CARE HOMES FOR OLDER PEOPLE
Belle Vue House 1-3 Mowbray Close Hendon Sunderland SR2 8JB Lead Inspector
Sam Doku Key Unannounced Inspection 29 May 2007 10:00 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.V338476.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 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 (15), Old age, registration, with number not falling within any other category (17) of places Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 30th January 2007 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/WCs and kitchen/laundry facilities. Other bathrooms/WCs 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. The scale of charges for the home is between £359.00 and £374.00 per week. Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was conducted over two days and involved one inspector. The inspection visits took place on the 29 and 30 May. Pre-inspection questionnaires were sent to the manager to be completed but these had not been returned to the Commission in time for the inspection. It has therefore not been possible to use the information requested for in the questionnaires to prepare for the inspection. The information that needed to reach the Commission before the inspection had to be obtained during the inspection visit. The home is well equipped with aids and adaptations suited to the client group’s age and disabilities. The home has sufficient communal spaces on both floors to meet the needs of the current service users on both floors of the home. The home is quite popular with service users and their families, and there is a great deal of involvement by the local community. This inspection process involved talking to service users, visitors, sitting in the lounges and observing staff interaction with the service users, discussions with the Manager and care staff, tour of the house, examination of health and safety records and service users’ personal file including care plans. The atmosphere in the home was calm and peaceful and service users and relatives were able to express their views freely to the inspector. In order to assess the quality of care provided for the individuals, the inspector selected four service users to examine their records including their care plans. The quality of staff training, recruitment and supervision were also examined. Three staff files were examined in order to make this assessment of staff recruitment and training. What the service does well:
Staff continue to support and encourage service users to access a wide range of activities and community facilities. One service user commented that, “the staff take me into town when I ask for it”. To further promote this, the staff of the home raised money through various events to purchase a minibus for the home to be used for the benefit of the service users. The staff provide care regime that empowers the service users and respects their right to independence. This was evidenced by the efforts of the staff to support one service users whose interest in gardening was maintained by providing him with a greenhouse to allow him to continue to enjoy his hobby.
Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 6 Staff also support and encourage people who live at Belle Vue to maintain contact with friends and family inside and outside the home. One relative commented that, “you are always made to feel welcome here and it makes you want to visit more”. The service users healthcare needs are met and the home keeps records of the care people receive from healthcare practioners. The home has a warm and friendly atmosphere. Staff work hard in the home and have good awareness of service users needs. The manager and the staff team put a lot of effort into making sure the home is run in the best interests of the service users and comments about members of staff and the care provided include: “I am glad I chose to come and live here. I am so proud of this place I always talk about it people”. “They always have time to talk to you. They are never too busy.” “There is always plenty to eat and the food is really good here”. “The staff are kind and supportive”. In discussions with service users, it was evident that the home provides good choice of home cooked meals on a daily basis and the service users and relatives appreciate this. The home had developed a very good and practical risk assessment for some of the service users. This is in pictorial format and indicates GO, CAUTION and STOP signs indicating a person’s ability to undertake certain tasks, especially in health and safety matters. The home has the ability to adjust the to suit the service users. For example, at one time the needs of the service users were such that the manager changed the start time from 08:00 a.m. to 07:00 to in order to meet the needs of the service. This was reverted back to 08:00 when the situation settled. The home operates in a way that ensures that individual preferences are catered for. For example, the arrangements for breakfast are organised to meet the needs of those who prefer to have breakfast in, others like to have theirs soon after the rise before getting ready. The manager, staff and service users confirmed this flexibility and attention to individual preferences. Consequently breakfast is from 07:00 a.m. to 10:00 a.m. Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4, 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home maintains its policy on receiving full assessment by a social worker before a service user moves into the home. The home also carries out their own assessment before admission is arranged. This allows the staff to decide if the person’s need can be met. It also provides confidence in the service users and their relatives that the home is capable of meeting their needs. Service users are invited to visit the home and to meet staff and other service users before deciding on coming to live in the home. This arrangement gives people who want to come and live in the home the opportunity to have a feel for the place before moving in. Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 10 EVIDENCE: The home adheres to its policy on receiving assessment from the care manager before admission is arranged. It is also the home’s policy carry out their own assessment to make sure they are able to provide the care that the person requires. Such assessments are carried out in the person’s own home or in the setting where they are living, such as hospital or another care home. Service users files show that the home follows it policy by obtaining assessments from social worker and also undertaking their own assessments. These assessments form the basis for the planning of care for the individuals. However, the assessments carried out by the home and the care plans that follow must be reviewed to ensure all information relating to a persons needs, wishes and aspirations are gathered to ensure these are incorporated into the care plans. It is the policy and practice in the home for prospective service users to be invited to visit the home before admission is arranged. The first six week of residence is regarded as trial period. However, examination of one record relating to a privately funded service user shows that the company had no written contract with the service user. In another case, the contract was signed on behalf of the company by a senior care assistant and by the service user, but there was no witness signature. The amount payable by the service user was not stated in the contract. This is poor practice and must be addressed to ensure that both the service user and the company are clear about their role and responsibilities. The home has a Service User Guide in place, which is issued to each prospective resident upon admission. The guide provides information about the type of care and support a person will expect to receive upon admission into the home. This has also been developed in a large print format, which is accessible to people with visual impairment. Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users healthcare needs are fully met. However, the care plans which, set out the healthcare and personal care needs of the service users do not reflect the care that the service users are receiving. This does not ensure consistent approach to individual care. The home has good procedures in place for the safe administration of medicines. This promotes and health and welfare of the service users. Service users are treated with respect and dignity and their right to privacy is upheld in the home. Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 12 EVIDENCE: Since the last inspection, there had not been any significant development in the quality of the care plans for the service users. The care plans lack detailed information about the care needs of the individuals. Although it is evident that the service users healthcare and personal needs are being met the care plans do not reflect the care that is being provided. In order to provide a consistent approach to individual care programmes, the manager must ensure that effective and workable care plans are formulated, and is followed by all staff. The care needs of one service user who was confined to bed was examined. It was noticed that fluid balance chart and the diet intake chart have not been kept up to date. There were days when these had not been completed. For example, on the fluid chart, there were three out of seven days when no recorded intake of fluid was reported. In the case of the diet sheet, in one out of seven days, nothing was recorded, and no reason was given why this was the case. The care plans generally lack information about the individual’s persons social or emotional needs. A lot of the information were not specific enough and often repetitive. Evaluations for the service users care plans do not always give enough information about how the care plan is achieving its stated objectives. Some care plans have not been reviewed for a long time even though dates have been set to review them, these have not been followed. All the service users have access to healthcare related professionals and records show that regular visits by GP’s, Opticians, the district nursing service and Chiropodists. Staff also record any changes in a persons health or wellbeing in daily report book where staff will take steps to contact the relevant professional if necessary. The manager and the senior staff are responsible for the administration of medicines in the home. Since the last inspection, considerable improvements have been made to administration and management of medicines in the home. Random checks of medicines were undertaken by the inspector and no discrepancies were noted. Service users and visitors confirmed that the staff treat them with respect and dignity. Service users also confirmed that they are supported in ways that promote their independence. Personal tasks are always carried out in a discreet and respectable manner. Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service Service users are supported and encouraged to maintain close relations with the friends and families. Visiting times are flexible and unrestricted, which encourages people to visit regularly, thus promoting regular contacts with families and the community. Staff provide the opportunity for service users to exercise control and choice which promote independence and self-determination. The service users are offered an excellent variety of wholesome and nutritious meals in comfortable and pleasant surroundings, which promote health and well-being. Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 14 EVIDENCE: The positive comments made in the last inspection report regarding daily life and social activities are repeated here as the home continues to maintain this set of standard extremely well. The home continues to maintain a flexible approach to social and recreational activities in the home. The manager, staff and service users confirmed that activities are very often carried out spontaneously and sometimes these come as a request from the service users. Activities generally include arts and crafts, dominoes and sometimes the home has entertainers coming into the home. Some service users regularly go for a bus ride in the mini bus. One service user commented that there is always something for them to do. “Sometimes just talking to the girls is good enough”. The staff did a number of fundraising activities to purchase a mini bus for the home. Other activities include clothes parties, pie and pea super and sing a longs. The home has good links with the local community and has occasional visits from local schoolchildren and entertainers. Relatives and visitors are welcome at any reasonable time throughout the day and evening. A lot of service users have visiting relatives on a regular basis. Visitors will usually meet with their relatives in the privacy of their own room or in the homes lounges or dining room. The manager and staff confirmed that beverages and snacks are always available for visiting relatives. Service users said that they are able to get up and go to bed when they choose thus promoting their independence. Everyone is encouraged to move freely around the home, and given assistance to keep links with the local community, families and friends. Mealtimes are flexible and relaxed and residents are offered a choice of healthy and nutritious meals. The home has in a place a 4 weekly menu, which is planned with service users. Meals are generally served in the homes dining room, which is nicely decorated and benefits from plenty of space to enable staff and service users to sit together and enjoy their meals. If service users prefer not to eat in the dining room staff will support them to have their meals in their preferred area. Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives have information about how to make a complaint and are confident that any complaints will be acted upon by the management, thus promoting their right to complain about the service if they feel they need to. All Staff are aware of the Protection of Vulnerable Adults procedure, and suitable training in protection of vulnerable adults has been provided. This protects the service users from abuse. EVIDENCE: The home has a complaints procedure and copies are freely available in the home. Service users and relatives are aware of the procedure. A copy of the complaint procedure is also included in the homes Service User Guide. Two relative and a service user stated that if they have any concerns they would know how to go about complaining to the manager. The two visitors said they have never had the need to complain but they feel confident that the manager would deal satisfactorily with any concerns they may have. Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 16 Majority of the staff members have received training in Protection of Vulnerable Adults procedures. The manager has plans in place for the remainder of staff to complete training to ensure all staff have awareness of procedure to follow in the event of abuse. The home’s complaints procedure is in line with the City of Sunderland Safeguarding adults procedures. Staff showed understanding of the complaints procedure and knew what to do if they observed any incident that could be considered as abuse. There is a system for recording complaints received. Since the last inspection there has been no complaint received. Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users live in an environment, which is generally well maintained, clean and comfortable. However, continuous attention to wear and tear in some parts of the building should be addressed. EVIDENCE: The home is an adapted properly which has been converted to accommodate older people, some of whom may have mobility problems. Access into the home is generally good and meets the needs of those service users who have mobility problems. However, the narrow corridors and the number of internal doors along the corridors, especially on the first floor make access for people with severe mobility problems difficult. The structure of the house and the limitations make it difficult for service users on the first floor to freely wonder.
Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 18 There are specialist bathing facilities and shower rooms to meet the need of all the service users. Some of the service users room have en-suit toilet facility. During the inspection it was noticed that access to the toilet were limited by the placing of “Wet Floor” signs at the entrance of the toilet doors. This practice must cease as it prevents service users from spontaneously accessing the toilets when they need it. The home is close to local shops, other amenities, and to local transport routes. These have provided the opportunity for service users to continue to exercise independence and choice and to access to community facilities. Window restrictors have been fixed to all windows and all radiators have suitable covering. All the servicing records are up-to-date. These include lift servicing, water treatment, fire safety equipment, gas servicing and other maintenance. The home has written policies and procedures relating to safe handling of hazardous materials for staff to follow. The manager indicated that staff have had training in health and safety, infection control and food hygiene. The home is clean and free from offensive odour. The laundry machines have facilities for sluicing and washing foul linen at very high temperature to avoid the spread of infection. The above safety measures, practices and policies ensured that service users live in safe and comfortable environment thus promoting their welfare. Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has an effective and flexible staff team, which is sufficient in numbers and skilled to support service users needs. The home has good recruitment procedures in place but this is not always followed. This practice, potentially compromises the safety and wellbeing of the service users. Members of staff receive regular training opportunities that ensure service users are appropriately supported and protected. However, the procedures for the induction of new staff into the work place must be properly documented to ensure any new carer is deemed competent to carry out their duties unsupervised. Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 20 EVIDENCE: Examination of past rotas show that the home provides sufficient numbers of staff on duty throughout the day and night to meet the needs of the service users. The manager described the recruitment process and stated that any all newly appointed staff have two satisfactory references taken before they commence work. She confirmed that all staff have had enhanced Criminal Records Bureau (CRB) clearance and POVA register checks. Three staff files were examined. All three staff have had enhanced CRB done. In one case there was only one reference. This is contrary to the company’s recruitment policy. All staff have had the mandatory training although it was noticed that only seven of the current staff have valid food hygiene training. The record of staff training is poorly documented and the manager needs to retain evidence of the training that staff have received. Of the three files examined two had no record of evidence regarding the induction they received. Staff do not receive regular three monthly and six monthly fire safety instructions as required. The manager was advised of this and the Fire Safety Officer of the local fire brigade was contact during the inspection about his advice. This advice was passed on to the manager. Three staff files were sampled and one file included an induction checklist, which was not complete; two files did not include any evidence of induction training after the members of staff commenced in post. The manager confirmed that an induction is carried out for each new member of staff however documentation did not support this. The Manager needs to review the way staff training records are kept and develop a plan that will clearly identify the areas of training received and the areas where training is needed. Discussions around developing a training matrix and reorganising staff files were held with the manager. Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is not following the company quality audit systems that would ensure regular monitoring and review of all aspects of the care and procedures in the home. This has resulted in lapses in some aspects of management of the home. There are good systems in place to safeguard the finances of the service users. Staff work well to maintain a safe environment and protect service user’s safety and well-being. Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager has a long experience of working and a care home. She is well experienced and competent to run the home to met its stated purpose, aims and objectives. However, as noted in the last inspection report, there are a number of areas identified throughout this report that needs action to ensure the manager is fulfilling her responsibilities, particularly in relation to setting out workable care plans, reviewing care plans, staff supervision and following the company’s recruitment procedures. All staff have received statutory training in health & safety matters, including Fire Safety, Infection Control and Emergency First Aid however day and night staff do not receive regular three and six monthly training in fire safety instructions. The company’s Health and Safety policies remain in place. These cover policy areas such as fire prevention and Care of Substances Hazardous to Health (COSHH). Servicing records confirm that all portable appliances have been tested. A record is maintained of regular water temperature tests in the home. Regular servicing of fire equipment, gas and electrical appliances have been carried out by the contracted companies. All the servicing records that were examined were up to date. These included servicing of hoists, water treatment, electrical installation and gas servicing. Up to date servicing and maintenance of these services and equipments ensure a safe environment for the service users and the staff who work there. The home is clean and tidy and suitable cleaning procedures are in place to ensure that the home remains free from odour. The home is kept generally clear of hazards to the health and safety of service users, visitors and staff. The home keeps service users’ personal allowances in a locked safe. Records of all transactions are kept along with receipts. Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 23 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 2 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 2 3 X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X 2 2 X 3 Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5(1)(c) Requirement The company must take appropriate steps to ensure that service users are provided with contracts setting out the terms and condition of residence. The registered manager must carry out assessments that reflect the care needs of the service users. Where these have been done, they lack details and provide very little information about the individual. The service user plans must be regularly reviewed. This include sufficient information that reflect the prevailing care needs of the service users. The current reviews were not carried out promptly and therefore did not reflect the current care needs of the service users. Care Plans must be kept under regular review to make sure that people’s care needs are identified and addressed. All parts of the home must be kept reasonably decorated. Peeling wallpaper in hallway needs to be addressed. Timescale for action 30/09/07 2. OP3 15(1)(a) 30/09/07 3. OP7 15(1) 30/08/07 4 OP8 15(2)(b) 30/08/07 5. OP19 16,23 31/08/07 Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 25 6. OP20 21(1) 7. OP28 23(4)(e) 8. OP29 19(4)(c) 9. OP30 18 (1)(c) The practice of keeping “wet floor” signs at toilet doors for long period must cease as this potentially adds to service users confusion and incontinence. All staff must receive regular fire instructions to ensure that safety and wellbeing of the service users. The manager must follow the company’s recruitment procedure and obtain two satisfactory references before offering a position. All new members of staff must receive induction training and details of training recorded. (Previous timescale of 31/05/06 not met.) The quality audit system must continue to be implemented in a systematic and robust manner. Timescale of 31/08/06 not met. 01/07/07 01/08/07 01/07/07 31/08/07 10. OP32 35 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Belle Vue House DS0000015705.V338476.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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