Inspection on 09/05/06 for Belle Vue House

This inspection was carried out on 9th May 2006.

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 23/11/05

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 Gillian McCabe Key Unannounced Inspection 9th May 2006 09:30 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.V292998.R02.S.doc Version 5.1 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.V292998.R02.S.doc Version 5.1 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.V292998.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 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/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. Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over nine hours and thirty minutes in May 2006 and was a scheduled unannounced inspection. As the inspection was unannounced the views of service users, relatives and other visitors to the home were not gathered before the inspection. The inspection involved looking at the homes pre inspection questionnaire, which was completed by the homes manager. Views from comment cards were also looked which were received from visitors to the home. The inspector met with residents throughout the day, and time was also spent talking with residents about the care and support they receive. Time was spent observing life and daily routines in the home. As part of the case tracking exercise the care of three residents was looked at. This included looking at risk assessments, activity records, menu’s, accident records, looking around the home and other records the home must keep. Time was also spent with the manager and proprietor’s representative talking about the running of the home. Time was spent talking with members of staff about the training and support they receive to help them to do their jobs. Staff training records were looked at, recruitment procedures were looked at along with the homes policies and procedures, quality assurance records, accident records, medication records and procedures, fire records and the homes complaints procedure. A tour of the home was carried out looking at the standard of accommodation on offer and the homes systems for maintaining a safe living and working environment. What the service does well: Staff support and encourage residents to access a wide range of activities and community facilities. Staff also support and encourage people who live at Belle Vue to maintain contact with friends and family inside and outside the home. Good records are kept about resident’s health care needs and regular appointments are made to various health care professionals when required. The home has a warm and friendly atmosphere. Staff work hard in the home and have a good awareness of residents needs. The manager and the staff team put a lot of effort into making sure the home is run in the best interests Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 6 of the residents and comments about members of staff and the care provided include “commendable” “always approachable”. “always get stuck in”. The home provides a good choice of home cooked meals on a daily basis and residents comments include “The meals are lovely, you get ample”. “You can have your meals in your room if you want” “You always get cakes or biscuits with your afternoon tea”. The residents always get plenty of drinks and snacks throughout the day. Recruitment procedures in the home are good. All necessary employment checks are carried out before a person is employed to ensure residents are protected. What has improved since the last inspection? The Manager has recently developed the Service User Guide to ensure that it is accessible for people with a visual impairment. The Owner is thinking about other ways to make information easy to read. The Manager has looked at the way care plans are put together since the previous inspection however work is still needed to ensure residents are given the right kind of support. The room where medication is stored has been improved to include a washbasin and extra shelving which provides extra storage for resident’s medicines. The roof had been re tiled since the last inspection however, water is still coming through in some parts of the building. Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 7 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 DS0000015705.V292998.R02.S.doc Version 5.1 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.V292998.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 &3 It was not necessary to look at standard 6 as the home does not provide Intermediate Care. Quality in this outcome is good. This judgement has been made from evidence gathered both during and before the visit to this service. All prospective residents’ needs are assessed prior to the person being offered a place. This helps to ensure that residents are offered the right type of care and no one is admitted appropriately. The home does not provide intermediate care. EVIDENCE: Care management assessments are available in resident’s individual files. The home carries out a pre admission assessment, which has recently been developed by the manager, prior to the person moving into the home. The manager and staff carry out an assessment in the person’s home or sometimes in hospital. The information gathered is then looked at along with Care Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 10 Management assessments to determine if the home can meet the person’s needs. As part of case tracking exercise, three residents files were sampled and all contained pre admission and care management assessments giving basic details of each person needs. Pre admission assessment documentation needs to be reviewed to ensure all information relating to a persons needs, wishes and aspirations are gathered to ensure the correct level of care and support is given. All the information gathered is then looked at to determine if the home can meet the person’s needs. As part of the pre admission process prospective residents are invited to visit the home and/or have a trial stay. This gives prospective residents the opportunity to meet other residents and staff before making a decision to move in permanently. 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. However, not everyone has a Service User Guide in his or her possession. The manager has recently developed the service user guide so it is accessible for residents who have a visual impairment and consideration is being given regarding the guide accessibility in other formats. The guide in its current form is not accessible for all residents living in the home. Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The manager and staff have worked hard to develop care plans to ensure resident’s needs are met. Residents have regular access to health professionals to ensure healthcare is promoted. Medication arrangements at present are not managed appropriately to promote the health and well being of residents. Residents are treated with respect and dignity and privacy is upheld in the home. EVIDENCE: The manager and staff have worked hard to develop residents care plans since the previous inspection; however more work is needed to ensure the right kind of information is included in a persons care plan which will enable staff to give Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 12 the correct level of care and support. One person requiring support with pressure care needs did not have specific information for staff to provide the correct amount of support. One person had risk assessments in place for manual handling, the person was able to mobilise and transfer safely without assistance. Three care plans showed a lot of information about a persons needs but did not include detailed information about a persons wishes or aspirations. For example, no plans were in place for a persons social or emotional needs. A lot of the information included in a persons plan were not individual to the persons concerned, plans were often repetitive and written generically. Time was spent advising the manager on how to develop the care plans further and what kind of information should be included to ensure that residents are supported to have full and valued lives. Plans have been reviewed but reviews were not consistent. Evaluations for the person’s plans do not always give enough information about how the person’s goal/plan is being achieved. For example, evaluations are quite often recorded as ‘continue with care plan’, ‘no change’. From observation and discussion with members of staff it is clear that all staff have good relationships with the residents at Belle Vue. Staff clearly carry out appropriate interventions and therapeutic activities to support residents, however such good practices are not recorded in care plans. All residents have access to healthcare related professionals and records show that regular visits to GP’s, Opticians, and Chiropodists etc are maintained when necessary. Staff also record any changes in a persons health or wellbeing in daily notes book where staff will take steps to contact the relevant professional if necessary. The manager and a proportion of staff are responsible for the administration of medicines in the home. All staff that have responsibility for handling medicines have completed training in ‘Safe Handling of Medicines’, which ensures staff are competent. All medication is stored in a locked facility within a locked storeroom. The room for storing mediation is very small and does not have any ventilation. Since the previous inspection, extra shelving has been fitted to provide more storage space. A washbasin has also been fitted to assist staff to carry out safe practices when handling medicines. The home does not have any controlled drugs or oxygen in use at present, although staff are aware of procedures for the management of these items. MARS (Medication Administration Record Sheet) sheets do not show the correct amount of stock currently held by the home. Three records were looked as part of case tracking and all sheets showed stock held for one month’s supply. The home had in storage two months supply of stock for three records sampled. The manager has previously contacted the pharmacist to discuss the Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 13 overstock of medicines and the pharmacist will be visiting within the next seven days to review the medication. Two recording errors had been made on one person’s medication records. Staff had administered medication but had not recorded this on the MARS record. Weekly audits are not carried out as part of medication and quality monitoring procedures; these audits are vital to ensure any errors are highlighted and rectified immediately and also to ensure the safety of residents at the home. Staff spoken with demonstrated a good knowledge of all areas of medication procedures despite errors being made. The manager would benefit from reassessing the competence of all staff responsible for handling medicines and address any learning needs through training and individual supervision sessions. Staff ensure residents are treated with respect and support is given sensitively and discreetly. Assistance with personal care is always carried out in the privacy of a person’s room or bathroom. One resident confirmed that staff always knock on their bedroom door before entering. Observations of this good area of practice were made during the inspection. Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 14 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): 12,13,14,15 Quality in this outcome is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are able to follow their own daily routines, which satisfy their social, cultural and religious needs. Friendships with people outside and inside the home are encouraged and resident’s family members are welcomed to visit the home at any reasonable time. This helps to prevent social isolation. Staff encourage residents to take control and make choice in their lives, which helps to promote independence. Residents are offered an excellent variety of wholesome and nutritious meals in comfortable and pleasant surroundings, which can promote health and wellbeing. EVIDENCE: Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 15 The home does not have a structured programme of activities in place. The manager confirmed that activities are quite often carried out spontaneously and at the request of the residents. Members of staff said that activities can include arts and crafts, dominoes and sometimes the home has entertainers coming into the home. Residents’ comments about activities include “If you want to do something you can, I like to stay in my room” One resident talked about trips out when the weather is nice, to local places of interest. “Sometimes staff will take me for a walk outside, If I want to do anything, I can” One resident said “There is not a lot going on”. The manager and staff talked about fundraising events the home has to raise funds to purchase transport for the home. Other activities include clothes parties and sing a longs. Discussion was held with the manager about recording and planning resident’s activities and interests to ensure all residents have the opportunity for social stimulation. 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 residents 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. Residents said that they are able to get up and go to bed when they choose thus promoting peoples 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 residents. Meals are generally served in the homes dining room, which is nicely decorated and benefits from plenty of space to enable staff and residents to sit together and enjoy their meals. If residents prefer not to eat in the dining room staff will support them to have their meals in their preferred area. Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 16 Meals are freshly prepared on a daily basis and staff encourage residents to include fruit and vegetables in their choice of meals to ensure a healthy diet is maintained. Hot drinks and snacks are always available throughout the day and evening. Examples of meals on the menu include things like ‘gammon steaks’, ‘chicken casserole’, ‘toad in the hole with spring cabbage, butter beans and potato’s. Examples of sweets include ‘treacle pudding and custard’, ‘fresh fruit and custard’. Staff were observed to offer support and assistance to residents during mealtimes where necessary, in a discreet and sensitive manner. Resident’s comments about the meals include “The meals are lovely, you get ample”. “You can have your meals in your room if you want” “You always get cakes or biscuits with your afternoon tea”. Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 17 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 Quality in this outcome is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Residents and relatives have information about how to make a complaint and are confident that any complaints will be acted upon immediately. All Staff are aware of the Protection of Vulnerable Adults procedure, only a proportion of staff have received training in protection of vulnerable adults training. EVIDENCE: Complaints in the home are handled openly with the manager and staff. The home has a log in place for recording all complaints. There have been no complaints made to the home or to the Commission for Social Care Inspection since the previous inspection. The homes complaints procedure is displayed on a notice board in the main foyer, which is accessible for residents, staff and visitors. A copy of the complaint procedure is also included in the homes Service User Guide however in its current format it may not be accessible for all residents at Belle Vue. Systems are not in place for accessible copies of the procedure to be produced when requested. This was discussed with the manager during the inspection. Staff are aware of the complaints procedure and residents spoken with during the inspection confirmed they would talk to the staff or manager if they had any complaints. Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 18 Fourteen 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. Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 19 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 & 26 Quality in this outcome is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. People who live at the home benefit from an environment, which is generally well maintained, clean and comfortable, however there are some outstanding repairs and storage issues which require attention. EVIDENCE: A tour of the home identified some maintenance issues requiring attention. As a result of general wear and tear, some areas of the home require re decorating. A carpet is currently on order for the lounge and hallways, the manger confirmed that this would be fitted within the next few weeks. Repair work has been carried out to the roof however, water is still leaking through when there is a heavy downpour. Areas in some parts of the stairwells would benefit from re decoration as wallpaper is starting to peel off the walls. Generally the home is pleasantly decorated and residents are happy with the furnishings. Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 20 The manager needs to develop a maintenance plan for the home and a copy forwarded to Commission for Social Care Inspection. This will ensure areas of maintenance throughout the home are highlighted and followed up on a regular basis. Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 21 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): 27,28,29 & 30 Quality in this outcome is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home has an effective staff team, which is sufficient in skills and numbers to support residents assessed needs. The home follows a robust recruitment policy to ensure sure residents are protected. Members of staff receive regular training opportunities that ensure service users are appropriately supported and protected. Updates and refresher courses have not always been carried out. EVIDENCE: On the day of inspection 22 residents were accommodated. The Registered manager and six care staff were on duty. The homes rota shows there are sufficient numbers of staff on duty throughout the day and night, which ensures residents, are fully supported with their needs. Before any prospective employees are invited to take up a post at the home, two satisfactory written references are sought and enhanced Criminal Records Bureau (CRB) clearance and POVA register checks are required. This helps to ensure that only people of the required calibre can begin to work there and Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 22 residents are protected. Three staff files all held the necessary employment checks in place. All staff have completed mandatory training courses, First Aid, Moving & Handling, Infection Control etc however, some staff need to complete refresher courses. The manager confirmed that over half of care staff have completed NVQ Level II in ‘Care’ and plans are being made to secure training for staff who have not completed an NVQ Level II. Staff do not receive regular three monthly and six monthly training in fire procedures, this kind of training is vital to ensure the health safety and welfare of service users. 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 does not evidence 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. The recruitment process is carried out fairly and the home has standardised documentation for the interview process, which again ensures fairness and consistency. Following an interview with the company, candidates are also invited to visit the home so that residents may contribute to the selection process if they so wish. Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 23 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): 31,33,35 & 38 Quality in this outcome is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The home has a good quality auditing for carrying out audits throughout the home however, the manager has not carried out regular audits to identify areas of good practice or areas for improvement. Records are maintained that confirm residents finances, however regular balance checks are not carried out which means residents monies may not be safeguarded. Staff work well to maintain a safe environment and protect service user’s health and well-being, however, staff do not receive regular in house instruction in fire prevention and the procedures to be followed in the event of a fire. This compromises the safety of everyone who lives and works at the home. Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 24 EVIDENCE: The homes manager has been in post for 22 years. She is well experienced and competent to run the home to met its stated purpose, aims and objectives. However, 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 health & safety matters. 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 procedures. Water temperatures are not checked regularly, which could also place people at risk. Water temperatures in the home were tested and measured too high. An immediate requirement notice was issued for these matters to be put right immediately. The home is clean and tidy and robust cleaning procedures are in place to ensure that the home remains free from infections. The home is kept generally clear of hazards to the health and safety of residents, visitors and staff, although one bathroom was being used for the storage of ramps; this practice poses a safety risk to residents and staff using this area. The home has a good quality-auditing tool in place however, the manager has been unable to carry out regular audits using this tool. Discussions were held with the manager about delegating specific areas of work and giving individual staff areas of responsibility. This would free up some of the manager’s time for enable her to carry out management duties within the home. Questionnaires have been sent out to visitors, relatives and residents as part of measuring quality and the information received back has been very positive. This kind of information could be included in the homes Service user Guide as this would give prospective residents an insight into the home from residents and their relatives. The residents and staff speak very highly of the manager and comments from residents include “she is lovely” “she always gets stuck in” Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 25 Visitors surveys held in the home confirm that the care given at the home is “commendable” and the manager is “always approachable”. The home keeps residents personal allowances in a locked safe. Records of all transactions are kept along with receipts. Discussions around numbering individual receipts were held, as this would ensure a clear trail for the purpose of auditing. Also discussion about the type of records used for recording resident’s finances, it would be advisable to have a hard backed book with numbered pages to record all transactions. The manager also needs to carry out regular balance checks on monies held and record details of checks made. This will ensure resident’s finances are safeguarded. The manager has not always notified the Commission for Social Care Inspection of all significant events that may have taken place in the home. Discussions were held with the manager about the kind of incidents that need to be reported. The home has a file in place and all accidents are recorded and stored in an ‘accident file’. Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 26 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 27 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, 30/11/05,31/03/06 not met) Issues regarding storage and administration of medicines identified in this report must be addressed. Registered Person must ensure all staff are trained in Protection Of Vulnerable Adults training. Repairs to the roof must be of a satisfactory standard to prevent water ingress to the building. (Previous timescale of 30/11/05. 31/03/06 not met) All parts of the home must be kept reasonably decorated. Hallway and Lounge carpets need replaced. Peeling wallpaper needs to be addressed. All new members of staff must receive induction training and details of training recorded. DS0000015705.V292998.R02.S.doc Timescale for action 31/08/06 2. OP9 12, 13 17/05/06 3. 4. OP18 OP19 13 (6) 16, 23 31/07/06 31/07/06 5. OP19 16, 23 31/07/06 6. OP30 12, 18 31/05/06 Belle Vue House Version 5.1 Page 28 7. 8. OP30 OP33 12,18 35 All staff must have regular in 30/06/06 house fire training and refreshers in all mandatory training The quality audit system must 31/08/06 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. The registered person shall ensure that all parts of the home to which residents have access to are so far as reasonably practicable free from hazards to their safety. Water temperatures must be monitored and recorded. 30/06/06 9. OP35 35 10. OP38 12 4 (a) 09/05/06 11. OP38 13(4) 23(2)(j) 09/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations Consideration should be given to relocation of the medication storage room to a more accessible area of the Home. Belle Vue House DS0000015705.V292998.R02.S.doc Version 5.1 Page 29 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. 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