came into the home with. This detail was not recorded. The CSCI had not been notified as is required by regulation. Staff practice when mobilising service users in their wheelchairs was not in keeping with health and safety guidance, service users being taken in wheelchairs without the use of footrests. This compromises service users’ safety. One service user was seen being taken backwards down the corridor by a member of staff, in a shower chair, without any clothing over her shoulders. This compromises the service user’s dignity. Service users were seen sat at the dining table in their wheelchairs, as opposed to sitting in a dining chair. One service user said they didn’t feel near enough or high enough at the table. The service user didn’t know any reason why they couldn’t sit in a dining chair. District nurses said they attend the home on a number of occasions, to see service users who had skin tears or abrasions. A number of staff have not had moving and handling training whilst they have been employed at the home or they have not received this as regularly as they should do in line with health and safety guidelines. Examination of the medication records identified, in the main, that they were completed appropriately. The initials in the medication records for the morning’s medication appeared different in the two records provided. The deputy stated that she had completed the records on administering the medication to individual service users. This is disputed. The stock of controlled drugs was as recorded in the register. Controlled drugs for service users no longer at the home were still in stock. Stocks of medications should be returned to the pharmacist in a timely manner. Refrigerated medication was stored in an unlocked refrigerator and the temperature of the fridge was consistently at the highest temperature permitted. A maximum/minimum thermometer is not used. Medication is administered by staff who have received very basic training in the handling and administration of medication. There is no formal assessment of carer competency in medication administration. There had been some improvements to the storage and recording of medication since the last inspection. The shortfalls in medication must be addressed by the home to safeguard service users. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. Not all service users have planned or structured opportunities to socialise but meals and mealtimes are enjoyable, with a varied and nutritious menu. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Service users said they could “do what you want when you want to”. Service users said they still go out to Southport, Blackpool and Chester and that “anyone can go if you are well enough”. Examination of the activities record identified that the same service users go out on trips. Staff said this was the case. The deputy said she was going on the trip next week and some different service users were going along. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 Page 15 It appears that the more independent service users go out on trips. One service user said they would like to go out occasionally. The activities within the home appear to be centred on quizzes. Some service users said they like the quizzes, others said it wasn’t what they liked to do. The activities organiser was on holiday and service users said they wouldn’t have any activities during her holiday. Service users confirmed that visitors were made welcome at the home and service users kept in touch with family and friends. Service users told the inspector that they enjoyed the meals provided at the home. Lunch was the main meal of the day, the teatime meal was a light snack and breakfast was served in service users’ bedrooms. The inspector observed the lunchtime meal, which was well presented and freshly made. Three choices are available for the teatime meal. One service user said “and if you don’t fancy any of those, they will make something else”. One relative comment card said, “The residents praise the meals”. A comment card indicated that the main dining room has no smoking signs, but staff use it for their tea break and smoking”. The kitchen contained defective equipment that was still in use. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. Service users are not fully protected from potential abuse nor can service users be confident that complaints procedures are followed correctly. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A complaint record is in place and details one complaint. The record did not include an investigation or what was done as a consequence of the complaint. A separate record of complaint was shown to the inspector. The complaint had not been addressed in line with the complaints procedure. The comments and complaints from service users and their representatives are 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 said that they had not had a residents meeting this year and this is an opportunity to discuss anything “that needs sorting out”. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 Page 17 Two service users said they know who to speak to if they are not happy and they know how to make a complaint. Eleven relatives indicated that they were not aware of the home’s complaints procedures. One relative indicated, “The only time we had to make a complaint it was dealt with quickly and satisfactorily”. 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. Some staff commented that they had not had this training. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 23 & 26 Quality in this outcome area is adequate. The lack of replacement and upkeep of the home does not promote the safety, security, comfort and respect of service users. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: As reported on past inspections, the safety of the service users was compromised by the practice of wedging open fire doors. This matter must be addressed by the home and the routine and practice of staff changed to safeguard service users and themselves. Radiators in the home need to be guarded or have low surface temperatures to safeguard service users. Additional radiator covers have been installed since the last inspection. It was thought that about eight more were needed. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 Page 19 A service user commented that the central heating needed attention, as “sometimes it is too hot and sometimes too cold”. The handyman said contractors had been out to the home to attend to this. It was reported on the last inspection that 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 was to be undertaken to the side of the home, which, once completed, will provide additional bedroom and living accommodation. A relative indicated, “The Belmont is in need of refurbishment, despite being notified last March that redecoration and refurnishing is planned, nothing has happened so far”. This building work scheduled to commence in February 2006 has not commenced. The registered person said he would contact CSCI in the next few weeks to inform when this work is to begin. The furniture and furnishings in service users’ bedrooms continue to need repair and replacement. A number of bedrooms have been repainted and new duvet covers and curtains have been purchased which makes the bedrooms look clean and fresh. A call system is provided in the home, which enables service users to call for the assistance or support of staff. When in the lounge, service users need some degree of mobility to get to the call bell. Service users commented that when asking for assistance, this is provided, however they are, on occasions, left for long periods of time awaiting the return of staff. There are two hoists in the home, one electric and one manual. A number of service users need to be hoisted by two staff. The manual hoist was reported to be heavy and difficult to use. The hoists had been serviced and were reported to be in working order. Staff commented on the difficulties they have mobilising the hoist from one room to another and how difficult it was to manoeuvre in comparison to the electric one. Staff reported that one of the lifts only ascends to the second floor due to a faulty door that needs repairing. Other equipment in the home could not be used, as it needed repair or replacement. There was no evidence of wheelchairs being checked or maintained, these practices need to be in place to ensure the safety of service users and staff. The home was clean and free from any odours. Service users said the house is always clean. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. Staffing levels, deployment, training and recruitment practices were inadequate to meet service users’ needs and to promote their health and safety. This judgement has been made using available evidence, including a visit to this service EVIDENCE: During the morning, staff are very busy and service users do not receive the support they need due to the organisation of the morning routines. There are dedicated laundry and domestic staff on duty. The number of staff on duty after 8:00pm is not sufficient. Previous inspection reports have reported on this fact, which the home has made no efforts to address. Staff indicated that, in their opinion, there were times when there were insufficient numbers of staff on duty. Relatives said, “staff are always cheerful”. A number of relatives indicated there were insufficient staff on duty in the evenings and at weekends. The duty roster for laundry and domestic staff was not up to date and was not reflective of the staff employed. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 Page 21 The home employs two cooks, one has basic food hygiene training, the other has not. The attendance to training keeps cooking staff up to date with changes in legislation and best practice guidance and safeguards service users. Examination the files of two recently appointed staff, identified that there was no up to date Criminal Record Bureau check on one file and on the second file there was no evidence of a Criminal Record Bureau having been requested. Four staff have been appointed to the home from abroad. They have not had Criminal Record Bureau checks undertaken. There was evidence of staff taking part in mandatory training. However, this did not include all staff and updates for some training were necessary. Some staff have obtained NVQ levels 2 or 3, with other staff studying for this qualification. A relative indicated, “I have no fault to find and have only praise for the staff. They have been great and did their best”. Additional positive comments were made by relatives and visitors about the carers being friendly. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is poor. The lack of a manager at the home has impacted on the level of service provided and the inconsistencies in leadership do not promote service users’ health and safety. This judgement has been made using available evidence, including a visit to this service EVIDENCE: The registered manager has been absent from the home for a period in excess of six weeks. The CSCI was not notified in line with regulations. The registered person has not put in additional management cover. The deputy is working most days and, in her absence, care staff are taking the responsibility. This arrangement is not satisfactory. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 Page 23 Staff appear unhappy with the current management arrangements and feel that confidentiality is not maintained and staff are not treated equally in relation to duty rotas and work allocation. One member of staff said, “I hope the manager will be back soon, then things can get back to how it used to be, everything done fairly”. The registered person undertakes monthly visits to the home, the reports of which are not routinely sent to CSCI, as required by Regulation. The registered person said it was his understanding that they were sent to CSCI. 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. Service users commented that they had not had a residents meeting this year, when the opportunity is used by them to comment on the care and support they receive. The deputy confirmed that the meetings hadn’t taken place for some time. The notes of the meetings were recorded up to October 2005. As reported on previous inspections, the fire records identified that some staff had not received fire training as required by the Fire Authority. Checks to the fire safety systems were recorded as having been undertaken. 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 available on the visit. It was not clear whether this was in place. The requirement to produce this is repeated on this visit. A record is maintained of any accidents, incidents or occurrences experienced by service users. The books need some organisation, as it was difficult to read due to pages not being completed consecutively. Examination of staff files identified that not all staff had received supervision. Staff said they had never had supervision. The deputy stated that it was her intention to recommence these sessions. Three staff said that they didn’t feel they get the support they need and one staff member said, “Never listen to anything we say, it’s as though opinions don’t matter”. Examination of health and safety certificates included servicing of the lift and hoists. Work indicated on the contractor’s record did not detail whether the identified work had been completed. The maintenance man said that when work is identified, this is passed to the registered person for authorisation. There was no recorded evidence that the described work had been undertaken. Examination of the kitchen-cleaning schedule identified that specific jobs had not been recorded as having been undertaken. The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 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 2 17 X 18 2 2 X 2 2 2 X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 2 X 2 The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 Page 25 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 and reviewed. (Previous timescales of 31/07/05 and 31/12/05 not met). The registered person must develop the staff team and provide direction and supervision in what should be recorded within the daily reports. (Timescale of 31/01/06 not met). The registered person must amend the routine in the morning so that service users are provided with the support and assistance they need at a time which is appropriate and provide breakfast at a time that suits them and their abilities. The registered person must provide all staff with moving and handling training and updates at the regularity of health and safety guidelines. Timescale for action 09/08/06 2 OP7 15 09/08/06 3 OP7 12 09/08/06 4 OP7 18 09/08/06 The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 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. 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. (Timescale of 14/11/05 not met). 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. (Timescale of 12/12/05 not met). The registered person must provide staff that have the responsibility of administering medication with appropriate training. The registered person must develop the type and routine of activity and stimulation provided to service users giving all the opportunity and encouragement to participate. Timescale for action 09/07/06 6 OP9 13 09/07/06 7 OP9 13 09/08/06 8 OP12 12 09/08/06 The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 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. 9 Standard OP16 Regulation Schedule 4 Requirement The registered person must develop the recording in the complaints record and follow the procedure when investigating complaints, ensuring the process is thorough and safeguards service users and staff. (Timescales of 31/08/05 and 31/12/05 not met). The registered person must provide all staff with training in what constitutes abuse and how to recognise the symptoms. The registered person must cease the practice of wedging bedroom doors open. (Previous timescales of 07/06/05 and 10/11/05 not met). The registered person must redecorate all bathrooms and toilets. (Previous timescales of 01/09/04, 30/09/05 and 31/12/05 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. (Timescale of 20/12/05 not met). Timescale for action 09/07/06 10 OP18 18 09/08/06 11 OP19 23 09/06/06 12 OP21 23(1)(2) 31/08/06 13 OP22 12(1) 09/06/06 The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 Page 28 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. 14 Standard OP22 Regulation 22 Requirement The registered person must provide suitable and sufficient numbers of hoists that are easily used by staff and comfortable and efficient for service users. The registered person must maintain equipment and appliances and repair or replace identified equipment. The registered person must fit covers to all the radiators in the home. (Previous timescales of 30/11/04, 31/08/05 and 31/12/05 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 and 31/12/05 not met). The registered person must ensure the staff duty roster is accurate and details all staff working at the home and their role and hours. The registered person must provide sufficient staff on duty and organise routines so that service users receive the support they need. Timescale for action 09/08/06 15 OP22 22 09/08/06 16 OP23 16(1)(2) 13(c) 09/08/06 17 OP23 16(1)(2) 09/09/06 18 OP27 Schedule 4 24/05/06 19 OP27 18 24/05/06 The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 Page 29 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. 20 Standard OP28 Regulation 18 Requirement The registered person must provide staff with the training they need to undertake the position they are employed to do which must include, at a minimum, moving and handling, NVQ 2, first aid, infection control, dementia care, basic food hygiene and health and safety. The registered person must operate a thorough recruitment procedure to include at a minimum obtaining CRB checks or POVA first checks for all staff before commencement in post. The registered person must arrange for all staff who have the responsibility of preparing or cooking food with basic food hygiene training and for full-time cooks, advanced level training. The registered person must propose to CSCI, in writing, the temporary management arrangements in the absence of the registered manager. The registered person must, as part of the Regulation 26, visit and prepare a detailed written report on the conduct of the home at the regularity prescribed by the regulations, which is forwarded to CSCI. DS0000060734.V293283.R01.S.doc Timescale for action 09/07/06 21 OP29 19 Sch2 24/05/06 22 OP30 18 09/08/06 23 OP31 8 24/05/06 24 OP31 26 24/05/06 The Belmont Version 5.1 Page 30 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. 25 Standard OP33 Regulation 24 Requirement The registered person must reinstate service users meetings at an increased regularity to provide an opportunity for service users to comment on the care and support they receive. 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 and 31/12/05 not met). The registered person must provide staff with development supervision at a minimum of six times each year. The registered person must arrange for the production of a fire risk assessment, which is forwarded to the fire authority for agreement. (Previous timescale of 30/11/05 not met). The registered person must maintain all service records (hoist, lift, etc.) available for examination and ensure written confirmation of work carried out to equipment is maintained on file. Timescale for action 09/07/06 26 OP33 10(1) 09/07/06 27 OP36 18 09/07/06 28 OP38 23(4) 09/07/06 29 OP38 23 24/05/06 The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 Page 31 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. 30 Standard OP38 Regulation 23(4) Requirement The registered person must amend the fire safety policy to reflect actual practice for an emergency situation. (Previous timescale of 30/11/05 not met). Timescale for action 09/07/06 The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 Page 32 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 3 Refer to Standard OP7 OP15 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 ensure the cook has access to a safely functioning food mixer. 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 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 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 the competency of carers with responsibility for medication administration is assessed regularly on a formal basis. 4 OP9 5 OP9 6 OP9 The Belmont DS0000060734.V293283.R01.S.doc Version 5.1 Page 33 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.V293283.R01.S.doc Version 5.1 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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