Inspection on 28/09/07 for The Belmont

This inspection was carried out on 28th September 2007.

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 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 15/09/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Belmont Schools Hill Cheadle Stockport Cheshire SK8 1JE Lead Inspector Steve Chick Unannounced Inspection 28th September & 2nd October 2007 11:15 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.V344034.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.V344034.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.V344034.R01.S.doc Version 5.2 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. 27th February 2007 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 £321 and £450 per week as at October 2001. The Belmont DS0000060734.V344034.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. For the purpose of this inspection four service users were interviewed in private. A discussion was held with one visiting healthcare professional. Two staff were interviewed in private and discussion took place with the acting manager and the deputy manager. We also undertook a tour of the building, including communal areas and a selection of service users’ bedrooms. We also looked at a selection of service user and staff records, as well as other documentation, including staff rotas, medication records and the complaints log. This key inspection included an unannounced site visit the home and a subsequent visit several days later to talk with staff and service users. All key standards were assessed. This report also uses information gathered since the previous visit. This includes information provided by the acting manager in a written selfassessment of The Belmont’s strengths, weaknesses, and achievements over the preceding year. This document is called the Annual Quality Assurance Assessment (AQAA). Questionnaires and comment cards were received from six service users and 13 relatives. The questionnaires were received over two periods of time, one group in August 2007 and the other group in October 2007. While some respondents were not entirely positive, overall, there appeared to be a good level of satisfaction with the care offered. Service users’ comments included “I am very happy”; “you are free to do what you want …” And “I am satisfied. Its champion.” What the service does well: The home completes a profile of each service user which assists in relating to service users as individuals. There are examples of religious and cultural needs being identified, with clear and achievable strategies to ensure those needs were routinely met. Service users’ dignity is maintained and the administration of medication is undertaken safely. The Belmont DS0000060734.V344034.R01.S.doc Version 5.2 Page 6 A range of activities are provided which include regular outings for small groups of service users. Visitors experience the staff as welcoming and friendly. The provision of food, both in terms of its quality and quantity, was positively reported on by all. The Belmont provides pleasant homely accommodation with a choice of different communal or private places and is set in pleasant grounds. What has improved since the last inspection? What they could do better: Several issues were identified in connection with ineffective record-keeping. While these did not present as having an immediately detrimental impact on service users, it did have a negative impact on The Belmont’s ability to be accountable for their care and safety. More consistency in documentation is required. Particularly, this is around care planning and risk assessments to ensure that all written plans give consistent, complete and accurate information. Staff should seek to consistently be able to demonstrate the ways in which service users, or if appropriate, their relatives or representatives are consulted and in agreement with the way in which identified care needs are to be met. Complaints records should include informal complaints to enable management to quickly identify any patterns which may indicate that standards of care are falling. The recruitment and vetting of staff must be undertaken, as a minimum, with the rigorous adherence to the statutory requirements, to ensure that all reasonable steps are taken to protect vulnerable service users from exposure to inappropriate staff. The Belmont DS0000060734.V344034.R01.S.doc Version 5.2 Page 7 Quality assurance processes need to include an assessment of responses and a written action plan or developmental plan which demonstrates how the views of service users and their representatives positively influence the running of The Belmont. Some issues around health and safety, particularly in relation to written risk assessments and ensuring all staff have training appropriate to their roles, need to be undertaken to ensure the safety of both service users and staff. 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.V344034.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.V344034.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 and 6. Quality in this outcome area is good. Service users’ needs are assessed before moving into the home to ensure their needs can be appropriately met. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A selection of service users’ files was looked at. All had a written assessment of their needs. The acting manager reported that, other than in an emergency, prospective service users were always assessed to ensure The Belmont could meet their needs. Respondents to service user and relatives’ questionnaires were generally positive in their views of the overall care offered. The Belmont DS0000060734.V344034.R01.S.doc Version 5.2 Page 10 This process of assessment was also confirmed by the home’s self-audit (AQAA) which had been submitted to us before the site visit. The Belmont does not offer intermediate care. The Belmont DS0000060734.V344034.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 and 10. Quality in this outcome area is good. Service users receive appropriate care in spite of inadequate administrative systems. The home’s procedures in connection with the administration of medication are implemented to the benefit of service users who have access to appropriate community based medical services. Staff practices serve to promote the dignity of service users. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A selection of service users files was looked at. All had a written plan of care. The care planning system in use at The Belmont involved several assessment tools which, when used correctly, can offer a useful starting point to aid effective strategies to meeting an individual’s identified needs. The Belmont DS0000060734.V344034.R01.S.doc Version 5.2 Page 12 The quality, and hence usefulness, of the completed documentation was inconsistent. Examples were seen where assessment tools were incorrectly completed. Examples were seen where the assessment tool identified the level of risk, but with no apparent plan as a consequence. Daily records were also inconsistent. They sometimes identified issues but with no corresponding record of any action. Care plan reviewing was also inconsistent. One example was seen where events recorded on the file should have resulted in an amendment to the plan but did not. This was in spite of a review having taken place. Some bedrails appeared to be being used without a thorough written risk assessment. There was some documentary evidence that service users, or their representatives, were involved in the care planning process but, again, this evidence was inconsistent. There were also areas of good practice in the recording. Examples were seen of some useful profiles of the service users. These would assist staff in seeing the service user as a discreet individual. Specific religious and cultural needs were seen to be appropriately addressed in a respectful and sensitive manner. Staff who were spoken to during this visit explained that, in addition to the care planning documentation, there was a thorough verbal update given at each shift change. This identified any current issues relating to each service user. Staff were confident that this system worked and that they were aware of the individual needs of individual service users while they were at work. All service users spoken to were positive about the care they received. One service user said the staff treat me well. If I want anything Ive just got to ask. Another confirmed that they could influence the way in which their care needs were met, saying you can talk to the staff and they take notice of you. Most questionnaires which were returned to us were positive about the way in which care needs were met at The Belmont. The Belmont DS0000060734.V344034.R01.S.doc Version 5.2 Page 13 As with care planning, documentary evidence in connection with access to health care was not as rigorously maintained as best practice demands. One relative respondent to the questionnaire expressed some concern that on one occasion they had been unable to establish from staff if a medical appointment had been made. However, all service users and staff spoken to expressed confidence that people had access to the full range of medical and paramedical services available in the community. Similarly, all service user questionnaires confirmed they received the medical support they needed. One visiting health care professional was spoken to briefly during this visit. They reported positively on care which they had observed and on the communication between their service and The Belmont. The Belmont uses a pre-dispensed monitored dosage system to administer service users’ medication. Medication was seen to be stored appropriately. A sample of medical administration records was looked at and presented as being appropriately maintained. Service users who were spoken to said they were treated with respect and that their dignity was maintained. One relative commented in their questionnaire, when asked what the home does well, staff are friendly and appear to respect the residents. The Belmont DS0000060734.V344034.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 and 15. Quality in this outcome area is good. An appropriate range of activities was available to service users, and visitors are welcome in the home, which enhances service users’ fulfilment and social stimulation. The provision of food to maintain service users’ health and well-being is good and service users are able to maximise their autonomy within the context of communal living. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Several respondents to the relatives’ questionnaire which were received by us in August commented on the lack of social activities available for service users at The Belmont. Questionnaires received in October did not highlight this as a problem area. This may indicate that the return of the activities co-ordinator from a lengthy period of sickness has successfully addressed the apparent lack of social activity and fulfilment. The Belmont DS0000060734.V344034.R01.S.doc Version 5.2 Page 15 A record of activities is maintained, including a range of outings. Activities are promoted on a notice board in the home, although at the time of this visit they were out of date. Service users spoken to confirmed these outings and activities took place. One service user said they had been to some lovely places. The Belmont has a policy of allowing visitors at any reasonable time. Their self-assessment says visitors are welcomed at all times and are not restricted to certain visiting hours. Residents are actively encouraged maintain contact with their relatives and friends as this enables them to feel involved in the local community. This was borne out by service users spoken to and all returned questionnaires. Several respondents to the relatives’ questionnaire commented on the friendliness of the home. One said staff are always welcoming and friendly towards visitors and another commented the staff are friendly ...”. Service users and staff who were spoken to expressed the view that service users at The Belmont could exercise choice and autonomy over their lives, within the context of their abilities and communal living. Service users confirmed they could get up and go to bed when they wanted. One service user said they liked the fact that they can have breakfast in bed. Another service user cited as the best thing about the home you are free. All service users who were spoken to, and all who returned the questionnaire, were positive about the provision of food at The Belmont. One service user said “I love the food and can leave what I don’t want.” Another said “staff ask you what you want, you always get enough and sometimes have to leave some.” Two respondents to the relatives’ questionnaire, when asked what The Belmont does well, commented on the food. One said residents “enjoy their meals” and another “the food is excellent”. The Belmont DS0000060734.V344034.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 and 18. Quality in this outcome area is good. Service users are confident that any complaints they may have would be dealt with appropriately, and are protected from abuse or exploitation by the home’s policies and practices. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The Belmont has a complaints policy which has been found to be appropriate on previous inspection visits and was not looked at on this occasion. The complaints log was looked at. No entry had been made since the previous inspection visit. Discussions with the acting manager indicated that only formal, written complaints were recorded in that log. As mentioned at the last inspection visit, a more structured recording of informal complaints and comments helps to give a managerial overview of any difficulties developing in the home which would enable swift action to improve. There was documentary evidence in one service user’s file seen, where two “complaints” had been made, appropriately dealt with and recorded. This indicates that individual concerns are appropriately dealt with, but it would be hard to identify overall patterns. The Belmont DS0000060734.V344034.R01.S.doc Version 5.2 Page 17 One respondent to the relatives’ questionnaires expressed the view that a concern of theirs had not been effectively resolved in a timely manner. Other respondents were more confident about The Belmont’s complaints procedure. All service users spoken to were confident they could make a complaint and that staff would listen to them and take appropriate action. Staff who were spoken to also expressed confidence that their colleagues and management would respond appropriately to any complaint. All service user questionnaires reported that they knew who to speak to if they were not happy. One service user commented “I ask to speak to who is in charge. There is never a problem for them to come to talk to me.” All service users spoken to felt safe at The Belmont. The AQAA reported that all staff were aware of safeguarding adult procedures. All staff who were interviewed at this visit were confident that service users were safe. All staff spoken to also reported that they would pursue any concerns they had about any abuse, but not all were clear about how they would do that. There have been no safeguarding issues since the last inspection. No returned questionnaires expressed concern about service users being at risk of abuse or neglect. The Belmont DS0000060734.V344034.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 and 26. Quality in this outcome area is good. The home is appropriately maintained, decorated and cleaned to enable service users to live in a pleasant, safe and hygienic environment. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: During the visit to the home a tour of the building was undertaken. This included communal areas and a selection of service users’ bedrooms. There were several communal areas where service users could spend their time, or they could access their rooms when they chose. The Belmont DS0000060734.V344034.R01.S.doc Version 5.2 Page 19 Service users’ bedrooms showed clear signs of personalisation. The home has a policy that, subject to space and health and safety requirements, service users can bring in their own furniture, etc. This was confirmed as being the case by one service user spoken to. There was evidence of water damage to the ceiling outside one bedroom. It was reported that the source of this leak had been repaired and that the area would be redecorated soon. There was documentary evidence that staff were able to record any remedial work needed so that the maintenance person could quickly address any problems. No specific remedial work was identified in connection with the fabric of the building at this visit. There was a “loop system” in place in the television lounge to assist service users with hearing aids. Some lounges also benefited from the presence of caged birds and an Aquarium. The home presented as being clean and tidy with no unpleasant smells. This was confirmed as being the normal state of the home by service users and staff who were spoken to. One service user described their room as “very nice” and another said “it’s the nearest you’ll get to living in your own home, it’s clean.” Another service user included “cleanliness and beautiful gardens” as amongst the best things about The Belmont. Respondents to the relatives’ questionnaires when asked what The Belmont does well included “generally cleanliness always seems to be of a high standard”; “it is warm and comfortable and the décor is fresh and pleasing”; “X’s room is clean and bedding is changed regularly”. The Belmont DS0000060734.V344034.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 and 30. Quality in this outcome area is adequate. The numbers and skills mix of staff on duty promotes the independence and well-being of service users. Recruitment procedures are not always applied with sufficient rigour to minimise the risk to service users of inappropriate staff being employed. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The staff rota for the week beginning 27/08/07 was looked at. This demonstrated that a minimum of four or five carers in addition to a manager were on duty during the day. Three carers were on duty at night. The shift pattern and details of who is on duty for each day is recorded on a whiteboard in the foyer. This is good practice as it enables service users and visitors to identify which staff are on duty on that day. In addition to carers, the home employs ancillary staff including laundry assistants, domestics, cooks and an activities co-ordinator. The Belmont DS0000060734.V344034.R01.S.doc Version 5.2 Page 21 Information provided in the AQAA indicated that 50 of staff held NVQ II or above. The acting manager reported that at the time of this visit two staff were undertaking NVQ III and three more staff were planning to commence NVQ II later in the month (October). A selection of staff files was looked at in connection with the recruitment and vetting procedures. Although the AQAA reported that all necessary recruitment checks had been undertaken, evidence was seen where more rigour was needed. Examples were seen of employment histories which did not give clear dates of employment which would make the effective exploration of any gaps very difficult. Examples were seen where staff appeared to have started work before a POVA first had been obtained. Although previously obtained CRB’s were held on file (either from a previous period of employment at The Belmont or another care home) this is not acceptable within the current regulations relating to employment in a care home. One example was seen where a reference raised a query over the suitability of the applicant, but there was no documentary evidence that this has been satisfactorily explored with the applicant. It was reported by the acting manager that all new staff undergo a period of induction. This was confirmed in discussion with staff who were interviewed. The documentary evidence which would also fully support this was inconsistently maintained. Care staff confirmed the availability of appropriate training and that they were always supported in their work by both colleagues and managers. One member of the catering staff did not have an up-to-date food hygiene certificate. Questionnaires returned to us by relatives and service users were predominantly positive in connection with the attitude and approach of staff. One respondent said “some of the staff are young and there appears to be quite a few staff changes on a regular basis, however, there is a core of older staff who have worked there a long time.” Another said “staff seem caring towards residents.” Service users spoken to at this visit were all positive about the attitude and competence of staff. Comments included “[ you can] have a good laugh with them”… “oh yes I get on well with staff” … “each resident has your own carer, you asked them to see to it which they do.” One service user responded, when asked what is the best thing about The Belmont “ … you can ask them to do things and they do (not always there and then, but they always come back).” The Belmont DS0000060734.V344034.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 and 38. Quality in this outcome area is adequate. The absence of a registered manager diminishes the ability of the home to demonstrate it is using the quality audit systems and implementing the health and safety procedures for the benefit of service users and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of this inspection visit the registered manager had been off sick for approximately twoyears. An acting manager was in post and, together with the deputy, was attempting to maintain managerial inputs and overview. The acting manager reported that she was working towards completion of the The Belmont DS0000060734.V344034.R01.S.doc Version 5.2 Page 23 Registered Manager’s Award. She also reported that she understood the registered manager may be returning to work in the near future. There was documentary evidence that quality assurance questionnaires had been sent out, at least to some relatives and healthcare professionals. Six relatives’ questionnaires had been returned, as had one healthcare professional’s questionnaire. These were briefly looked at and presented as reflecting positively on the care offered. However, the questionnaires had not been properly analysed nor was there any documentary evidence that the results had initiated an action or development plan. Money held on behalf of service users was reported as being administered by the part-time activities co-ordinator. The acting manager confirmed that in the activity co-ordinator’s absence, service users would be able to access their money via the petty cash which would subsequently be repaid. A sample of the records of monies held on behalf of service users was looked at. These records presented as predominantly appropriately kept, although there were some minor anomalies in connection with the payment of newspaper bills. These did not present as being to the detriment of the service users and appeared to be created when a newspaper bill was paid by a relative and the receipt kept with the service users financial record. Issues in connection with health and safety for service users and staff presented as being predominantly appropriately addressed. There was documentary evidence of appropriate contracts for the servicing of equipment. However, there was not always clear documentary evidence that work identified as being necessary, following a maintenance check, had actually been completed. For example, the acting manager could not confirm that issues relating to the recent inspection of the passenger lift had been done, but was able to report that the food hygiene inspection requirements had been implemented. Other areas relating to health and safety which needed to be addressed included: insufficient detail in written risk assessments for bedrails; some unprotected radiators with no written risk assessments; one chef without a current food hygiene certificate (it was reported they were to be going on a course in October 2007); staff not always encouraging service users to use the footplates on wheelchairs. All staff spoken to during this visit confirmed the availability and use of disposable gloves and aprons to minimise the risk of cross infection. The Belmont DS0000060734.V344034.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 The Belmont DS0000060734.V344034.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 Requirement In order to ensure, as far as is reasonable, that service users are not exposed to inappropriate staff, the registered person must ensure rigorous adherence to, at least, the minimum legal requirements for vetting new staff. Specifically, in addition to steps already taken, a full employment history together with a satisfactory explanation of any gaps must be obtained; a CRB (Criminal Record Bureau) disclosure or in exceptional circumstances a POVAfirst declaration must be obtained and any potentially negative issues in any reference must be explored and recorded. Timescale for action 01/11/07 The Belmont DS0000060734.V344034.R01.S.doc Version 5.2 Page 26 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 In order to ensure that service users receive a consistent service which meets their identified needs, the registered person must maintain the written care planning records accurately, fully and consistently. In order to demonstrate that service users, or their representatives, are involved in influencing the way in which their care needs are being met, the registered person should record that consultation. The registered person should develop the recording in the complaints record, including complaints which are not ‘formal’ or in writing, and follow the procedure when investigating complaints, ensuring the process is thorough and safeguards service users and staff. In order to demonstrate how the registered person is taking account of the views of service users, findings from the Quality Audits undertaken should be incorporated in an action plan and be publicised within the service. In order to protect the health and safety of service users and staff, the registered person should ensure that written risk assessments exist, which address strategies for dealing with predictable risks. In particular this related to the use of bed rails and unprotected radiators. In order to protect the health and safety of service users and staff, the registered person should ensure that staff are appropriately trained for their role. In addition to existing training this relates to food hygiene training for all staff involved in the preparation of food for service users. 2 OP7 3 OP16 4 OP33 5 OP38 6 OP38 The Belmont DS0000060734.V344034.R01.S.doc Version 5.2 Page 27 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.V344034.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!