Inspection on 01/06/06 for Belle Vue Nursing & Residential Home

This inspection was carried out on 1st June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 Nursing & Residential... 05/05/09

Belle Vue Nursing & Residential... 17/05/07

Belle Vue Nursing & Residential... 12/12/05

Belle Vue Nursing & Residential... 19/05/05

Belle Vue Nursing & Residential... 10/01/05

Belle Vue Nursing & Residential... 22/06/04

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

CARE HOMES FOR OLDER PEOPLE Belle Vue Nursing And Residential Home 1 Stanmore Road Heaton Newcastle Upon Tyne Tyne & Wear NE6 5SX Lead Inspector Suzanne McKean Key Unannounced Inspection 1st June 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 Nursing And Residential Home DS0000000393.V290459.R01.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 Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belle Vue Nursing And Residential Home Address 1 Stanmore Road Heaton Newcastle Upon Tyne Tyne & Wear NE6 5SX 0191 209 0300 0191 209 0301 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) Bawi Homes Limited Mr Paul Fergus Owen Herrity Care Home 49 Category(ies) of Dementia - over 65 years of age (49) registration, with number of places Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specified person under the age of 65 may be accommodated for as long as they are in residence. The CSCI must be informed at that time so that this condition can be removed. 12th December 2005 Date of last inspection Brief Description of the Service: Belle Vue House is a purpose-built two-storey care home of traditional brick build and tiled roof construction. It is situated in the Heaton suburb of Newcastle upon Tyne. The home is well located with ease of access to the nearby Chillingham Road and its variety of public amenities including shops, cafeterias, schools, public houses, parks, churches and regular transport services. The home is registered to provide care with nursing to people over the age of 65 years who have Dementia. Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took nine hours over two days by one inspector. All of the key standards have been assessed during these visits and from other information provided to the Commission. Eight residents and five staff were spoken to. Others were chatted to briefly. Two relatives were spoken to during the visits. Four care plans, training records and records for medication were examined. Staff files, training records and health and safety documentation were looked at. Ten questionnaires sent out to residents and relatives (20 in total) were generally positive with 8 relative and 10 resident questionnaires being returned. The details are contained in the report. What the service does well: What has improved since the last inspection? It was a positive inspection with evidence of improvements being maintained. The Manager and staff have undertaken a significant amount work to ensure that they are able to demonstrate their compliance with the standards especially in relation to the training provided. There were two requirements identified during the last inspection one of which has been met although three additional ones were identified. Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 6 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 Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6 (The home does not provide intermediate care) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. No resident enters the home without having a pre-admission assessment. The service user guide and statement of purpose are being updated to reflect the recent changes in management. EVIDENCE: The four care plans examined contained information to allow the home to judge if their needs could be met and that they could be cared for safely. The senior staff visit potential residents prior to placement and an assessment is completed from which a care plan is developed. All care plans contained a pre-admission assessment. The home gives information prior to admission and potential residents and relatives are made welcome and encouraged to find out as much as possible about the home. The service user guide and statement of purpose is not up to date and does not reflect the service being offered. Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is satisfactory. This judgment has been made using available evidence including a visit to this service. All residents have a care plan identifying their health and social care needs, service users have their health care needs met and are being administered their medication in line with good practice. The disposal of medication records were not complete. EVIDENCE: Four care plans were examined; they were of a satisfactory standard, with relevant risk assessments for the prevention of falls, nutrition, wound care, moving and assisting, continence promotion and mental health status. The plans showed that they are regularly reviewed and updated although some were now slightly overdue. The Manager has in place a system for this to be addressed. The care plans showed residents have access to all NHS services and facilities. There is a range of pressure relieving mattresses for prevention of pressure sores. A number of appropriate assessment tools are in use. Daily reporting of Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 10 residents care was generally satisfactory, and the changing health care and mental health care of residents was reviewed and updated. Throughout the visit staff were treating residents with respect and dignity. Personal care was given in privacy, staff used residents preferred name at all times. The medicines in the home are generally well managed and there is now a contract in place for the disposal of medicines including controlled drugs. The treatment room was very tidy and well organised. Two residents medication was examined in detail as part of the case tracking and were satisfactory. There is good stock control and all opened topical medications are dated on commencing use. There was a separate list of signatures of staff on record for auditing purposes and this was up date for new staff. The controlled drugs could not be audited, as the records were not in place for the disposal of some medicines, which were no longer in the home this dates back to the time before the disposal contract was set up but must be investigated and addressed. Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Service users are being helped to exercise choice and control in their lives where possible and arrangements for residents to maintain contact with their family and friends and the local community are suited to each individual’s needs and vary accordingly. Service users are receiving a wholesome balanced diet in pleasant surroundings at suitable times. EVIDENCE: Residents spoken to who were able to respond to the question said that they are encouraged to make choices in their daily routines in simple but important ways including the time they get up, what and when they eat and how they spend their time. The home has a policy to ensure that residents can choose the gender of staff for personal care, however in a resident response this had not been accommodated, this is to be addressed by the new Manager. A weekly activities programme for residents was seen and showed a range of events taking place although this is dependent on the daily preferences and changing needs of the residents. Residents were seen spending their time in a Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 12 variety of ways including jigsaws, watching television and spending time together. Menus show a good range and choice of food with likes and dislikes recorded. There is a protocol of action for those residents loosing weight including referral to the General Practitioner. The bedrooms are personalised showing individual choices and preferences and two residents when asked said they were happy with the decoration. Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome good. This judgment has been made using available evidence including a visit to this service. The residents and their families have shown willingness to raise their complaints or concerns and there is evidence that they are taken seriously and acted upon. EVIDENCE: There is written guidance in place on dealing with complaints, which is available in a number of different areas including posted on the wall and in the service user guide. Two staff spoken to could describe the way in which a complaint handled. The six complaints which have been made since the last inspection were examined and the records showed that these have been investigated and either resolved or the complainant chose not to pursue them further. Two relatives spoken to on the day of the visit confirmed that they felt satisfied that any concerns or complaints raised would be dealt with appropriately. One questionnaire identified some concerns about complaints in the past and the new Manager aware of these issues. There are regular well attended resident and relative meetings in which general non resident specific issues are discussed. The home is providing Protection of Vulnerable Adults training for all staff, which is not yet completed and therefore remains a recommendation. Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The home generally safe, and well maintained and is well provided with toilets and bath with the on-suit facilities and communal toilets. The bathing areas offer a choice between showers and baths. The bedroom areas are tidy and decorated in line with the resident choice. One shower area needs repair and redecoration and there needs to be liquid soap, disposable hand towels and lidded bins in all of the communal toilets bathrooms and on-suite areas. EVIDENCE: The décor of the home is good and the home was odour free on both of the visits. Some areas have been recently redecorated and were pleasant and homely. A number of bedrooms were examined (at least 10) and were decorated and furnished in a pleasant and homely way. Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 15 The rear storage area is now tidier and allows for staff to move from the internal door to the exit. The radiator in the shower area on the first floor was damaged and rusty, which was unsightly; the flooring is also damaged making it an unpleasant place to shower as well as being difficult to keep clean. There were no bins in some the communal toilet and showers, which means that the disposable paper towels could not be thrown away safely. Bedroom on-suites do not have liquid soap, hand towels and lidded bins. All areas must be suitably equipped to make sure that staff and residents can wash their hands and dispose of the hand towels appropriately. The waste disposal unit in the kitchen is broken and requires repair or replacement. It is recommended that the home consider asking the Control of Infection Nurse to undertake with them an audit to look at any improvements, which could be made. Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The staffing levels are appropriate and qualified nurses are on duty in sufficient numbers to meet the resident’s needs. The recruitment and selection process ensures that they can provide safe care and is in line with the home’s policies Staff are offered a selection of training in both statutory and clinical areas. EVIDENCE: Staffing rotas showed that enough staff are on duty to meet the staffing levels set down prior to the change to the CSCI without reduction. When sickness and staff holidays occur they are usually covered staff picking up extra shifts. When this is not possible agency staff are being used, late reporting does occasionally result in fewer staff being on duty for short periods. Two staff records looked at were complete including application forms, references, records of interviews and CRB checks. The manager has arranged a number of training sessions on a variety of subjects as well as statutory training. The staff confirmed that they are being encouraged and supported to attend. The training record for four staff was examined, there is evidence of a lot of training being provided and confirmed that all staff had received statutory training. Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home is maintained in a safe condition and the staff are aware of health and safety issues. The monthly visits by the proprietor or his representative are now being undertaken with an exception of one month. Resident’s personal finances are being managed appropriately. Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 18 EVIDENCE: The Manager Paul Herrity was still in post on the first of the two visits for this inspection although he was no longer the manager for the second. The new manager is in post and is planning to apply to be the registered Manager. She had plans to introduce herself to the relatives and had already been around the home on a number of occasions to meet the residents and make herself aware of their needs. The personal records kept in the home of residents who are receiving assistance to manage their finances are detailed, logical and appropriate. Receipts were in place for purchases made on behalf of residents and signatures of either two staff or one and the service user were in place, and there is a small float available for the staff to access. There are now records of the visit by the proprietor with the exception of one month however this remains a requirement, as they must be completed without exception. The process for completing the Regulation 26 visits is under review. The proprietor makes regular and unannounced visits to the home and there is good communication between him and the home generally. Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 19 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 20 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 OP9 Regulation 13 (2) Requirement The record of controlled medicines must be kept in line with the legislation and Care Homes Regulations. The Manager must provide communal and bedroom areas with liquid soap, disposable hand towels and appropriate waste bins. The flooring and radiator in the shower area on the first floor must be repaired and the room decorated as necessary. The waste disposal unit in the kitchen is broken and requires repair or replacement. Written reports of monthly visits by the proprietor or his representative must be prepared and sent to the CSCI. OUTSTANDING Timescale for action 01/08/06 2. OP26 13 (3) 01/10/06 3. OP19 23 01/10/06 4. OP33 26 (2) 01/07/06 Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 21 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 OP18 Good Practice Recommendations It is recommended that staff are given formal Protection of Vulnerable Adults training as part of their programme of ongoing training. It is recommended that the home consider asking the Control of Infection Nurse to undertake with them an audit to look at any improvements, which could be made. 2. OP26 Belle Vue Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Nursing And Residential Home DS0000000393.V290459.R01.S.doc Version 5.2 Page 23 - 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!