Inspection on 30/06/05 for Belle Vue House

This inspection was carried out on 30th June 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 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

Belle Vue House 31/05/08

Belle Vue House 29/05/07

Belle Vue House 09/05/06

Belle Vue House 23/11/05

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 Announced Thursday 30 June 2005 at 10.00 am 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 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 B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Belle Vue House Address 1-3 Mowbray Close Hendon Sunderland SR2 8JB 0191 5673681 0191 5657405 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 Devinder Mohan Malhotra Mrs Christine Scott Care Home 32 Category(ies) of Old Age (23) registration, with number DE(E) Dementia over 65 (9) of places Belle Vue House B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7 February 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 B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over a period of six hours. The Registered Manager was present throughout the inspection supported by the Registered Provider’s representative. Several documents were reviewed including three resident’s care plans, residents and relatives consultation questionnaire returns, health and safety and medication audit results, staff training records and personnel files, minutes of staff meetings and residents personal finance records. As this was an announced inspection the Registered Manager submitted a preinspection questionnaire to the Commission for Social Care Inspection, which includes information such as about staff training, menus, accidents and staff duty rotas. A total of thirteen relatives/visitors comments cards and ten residents comments cards were returned to the Commission for Social Care Inspection. Extracts from the comments cards can be found throughout this report. However, in summary, ten relatives said they were satisfied with the care provided in the Home and made comments, such as, ‘delighted with the caring attitude of the staff’, ‘I could not ask for anything more’. Three stated they were not wholly satisfied particularly commenting on a view they thought staffing levels were too low. However, this Home is actually staffed over the required minimum levels, which is one of the positive points about the Home. Eight residents comment cards indicated satisfaction with the care and services in the Home, one was not happy about some aspects of care and one other requested more salads. What the service does well: Resident’s spoke very highly of the care they received from the staff. Several commented on how they ‘could not ask for more’ and ‘they will help you with anything’. Comment cards from relative’s confirmed this same view, particularly about feeling content that the resident’s were being well looked after. Comments are often made about the meals being ‘very good’. The menu has a good variety of food and there is never too long a gap between meals. The manager makes sure the resident’s have butter, rather than a cheap margarine, cream and other little luxuries, which is appreciated as one resident commented about the ‘treats in-between meals being numerous and varied’. Belle Vue House B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 Page 6 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. Belle Vue House B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Belle Vue House B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 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 standard(s) 3 The Home ensures they have adequate information about a residents assessed needs before they are admitted to the Home. Therefore residents and their relatives can be assured the Home has been recommended to them because it can meet their needs. EVIDENCE: Care manager assessments are available in the care records of residents, which give information about the needs of the resident so that a decision can be made about whether the Home can meet their assessed needs. The Registered Manager also has an assessment document that is used if a resident is self-funding therefore does not have a care manager assessment. Belle Vue House B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 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 standard(s) 8 & 9 Residents are assisted to access healthcare professionals so they are able to have their healthcare needs met. Significant progress has been made to improve medication storage and administration in the Home to ensure residents receive their medication safely. EVIDENCE: There is evidence in the residents care plans that healthcare professionals are involved in their care, for example, General Practitioners, district nurses and appointments to local hospitals. Several areas of concern raised in the previous inspection regarding the storage facilities for medication have now been addressed, including handwashing facilities and improved storage cupboards. The room used for storage of medication is not ideal as it is in a difficult location therefore staff have to carry all medication, equipment and records with them when giving out medication. A specimen copy of staff signatures is not available, which is helpful when carrying out audits to see who has administered medication. Belle Vue House B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 Page 10 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 standard(s) 12, 13 & 15 The range of activities offered meets the choices and needs of the residents accommodated. Visitors are encouraged and made welcome therefore resident’s can be assured they can maintain links with their friends and family when they come to live at the Home. Meals are nutritious, well balanced and in sufficient quantity contributing to maintenance of general health and well-being of the resident’s and accommodating for their tastes and choices. EVIDENCE: Several visitors were seen in the Home throughout the day of the inspection. One visitor said they had looked around several homes and chose this one as the staff came across as it not being ‘just a job’ and described how the staff are lovely and helpful. This was confirmed by several residents who said ‘it was like home from home’, ‘couldn’t ask for more’ and ‘some people think old people don’t matter but it is not like that here’. One resident was away on holiday overseas with their relatives, demonstrating the Homes commitment to helping relatives and residents to maintain an active lifestyle. Belle Vue House B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 Page 11 The Home is currently raising funds towards the purchase of a minibus. Events such as, car boot sales, race nights, raffles and coffee afternoons have been organised with the support of relatives. The Registered Provider is also making a significant contribution towards the cost of the minibus. This will enable residents to get out and about for social and recreational events. During the inspection the local priest visited to conduct a church service, which several residents attended. When asked about his views on the care provided at the Home he was positive and complimentary about the standard of care offered by staff. The Home does not employ an activity person. However staff are employed in sufficient numbers to enable care staff to organise social activities during the day. This is usually done according to resident’s choice and suggestion by staff and several resident’s enjoyed sing-a-longs, short walks outside the Home and tabletop games, such as dominoes and bingo. Residents enjoy the meals provided and the food is in sufficient quantity, hot and tasty. Comments were made ‘ the food is of a very high standard and the treats in-between are numerous and varied’. During lunch the residents enjoyed a three-course meal, which was served by staff in a courteous and non-hurried manner. The menu supplied shows that residents can enjoy a choice for breakfast of cereal, toast and cooked items, a three-course lunch, snack tea and another hot meal option for supper. This is supplemented throughout the day with hot or cold drinks and biscuits. The Registered Manager is keen to ensure residents are offered good quality food and makes this a high priority for resident’s enjoyment. Belle Vue House B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 Page 12 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 standard(s) These standards will be assessed at the next inspection. EVIDENCE: The pre-inspection questionnaire indicates there have been no complaints or referrals made to the Protection of Vulnerable Adults team since the previous inspection. Belle Vue House B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 Page 13 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 standard(s) 19 & 26 Progress has been made to address environmental aspects of the Home. There are still some 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: Some issues identified at the previous inspection have been addressed. However there are still some areas requiring attention: - Hairdressing salon is not tidy, has old furniture and equipment and is not well decorated therefore does not offer a pleasant environment for residents to use. - 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. Belle Vue House B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 Page 14 - 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. The Registered Manager now records environmental and water temperatures, contributing to the overall safety and comfort of resident’s. During the inspection the Registered Provider advised there is to be a new carpet fitted to the lounge and hallways, which will improve the general appearance of the Home. The residents made no comment about the décor and standard of furnishings. However, some comments in relatives feedback surveys to the Home included, ‘It might not be the poshest home but the staff more than compensate’, The furnishing is such that resident’s can identify with things they remember from the past’ and ‘there are high standards of cleanliness’. The Home was found to be clean and tidy. No significant odours were detected. Belle Vue House B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 Whilst the carers demonstrate they are a generally competent and mature staff group there are some areas of training, which are not updated sufficiently to ensure the residents are protected from harm. EVIDENCE: Staff training is mainly sourced through an independent training provider. The training for carers, through this organisation, is accredited with Training of Personal Social Services (TOPSS), which means care staff can do a reduced NVQ in Care commitment. Staff confirmed they had attended a variety of training courses, including fire safety; infection control, moving and handling and dementia care awareness. The Registered Manager advised a trainer from another one of the Registered Provider homes is to conduct training in fire safety, COSHH and food hygiene training for staff. Fire training records did not demonstrate recent training had occurred. No details of the training are recorded and the last official external training for some staff was noted to be 2003. Staff questionnaires reflected a high degree of satisfaction with the support provided through training. Three personnel records were reviewed and found to contain all relevant documentation including application forms, two references, interview records and Criminal Record Bureau clearance. Therefore demonstrating the recruitment process is carried out to ensure appropriate staff are selected to Belle Vue House B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 Page 16 work in the Home. However, the current filing system did not lend itself to easy retrieval of information. Belle Vue House B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 38 There has been limited progress with quality audits, which would identify issues to ensure residents are protected from harm and live in a safe environment. EVIDENCE: The Registered Manager has conducted audits to review medication and health and safety practices in the Home as part of a new quality audit system currently being introduced in the Home. No issues have been identified from initial audits; however this is not reflective of issues raised during the inspection, for example, fire safety training. This might change as the Registered Manager becomes accustomed to the process. Questionnaires have been issued to relatives and some visiting professionals, for example, district nurses to help gain information and views about the care and services at the Home. Comments have been included in other parts of this report. Belle Vue House B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 2 x x x x 2 Belle Vue House B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 Page 19 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 OP7 Regulation 15 Requirement Residents care plans must include sifficient information to enable care staff to meet their needs. (Previous timescale of 31/05/05 not met) Sample signatures of staff responsible for administration of medicines must be maintained in the Home. (Previous timescale of 31/3/05 not met) Lighting must meet the recognised standard of lux 150 in all areas used by residents. Repairs to the roof must be of a satisfactory standard to prevent water ingress to the building. All staff must attend fire safety training at the required frequency of twice a year for day staff and four times a year for night staff. Details of the content of fire training sessions must be recorded. The quality audit system must continue to be implemented in a systematic and robust manner. Timescale for action 30/11/05 2. OP9 12 & 13 31/8/05 3. 4. 5. OP25 OP19 OP27 & OP38 23(2)(p) 16 & 23 23(4) 30/9/05 30/11/05 30/10/05 6. 7. OP27 OP33 23(4) 35 30/10/05 30/06/05 Belle Vue House B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 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. 3. 4. Refer to Standard OP9 OP19 OP19 OP29 Good Practice Recommendations Consideration should be given to relocation of the medication storage room to a more accessible area of the Home. The hairdressing room should be refurbished to promote a welcoming and sociable area for use by residents. The Registered Manager should consult the fire authority for safety advice about the wall mounted heaters in 2nd floor bedrooms. The filing system for staff personnel files should be improved in a manner to enable easy retrieval of information. Belle Vue House B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Baltic House Port of Tyne South Shields Tyne & Wear 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 B52-B02 S15705 Belle Vue House V220947 300605 Stage 4.doc Version 1.40 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. 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!