CARE HOME ADULTS 18-65
Belgrave House School Road Terrington St John Wisbech Norfolk PE14 7SE Lead Inspector
Mrs Lella Andrews Announced Inspection 1st December 2005 10:00 Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 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 Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Belgrave House Address School Road Terrington St John Wisbech Norfolk PE14 7SE 01945 880087 07768384301 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) Mr Mukesh Bouri Mr Mukesh Bouri Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (3) of places Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home may accommodate up to three people aged over 65 within its registered numbers. The total number accommodated not to exceed 12. 19th July 2005 Date of last inspection Brief Description of the Service: Belgrave House is a care home currently providing care for eight adults with learning disabilities. The home is owned by Mr. Mukesh Bouri and was first registered in August 1984. Belgrave House is located in the village of Terrington St John and is within walking distance of local shops and community facilities. The home has transport to enable access to larger local towns. The home has eight single bedrooms (two with en-suite facilities) and two shared bedrooms (one with en-suite facilities). Bedroom accommodation is provided on the first floor. There are three lounges, dining room, kitchen, toilet and bathrooms. The laundry is situated on the first floor. The proprietor has recently completed the development of a hydrotherapy pool and sauna. Within the grounds of Belgrave House is a day care building which service users attend on a daily basis. This facility is solely for the use of people who live at Belgrave House. The grounds of Belgrave House are well maintained and have been landscaped to provide space for leisure and relaxation. Its situation offers pleasant views over the fenland landscape. Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This Inspection was announced and took place between 10am and 3.20pm on Thursday 1st December 2005. The Proprietor was available throughout the Inspection to provide information both verbally and in the form of records. The Inspector spoke to two members of staff on an individual basis and spent time in the day centre talking to residents. Completed comment cards were received from four relatives and three visiting professionals. These all contained positive comments. What the service does well: What has improved since the last inspection? What they could do better:
There is a need to update the procedure relating to the protection of vulnerable adults There is a need to ensure that all staff have up to date training with regard to Food Hygiene
Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 6 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. Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The Home has a suitable format for the assessment of prospective residents. EVIDENCE: The residents have all lived at the Home for several years. The Proprietor has an admissions procedure which includes a written format to record the assessment process. Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 The care plans contain detailed guidance for staff about how to meet the residents needs. EVIDENCE: Two of the care plans were seen and these contained detailed information about how to meet the residents individual needs. Assessments and notes of reviews are held within the care plans. There are individual risk assessments and detailed plans for specific care needs. The staff are aware of the content of the care plans. The care plans contain evidence that the resident themselves, other professionals and relatives are involved in the care planning process wherever possible. Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 15 and 17 Residents are supported to use local facilities within the community Residents are supported to maintain relationships with relatives Residents are offered a healthy diet and spoke highly of the meals EVIDENCE: All, except one, of the residents living at the Home are over the age of 50 and some are becoming more frail due to increasing age. The Home has a day centre in its grounds which is solely for the use of the residents living at the Home. The residents all spend time there between Monday to Friday. One of the residents has work experience at local supermarkets for two days per week. The Proprietor is aware of the need to constantly review the activities that the residents take part in due to their increasing age and possible changes in individual likes and dislikes. Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 11 The staff and residents told the Inspector about a recent holiday in which they all took part and enjoyed greatly. Residents also told the Inspector that they have been Christmas shopping and will be going to the Pantomime soon. Two of the residents walk to the local shop to buy a newspaper on a daily basis. Residents accompany the staff when doing the food shopping locally. The Home is situated in a small village but does have vehicles available so that staff can support residents to access facilities in the towns of Peterborough, Kings Lynn and Wisbech. Only a few of the residents have any contact with relatives but those who do are supported by the staff to maintain this contact. One of the care plans showed that there is regular contact, by phone and letter, between the Proprietor and the relatives of one of the residents. Four completed comment cards were received from relatives and these all contained positive responses about the Home. They all stated that they are kept informed of important matters affecting their relative. Three of the comment cards contained additional comments praising the Home for the high standard of care provided to their relative. The staff are responsible for cooking meals and the residents are involved in all stages of the process ie. Shopping, cooking, laying tables and washing up. The residents have lunch at the Day Centre during the week and on occasions may go out for lunch. Staff were heard asking residents what they wanted to have to eat and drink at lunch time. One of the residents helped staff make sandwiches whilst another set the tables. The staff are aware of the dietary needs of the residents and, in particular, the three residents who have specific needs. One of the care plans seen included information about the residents dietary needs. Residents told the Inspector that they enjoy their meals and that the staff know what they like. Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were measured EVIDENCE: N/A Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Some of the residents are aware of the complaints procedure which is available in symbol format as well as written Staff receive appropriate training with regard to the protection of vulnerable adults. There is a need to update the procedure so that it reflects the practice in Norfolk for action following an allegation of abuse EVIDENCE: The complaints procedure is available in symbol and written format and is displayed around the Home. Two of the residents told the Inspector that they would tell staff or the Proprietor if they were not happy with something. Some of the residents have communication difficulties and it is hard to assess whether they would be able to raise any concerns on their own behalf. Residents meetings take place twice a year and these are usually attended by an independent visitor who, the Proprietor advised, takes on an informal advocates role. Staff receive training within their induction period about the protection of vulnerable adults and both of the staff who spoke to the Inspector were aware of issues relating to abuse and were confident that the Proprietor would deal with any allegations appropriately. Staff said that this issue is regularly talked about at staff meetings and that written information is available which they are encouraged to read. The Proprietor has recently attended a seminar organised by the Adult Protection Unit and staff are due to attend training updates over the next month.
Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 14 It is required that the procedure relating to the protection of vulnerable adults is updated so that it reflects the current practice in Norfolk for action to be taken following an allegation of possible abuse. The Inspector looked at the financial records kept for two of the residents. These were detailed and it was possible to cross reference the record with receipts kept for expenditure. The Proprietor is the appointee for all of the residents. The residents have their own named building society accounts which the Proprietor, and the deputy Manager, are named signatories for. The Proprietor said that one of the residents uses their Disability Living Allowance to pay for a Motability car. The records for this were not checked on this occasion. Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were measured EVIDENCE: N/A Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 16 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Residents are supported by a staff team who receive appropriate training and support to carry out their roles effectively The Proprietor carries out appropriate recruitment procedures Staffing is provided in adequate numbers EVIDENCE: Staff who spoke to the Inspector are knowledgeable about the needs of the residents and are enthusiastic about their job. Staff were seen and heard to work with residents in a positive and relaxed manner. Residents told the Inspector that they like the staff and that they are kind and caring. Two of the completed comment cards particularly praised the staff team. Two of the recruitment files were seen and these contained the necessary paperwork. Staff said that they had completed an application form and that they had attended for an interview, prior to references and a CRB disclosure being applied for. The Proprietor is in the process of reviewing the induction programme in light of the review of Induction and Foundation standards by Skills for Care. Staff said that their induction had been thorough and effective. The staff do not follow the LDAF induction/foundation but this is acceptable as the induction
Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 17 that they do follow contains units about communication and working with people with a learning disability. Staff receive regular formal supervision from the Proprietor and records are kept of this. They also said that the Proprietor spends a lot of time at the Home and is always available to provide advice and support. The Proprietor himself usually carries out induction for new members of staff. Staff meetings take place on a regular basis. Records of staff training are kept and these were seen for two of the staff. Staff receive training in appropriate mandatory subjects such as Fire Safety, First Aid, Moving and Handling and Food Hygiene. It is recommended that the Proprietor ensures that all staff have up to date Food Hygiene training as some staff have not updated this recently. All staff are either undertaking or registered to undertake NVQ Level 2 or 3 training. The usual staffing arrangements are for there to be two members of staff on duty each morning and afternoon with additional staff on duty to enable residents to take part in particular activities. The rota indicates that the Proprietor is in the Home for four days of the week but he said that he is often in the Home for seven days a week and is available for support and advice at all times. The rotas show that additional staff are on duty if needed for specific activities. The Proprietor has recently increased the domestic hours provided in the Home so that there is now a member of domestic staff on duty at the weekend as well as between Monday to Friday. Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Residents benefit from a well run Home The Home has a quality assurance process which regularly monitors the service provided The health, safety and welfare of residents and staff are promoted and protected EVIDENCE: The Proprietor knows the residents well and understands their needs. The Home has a good philosophy which the staff understand well and work towards meeting. The Proprietor is working towards NVQ Level 4 and the deputy Manager is shortly going to undertake some Introduction to Management training. The Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 19 staff said that they receive good support from both the Proprietor and the deputy Manager. The Proprietor undertakes an annual review of the service provided and this covers all areas of the service. This process includes questionnaires sent to relatives and some of the comments on those returned are: “…first class staff….” “…can’t think of anything to improve.” All of the questionnaires rated all aspects as A which equates to “very satisfied”. It is recommended that the annual quality assurance report contains an audit of all of the monitoring that takes place during the year and an audit of the returned questionnaires. The deputy Manager takes responsibility for ensuring that the routine health and safety checks are undertaken. Records of these were seen and included monthly hot water checks, vehicle maintenance checks, service certificates for fire safety equipment and risk assessments. Staff said that they receive health and safety training within their induction. The Home employs a maintenance member of staff who undertakes some of the health and safety checks as well as undertaking maintenance tasks. The Home has a health and safety policy. Accidents are recorded appropriately. Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Belgrave House Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000027386.V260263.R01.S.doc Version 5.0 Page 21 no Are there any outstanding requirements from the last inspection? 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 23 Regulation 13 (6) Requirement It is required that the protection of vulnerable adults procedure is updated to include the action to be taken following an allegation of possible abuse Timescale for action 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard 32 39 Good Practice Recommendations It is recommended that the Proprietor ensures that all staff have received updated Food Hygiene training It is recommended that the Quality Assurance report contains an audit of the monitoring of individual aspects of the service Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Belgrave House DS0000027386.V260263.R01.S.doc Version 5.0 Page 23 - 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!