Inspection on 19/07/05 for Belgrave House

This inspection was carried out on 19th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Belgrave House 23/01/09

Belgrave House 09/01/07

Belgrave House 01/12/05

Belgrave House 01/03/05

Belgrave House 06/12/04

Belgrave House 16/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Belgrave House School Road Terrington St John Wisbech PE14 7SE Lead Inspector Lella Andrews Unannounced 19 July 2005, 12:00 th 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 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 Stationary 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 I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Belgrave House Address School Road, Terrington St John, Wisbech, Norfolk. PE14 7SE 01945 880087 Telephone number Fax number Email 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 I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 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. Date of last inspection 1st March 2005 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 I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was unannounced and took place between 12 and 3.30pm on Tuesday 19th July 2005. The Inspector spent time discussing issues with the Proprietor and was shown around the Home. The Inspector spoke to one member of staff and one of the service users on an individual basis and then spent some time with a group of service users and staff. The system for the administration of medication was inspected. A small selection of records were also looked at. What the service does well: What has improved since the last inspection? What they could do better: The Home has maintained the good standard of care provided and has put their own quality assurance system in place so as to be able to continually monitor and highlight any areas in need of improvement. The work being carried out to alter the shared rooms into single rooms will be an improvement. Belgrave House I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 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 I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Belgrave House I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 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 standard(s) none of these standards were inspected EVIDENCE: N/A Belgrave House I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 and 10 The service users are encouraged to make decisions about their own lives and are provided with support to do so. Service users are supported to take risks as part of an independent lifestyle. Staff respect the confidentiality of information about the service users EVIDENCE: Service users said that they are able to make their own decisions about where they spend their time, what time they get up and go to bed. They also said that they all decide on menus together. The Inspector observed situations where staff asked service users for their opinion about a range of issues as they arose during the day. The Proprietor and staff know the service users well and communicated positively with them. The care plans contain guidance about how to meet current needs and also information about plans which the service user might have for the future. The care plans contain information for staff about how individual service users like to be supported and how to do this effectively. Belgrave House I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 Page 10 Risk are recognised and assessed for a variety of issues. These are recorded within the care plan and the staff are aware of these. The care plans show evidence that the risk assessments are reviewed and updated regularly. The service users are involved in decisions made about the running of the Home. They are encouraged to make their views known and staff listen and take action where possible. Service users have recently attended the same First Aid training as the staff and have achieved certificates for this. Written information is correctly stored and staff are aware of the need for confidentiality. Belgrave House I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 Page 11 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 standard(s) 11, 12 and 16 The Home aims to encourage each service user to develop their social and communication skills and to increase their independence. Service users are supported to take part in a range of activities which are mainly based in the Homes own day service but does also include accessing facilities within the community. Staff respect the service users rights and choices about how they live their lives. EVIDENCE: Service users are provided with information in both written form and in symbols to help them to have a better understanding of information which affects them. Service users are encouraged to take part in daily household tasks such as cleaning their rooms, preparation of meals and washing up. Two of the service users helped a member of staff to shop for and then prepare the vegetables for the evening meal and one of the service users was washing up. Belgrave House I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 Page 12 The Proprietor has a good understanding of the cultural needs of one of the service users and ensures that particular needs are met with regard to this area. Service users are able to go to church if they wish to do so. One of the service users has recently started work experience at two local supermarkets on a part time basis. The other service users all take part in day services which are provided in the day centre which is situated in the grounds of the Home. Staff and service users described a range of activities which take place here which includes numeracy and literacy skills, art and craft, photography, cooking, music. The Home has extensive grounds and there is a nice area outside the day centre which is suitable for playing football and cricket as well as having a patio area with seating. The Proprietor has recently provided a small hydrotherapy pool, sauna and steam room in a separate building in the grounds of the Home. The service users spoke enthusiastically about using these on a regular basis. The service users and staff did also say that they use the facilities within the local community as well. These include shops, pubs and places of interest. The Home has the use of two vehicles. Service users told the Inspector that they all go away together each year on a holiday and that this will take place in September. The philosophy of the Home is to respect each service user as an individual and to support them to develop their skills and independence. The staff are aware of this and work hard to ensure that service users are able to have control over as much of their lives as possible. Service users are encouraged to decorate and furnish their bedrooms in their own style and they said that they can spend time in their rooms if they do not want to use the communal areas downstairs. Service users have unrestricted access to all areas of the Home except for other service users bedrooms and the office. They also have access to the grounds. Belgrave House I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 Page 13 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 standard(s) 18, 19, 20 and 21 Service users receive personal support in the way that they prefer and their emotional and physical health needs are met. The medication system in use ensures that medication is stored appropriately and safely administered to the service users. The Proprietor and staff handle the illness and death of service users with respect. EVIDENCE: The care plans contain details about how individual service users like to be supported. Staff are aware of the care plans and the information kept in them. Care plans contain very detailed guidance, where relevant, with regard to supporting service users with personal care and also with behaviour which can be challenging. The emphasis is on supporting the service user with respect and dignity at these times. Staff were seen to support service users with respect and on an individual basis. Staff advised that whilst supporting a service user to get up they continue to support that person until they have breakfast rather than trying to support several service users at the same time. Belgrave House I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 Page 14 Service users said that staff are kind when helping them and that they give them good support. Service users are obviously encouraged to develop their own sense of style and to wear age appropriate clothing. The Proprietor has fitted aids and adaptations around the Home to enable service users to move around independently. One of the service users said that the stair rails are particularly helpful to them. The Proprietor is aware of the possible need for additional adaptations that may be needed as several of the service users are older and may become more frail in the coming years. The care plans contain detailed guidance about how to meet individual health needs. There is evidence that service users have regular dental and optical check ups. Records are kept of all health appointments and of any action that needs to be taken as a result of these. The care plans show evidence of the involvement of other health professionals such as occupational therapists, speech and language therapists, psychologists. The care plans show evidence of the GP having been involved in the use of any homely remedies or alternative remedies. One of the senior members of staff is responsible for the ordering of medication and records are kept of medication received at the Home and returned to the pharmacy. The medication is stored appropriately and staff receive training prior to being responsible for the administration. Currently none of the service users are responsible for their own medication. The Proprietor spoke of a service user who recently died at the Home and of the support provided to the family, service users and staff at the Home. This showed great respect for all of those involved and an awareness of the differing levels of support required. Belgrave House I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 Page 15 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 standard(s) neither of these standards were measured EVIDENCE: N/A Belgrave House I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 Page 16 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 standard(s) 24 and 30 The service users live in a homely and comfortable environment which is clean and hygienic. EVIDENCE: The Inspector was shown around the communal areas of the Home and also saw a few of the bedrooms. One of the service users showed the Inspector their bedroom which was nicely furnished and decorated with evidence that the service user had been encouraged to personalise it with pictures, photos and ornaments. The service user has a comfortable armchair which they use when watching their television or listening to music. The Home is large with a choice of three communal lounges and two dining areas. There is also a conservatory with seating. All of the service users have their own room. One of the shared rooms is used by one service user only and there are plans to alter this and another room into two single rooms and a storage room. The other shared room is in the process of being altered into two single rooms. Belgrave House I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 Page 17 A housekeeper is employed every day between Monday to Friday and is responsible for the cleaning and the laundry. The Home was clean with no unpleasant odours. Belgrave House I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) none of these standards were measured EVIDENCE: N/A Belgrave House I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 38 Service users benefit from a living in a Home which is well run by a Proprietor with a positive leadership and management approach. EVIDENCE: The Proprietor clearly knows the service users well and understands their needs. The Home has a good philosophy which the staff understand well and work towards meeting. Service users and staff said that they receive good support from the Proprietor and that he often works within the Home with the service users. Staff said that they receive good formal and informal supervision and that regular team meetings take place at which staff are encouraged to voice their opinions. Staff said that the Proprietor is always available on-call if not working in the Home. There is a formal on-call system in place which involves the Proprietor and senior care staff. Belgrave House I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 Page 20 The records seen by the Inspector are up to date, regularly reviewed and they are stored correctly. Staff are aware of the care plans and what they contain. Belgrave House I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 Page 21 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 x x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 3 x x x 3 x Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Belgrave House Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 x x x x x I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 Page 22 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 Regulation n/a Requirement Timescale for action 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 n/a Good Practice Recommendations Belgrave House I55 s27386 Belgrave House v239323 UN 200705 stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 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. 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