Inspection on 23/01/09 for Belgrave House

This inspection was carried out on 23rd January 2009.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Belgrave House 09/01/07

Belgrave House 01/12/05

Belgrave House 19/07/05

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 18/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Belgrave House School Road Terrington St John Wisbech Norfolk PE14 7SE     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Alan Buttery     Date: 2 3 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 21 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 21 Information about the care home Name of care home: Address: Belgrave House School Road Terrington St John Wisbech Norfolk PE14 7SE 01945880087 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr Mukesh Bouri care home 12 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: 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 Brief description of the care home Belgrave House is a care home currently providing care for ten 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 currently has twelve single bedrooms. Some bedrooms have ensuite bathrooms whilst others have handbasins within the room. There are three lounges, dining room, kitchen, toilet and bathrooms. The laundry is Care Homes for Adults (18-65 years) Page 4 of 21 Over 65 3 12 Brief description of the care home 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. Care Homes for Adults (18-65 years) Page 5 of 21 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced visit, and on the day of the inspection we spent around 3 hours at the home, talking to care staff and residents, and looking at some of the records within the home. The proprietor of the service was not in the home on the day of our visit, and some records were locked away and not available for us to look at. Staff on duty were able to assist with information and experiences they had, and we looked at some of the individual care plans for people living in the home. Care Homes for Adults (18-65 years) Page 6 of 21 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 7 of 21 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 8 of 21 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Procedures are in place to ensure that anyone moving into the home would have their needs fully assessed before moving, and would be confident that these needs can be met Evidence: Although registered for up to 12 residents, the service presently has ten people living in the home, and there have been no new admissions since our last visit. Procedures are in place to manage any new admissions, and these were discussed with the staff members working on the day of our visit. The process would include a full assessment of need and visits to the service, and evidence was seen on three files that we examined that this process has been followed in the past. The Statement of Purpose and service user guide are now in a format that the people living in the home are able to follow, and staff are available to help people read through the documents. Care Homes for Adults (18-65 years) Page 9 of 21 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individual plans are in place that show how the identified needs should be met, and how this suits the individuals they relate to, Evidence: The service has individual plans in place, and three of these were looked at during our visit, and discussed with one of the senior care staff who takes responsibility for auditing the plans. The staff members checks the plans on a regular basis, organises reviews, and ensures that individual key workers make any required changes to the plans. The plans that we looked at contained information about the person, with details of their background and their likes and dislikes. Staff we spoke with during our visit advised that this information has been gathered mainly from family members. The plans cover identified health and social care needs, and include details of family Care Homes for Adults (18-65 years) Page 10 of 21 Evidence: contact. The individual plans are kept under review, as indicated above, and contain a record of significant events and activities. We were unable to see some of the reviews documents as they are kept separately and were locked away Care Homes for Adults (18-65 years) Page 11 of 21 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. a range of activities are available within the home offering people who live there a range of things to do, and they are encouraged to visit local facilities. Evidence: The service provides a range of activities for the people living in the home, with a large separate building on site which is used to provide a day service. On the day of our visit, 2 residents were at a day service in Kings Lynn, one was out shopping and another out to lunch. The remaining people were in looking at magazines, listening to music or helping with some cookery. Later in our visit, staff were helping the residents with various activities, and we Care Homes for Adults (18-65 years) Page 12 of 21 Evidence: observed in the way they interacted with the people they were supporting, which was very positive. We spoke with three of the people living in the home, who appeared settled, and happy with the activities they were able to do. We were advised by staff that other activities include swimming (the service has its own hydrotherapy pool), trips to the cinema, lunches out, holidays and day trips. The staff all contribute to cooking meals for the people in the home, who often assist with the meals. A range of freshly cooked food is provided, with fresh fruit and vegetables, and a record of meals served was seen during our visit. Care Homes for Adults (18-65 years) Page 13 of 21 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Individual plans include the health needs of the people living in the home which are met in a manner suited to the individual. Evidence: As indicated earlier, the individual plans details health and social care needs, and these were seen during our visit. People living in the home have a range of health needs, and these are met by the service with support from local health professionals. The people living in the home are all registered with the local GP practice, and receive support when needed from the district nurses based there. Procedures are in place to ensure medication is administered safely and staff that are involved with the administration all receive suitable training, and this was discussed with three members of staff. If any new residents were able to manager their own medication, this would be supported, and risk assessed to ensure it was a safe action to take Care Homes for Adults (18-65 years) Page 14 of 21 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home are aware of who to speak to with concerns and procedures are in place to ensure that any concerns, complaints or allegations are dealt with appropriately. Evidence: Everyone living in the home has a copy of the complaints procedure, and it is available in formats suited to the communication needs of the people living in the home. they are aware of who to speak with if they have any concerns, and care staff discuss his with the residents to ensure they are happy with the arrangements. The service has a safeguarding policy , in accordance with local procedures, and all staff receive training in safeguarding matters. In the past year, there have been no concerns or safeguarding issues raised. Care Homes for Adults (18-65 years) Page 15 of 21 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is set in an attractive home, which offers safety and comfort to the people living there. Evidence: The home provides a comfortable and homely environment for the people living there. Communal space is good, with a large lounge and a dining area with a large conservatory. In addition there is a large day centre, and a hydrotherapy pool and both are well used by the people living in the home, with support. The individuals living in the home all have single rooms, and some of these were seen during our visit. The rooms are well equipped, with personal items in evidence. The home is set in pleasant grounds, within easy reach of local facilities. Care Homes for Adults (18-65 years) Page 16 of 21 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. These standards were not fully assessed as the information was not available on the day of our visit Evidence: A full staff team is in place to assist in supporting the people living in the home, and during our visit we spoke with three staff members, who explained the recruitment procedures they had followed. They also said that they receive supervision every 3 months or so, however the proprietor was unavailable when we visited, and we were therefore unable to examine any staff records, as these were locked away. The staff we spoke to told us of the training they had been on, and this appeared good, but did say that supervision did not happen very often, every 3 to six months. As a result these standards were not evidenced. The judgment is based on that made at the last inspection Care Homes for Adults (18-65 years) Page 17 of 21 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well run, in the interests of those living there, and staff and resident are protected from risk by the health and safety procedures in place. Evidence: The proprietor of the service manages the home, and is experienced and well qualified, and appears well regarded by the staff working in the home. Procedures are in place to ensure that money is carefully managed on behalf of the people living in the home, and were explained by staff members. All the required policies and procedures are in place, and health and safety measures ensure that people living and working in the home are not at risk, and suitable training is provided to all staff. Care Homes for Adults (18-65 years) Page 18 of 21 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 19 of 21 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 6 36 care plans and reviews should be signed by the person completing them. Staff should be supervised on a more regular basis. Care Homes for Adults (18-65 years) Page 20 of 21 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 21 of 21 - 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!