Inspection on 23/11/05 for Belle Vue House

This inspection was carried out on 23rd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Belle Vue House 31/05/08

Belle Vue House 29/05/07

Belle Vue House 09/05/06

Belle Vue House 30/06/05

Belle Vue House 07/02/05

Belle Vue House 29/07/04

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

CARE HOMES FOR OLDER PEOPLE Belle Vue House 1-3 Mowbray Close Hendon Sunderland SR2 8JB Lead Inspector Sharon McDowell Unannounced Inspection 10.00 23 November 2005 rd 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 Belle Vue House DS0000015705.V253885.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 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. Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Belle Vue House Address 1-3 Mowbray Close Hendon Sunderland SR2 8JB 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) 0191 567 3681 0191 565 7405 Mr Devinder Mohan Malhotra Mrs Christine Scott Care Home 32 Category(ies) of Dementia - over 65 years of age (9), Old age, registration, with number not falling within any other category (23) of places Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th June 2005 Brief Description of the Service: Belle Vue House is located on a private mews close to Mowbray Park and comprises of 3 converted Victorian terraced houses. The original part of the building is three storeys high, with a two-storey extension having been added in recent years. It provides personal care for 32 older people, 9 of whom may have dementia. The Home does not provide nursing care. Many of the original features, including large fireplaces in the lounges and some bedrooms, have been retained giving the building its character. On the ground floor there is a choice of lounges with a central dining room; a small number of bedrooms; a bathroom/WC’s and kitchen/laundry facilities. Other bathrooms/WC’s are located on the other floors. Access to other parts of the home is via a shaft lift however this is not able to reach all parts of the home where mezzanine levels have been created when the buildings became adjoined. Although the main entrance is stepped, two ramped access points are available at opposite ends of the home and enable easy access for those people with physical disabilities. The Home is located just off the main public transport routes and on the outskirts of Sunderland town centre. Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors, Mrs S McDowell and Mrs S Head, carried out this unannounced inspection. It took place over a period of six hours during which time the Registered Manager was present with one inspector while the other inspector spent time talking with residents and staff and shared lunch with them. Several documents were reviewed including three resident’s care plans, staff training records and personnel files and residents personal finance records. What the service does well: What has improved since the last inspection? What they could do better: Documentation, including resident’s care plans, health and safety and quality audit issues could be better organised to ensure easy access to information, to promote the safety of residents in the Home and to identify areas of care and services that need attention. Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 6 Care plans need to be improved to demonstrate that staff know what to do for each resident and also to satisfy legal requirements for recording of information. Whilst some improvements have been made to the Home this has been limited to those aspects that staff in the Home and the Registered Manager can do something about. Some aspects remain unsatisfactory in some areas, such as, roof repairs. Work must continue to ensure the Home is maintained to a satisfactory standard for the resident’s to be looked after in a safe and wellmaintained environment. 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. Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 7 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 Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards have previously been assessed as met therefore were not reassessed in this inspection. EVIDENCE: Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 10 Care staff work hard to ensure the resident’s needs are met. However care plans are not completed in sufficient detail to provide evidence that staff are guided in their actions to provide for residents assessed needs. There is a great rapport between care staff and the residents demonstrating that residents are looked after in a friendly, homely and family environment. EVIDENCE: Care plans are available for each resident in the Home. Care manager assessments are available, demonstrating the assessed needs of the residents before they are admitted to the Home. In one care plan for a resident who had been recently admitted to the Home, little information had been entered about them despite risks being identified in the care management assessment about them being at risk of developing pressure areas, urinary tract infections being at risk of falls and having nutritional concerns due to them not eating very well before they came to live at the Home. There was no social care plan even though the Registered Manager advised that the resident had a problem with coming out of their room to socialise, therefore was at risk of social isolation as they had little or no contact with relatives or friends. Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 10 Another care plan was informative about the residents needs but had not been updated for seven months. This resident was giving great cause for concern to staff due to changes in their mental health but the written daily notes contradicted want staff were saying on the day as the notes conveyed there was no problem. Staff assist residents with personal care tasks in the privacy of their own bedrooms or in bathrooms. All residents looked well care for and well turned out with clean, matching clothing, tidy hairstyles and attention paid to personal hygiene such as finger nails being clean and trimmed. Staff are attentive and address residents in the manner they have indicated they would wish to be known as. There is an obvious rapport between residents, staff and the Registered Manager as they speak fondly to each other and enjoy health banter about the care provided in the Home. Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Staff support residents to remain independent so that they can continue to make decisions and choices about their daily lives. EVIDENCE: Residents are able to go about the home as they please and can request the help of care staff if needed. Meals are served at set times although breakfast is served over a period of time, seven-thirty to ten ‘o’clock, so that residents can have some choice as to when they are ready to get out of bed. One resident likes to get up at eight ‘o’clock and come down to the dining room for breakfast before they get washed and dressed. A choice of meals if offered and a range of drinks and snacks are available throughout the day. Therefore residents can choose from a variety of food and drinks. Visitors come and go to the Home and residents can choose whether to see their visitors in communal rooms or in the privacy of their bedrooms. Residents are encouraged to manage their own money where they can, if they are unable to do so, then families are asked to take this responsibility. If this is not possible then the Registered Manager will help residents with their finances so that they always have access to their money. Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 12 Some comments by residents included ‘it’s like The Ritz’, ‘they let me go my own sweet way’ and one resident was happy that they could ‘have a tipple’ as they enjoyed a drink of sherry. Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Complaints are managed in a manner, which ensures residents and relatives can be assured their views and concerns will be listened to. Staff are aware of Protection of Vulnerable Adults procedures therefore residents and relatives can be assured correct action will be taken in the event of harm occurring to a resident in the Home. EVIDENCE: The complaints procedure is available within the service user guide and is displayed in the home so that residents and visitors know what to do if they are concerned about anything in the Home. No complaints have been made at the Home and none have been made to the Commission for Social Care Inspection. The Registered Manager is very visible and residents appreciate being able to speak with her, which means she is easily accessible for residents and visitors to discuss any issues and to have them readily resolved if there are any concerns. The majority of staff have attended training in Protection of Vulnerable Adults. There have been some difficulties in accessing training as the training provider suspended training in this subject for a short time. The Registered Manager has a comprehensive package of information in the Home on Protection of Vulnerable Adults, which is given to staff when they start working at the home so they have information at the very beginning of employment. The local procedures for alerting suspected and actual harm to residents is available in the Home so that staff have a guide as to whom to contact to inform of such incidents. Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The only progress in the Home has been due to the efforts of staff in the Home otherwise no progress has been made to address outstanding environmental issues in the Home. There are areas, which need to be attended to so that residents and their relative’s can be assured that the Home is a safe and well maintained. EVIDENCE: This standard was reviewed at the previous inspection however it is noted that a significant effort has been made by staff in the Home to improve the hairdressing room so that residents have a pleasant place to go for their hair to be done and this could become a social meeting place. The Registered Manager has recently completed a course in care of people with dementia, which she said has made her more aware of the need to design the environment to enable people with this condition to maintain some independence. The Home currently has no adaptations to help people with dementia get around the Home or to recognise any areas, such as their own Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 15 bedrooms, toilets and bathrooms. Advice was given about dementia organisations and how to access information on the Internet. Outstanding issues from the previous inspection include: - Wall mounted heaters in some of the bedrooms on the second floor might contravene fire and health and safety guidance. - Lighting levels are poor in some areas of the Home. - An environmental audit has been previously carried out but has not been implemented on a regular basis therefore issues might not be highlighted or followed up. - Further repair work has been carried out to the roof but there are still problems with water leaking in when raining. - During the last inspection the Registered Provider advised there was to be a new carpet fitted to the lounge and hallways, which will improve the general appearance of the Home. However this has not been done. The Home remains very clean, tidy and reflective of the people living there. Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 Staff have now attended fire safety training so that residents safety is promoted in the event of a fire in the Home. EVIDENCE: In response to the previous inspection the Registered Provider allocated a staff member from another one of his homes to come to Belle Vue to provide fire safety training for the staff. Initial fire training was delivered in July to August this year with a view to implementing it three monthly to ensure all staff attend the required number of fire training sessions. Certificate from the trainer are available in staff personnel records. Advice was given how to implement a training matrix so that it was easier to see when staff were due to attend training in a range of subjects, particularly health and safety matters. Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 Resident’s finances are managed in a fairly robust manner however some aspects of audit do not fully safeguard their financial interests. EVIDENCE: Residents have an individual book for recording of their personal finances. This book is quite small therefore it was difficult to read some of the information therefore balance figures could be misinterpreted. The Registered Manager said she did conduct audits of the books and cash however this is not done regularly and it is not indicated in the cashbooks when an audit has been carried out. Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 18 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 2 X X X Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Residents care plans must include sufficient information to enable care staff to meet their needs. (Previous timescale of 31/05/05 and 30/11/05 not met) Repairs to the roof must be of a satisfactory standard to prevent water ingress to the building. (Previous timescale of 30/11/05 not met) Environmental issues identified in the body of this report must be addressed and specific timescales for completion of work submitted to the Commission for Social Care Inspection. Lighting must meet the recognised standard of lux 150 in all areas used by residents. (Previous timescale of 30/09/05 not met) The quality audit system must continue to be implemented in a systematic and robust manner. The Registered Manager must ensure that written evidence of audit of resident’s finances is documented appropriately. DS0000015705.V253885.R01.S.doc Timescale for action 31/03/06 2 OP19 16, 23 31/03/06 3 OP19 16, 23 31/03/06 4 OP25 16, 23 31/03/06 5 6 OP33 OP35 35 35 31/03/06 23/11/05 Belle Vue House Version 5.0 Page 20 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 OP9 OP19 Good Practice Recommendations Consideration should be given to relocation of the medication storage room to a more accessible area of the Home. The Registered Manager should consult the fire authority for safety advice about the wall-mounted heaters in 2nd floor bedrooms. Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Belle Vue House DS0000015705.V253885.R01.S.doc Version 5.0 Page 22 - 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. 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