Inspection on 07/06/05 for Belle Vue Nursing Home

This inspection was carried out on 7th June 2005.

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 Home 22/08/07

Belle Vue Nursing Home 03/10/06

Belle Vue Nursing Home 03/11/05

Belle Vue Nursing Home 21/09/04

Belle Vue Nursing Home 15/04/04

Belle Vue Nursing Home 26/01/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Belle Vue Nursing Home 26a Belle Vue Grove Middlesbrough TS4 2PX Lead Inspector Katherine Acheson Unannounced 7 June 2005 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 Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Belle Vue Nursing Home Address 26a Belle Vue Grove Middlesbrough TS4 2PX 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) 01642 852324 Belle Vue Healthcare Limited Mrs Dorothy Matthews Care Home 60 Category(ies) of OP Old Age - (0) registration, with number PD Physical Disability - (0) of places Belle Vue Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: To allow a maximum number of ten service users who have a physical disability, who are aged fifty and above to reside at the home. To allow a maximum number of six named service users who are under the registered age category to reside at the home. Date of last inspection 07/06/05 Brief Description of the Service: Belle Vue Nursing Home is registered to provide personal and nursing care to sixty service users. The home is situated on Belle Vue Grove in Middlesbrough, and is close to all Local amenities and shops. The home is a two storey, modern, purpose built facility providing accommodation in the form of fifty six single bedrooms and two double bedrooms. All bedrooms have ensuite facilities which comprise of a toilet and hash wash basin, all bedrooms meet the required amount of space. The home offers a large dining area and a number of lounges. Belle vue is set in grounds which are accessible to residents and provides car parking facilities for visitors. Belle Vue Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection started at 10am and lasted for six and a half hours. Six residents one visitor, three staff and the Manager were spoken to during the inspection. Numerous records including care plans, policies and procedures, maintenance records, staff recruitment and complaint records were examined. What the service does well: What has improved since the last inspection? It was highlighted at the last inspection that improvements were required in respect of the homes policies and procedures in recruiting staff. The Manager has taken steps to ensure that full employment histories are in place for staff members along with the explanation for any gaps in employment in order to ensure that residents are protected. Belle Vue Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 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 Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 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 Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 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, 4, 5 The home is able to meet the assessed needs of residents living at the home by ensuring that a thorough pre-admission assessment is carried out. EVIDENCE: Residents are admitted to the home following an assessment that is carried out by a Social worker or Health Care Professional. Qualified staff at the home also carry out a pre-admission assessment on all prospective residents to ensure that the home can meet their needs. Residents spoken to during the inspection said that either they or their family had looked around the home prior to admission. The home caters for a wide range of needs from those residents requiring assistance with personal care to those who have complex nursing needs. The home has a variation to registration which enables them to care for people aged fifty and above, a small number of residents who are under this age bracket also reside at the home. Belle Vue Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 Page 9 Six residents and one visitor were spoken to during this inspection all of whom spoke highly of the Manager, staff team and care that is provided. All residents said that their individual needs were met. One resident spoken to during the inspection said, “this is my home and I am highly delighted with everything they do”. The home does not provide intermediate care. Belle Vue Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 Page 10 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) 7, 10 The home provides a high standard of care, which ensures that the health personal and social care needs of residents are met. EVIDENCE: Three residents plans of care were examined during this inspection. Care plans were found to be comprehensive, well presented and individual to the needs of the resident. Files examined contained a record of visits carried out by chiropodists, G.P’s, opticians and other health care professionals. The Manager said that care plans are kept in the resident’s own bedroom which enables residents and their family to look at the plan of care anytime that they like. Care plans examined did contain signatures of residents or their family to confirm that they had been involved in drawing up the plan of care, however, their was not set system for this and as such was confusing as to who had signed what. Belle Vue Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 Page 11 Signatures of the resident or family member were not on file to confirm that they had been involved in reviewing the plan of care, however, copies of multidisciplinary reviews were available. A discussion took place with the Manager in respect of developing a system in respect of this. Two out of three of the care plans were found to have been updated on a monthly basis, the other had not. Residents spoken to during the inspection said that staff respected their privacy and dignity at all times. One resident said “the staff always knock on my door when they come in”. Staff through discussion demonstrated knowledge and awareness of residents living at the home. One staff member said “I talk to the resident while I am doing what is required, I tell them everything that I am going to do even if they are unable to talk to me” Belle Vue Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 Page 12 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, 14 Resident’s daily lives are enhanced by the social activities provided by the home and the welcome it extends to residents visitors. EVIDENCE: The home since last inspection has employed an Activity Co-ordinator who works twenty hours per week. A scheduled plan of activities was available in the home for inspection and included bingo, arts and crafts, dominoes, sing-alongs, trips out and entertainers/acts coming into the home. One resident interviewed during the inspection said, “I really enjoy the regular sing-a-longs” another said “I am registered on Dial a Ride, I enjoy my regular trips out with my sister”. One resident spoke of the flower arranging activity day that she had enjoyed. The Manager said that those residents who are able are encouraged to come and go as they please. She said that a couple of the male residents enjoy a walk to the local shops to buy their morning paper and place a bet at the local bookies. Belle Vue Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 Page 13 The manager said that at present there are no visiting Clergy, however, if a resident requested such a visit then this would be organised. Six residents spoken to during the inspection did not express any interest in practicing their religion. Residents interviewed said that contact with family and friends is encouraged and that visiting is at any time. One visitor spoken to during the inspection said that he was always made to feel welcome on his regular visits to the home. Residents interviewed spoke of flexibility in routine. One resident said “I can get up and go to bed when I like. I am one for my bed, I go to bed about 7pm so that I can relax”, another resident said “I like to go to bed late after I have had my whisky”. The inspector during the visit noted excellent relationships between staff, residents and visitors. Belle Vue Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 Page 14 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) 16, 18 The home has an effective complaints procedure, which enables residents to make any complaints they feel necessary. Development of the homes system of recording of complaints would further enhance this. The policies, practices and staff knowledge of adult protection ensures that residents are protected EVIDENCE: The home has a clear complaints procedure, details of which are also available in the statement of purpose and service user guide. Residents interviewed during the inspection said that the Manager and staff at the home are approachable and if they felt the need to complain then they would do so. It was highlighted at the last inspection that the Manager must develop a system in which to record complaints for residents individually, as yet thus had not been completed. A policy/procedure was in place in respect of adult protection and contained details of the action that staff should take if abuse is suspected. Two care staff spoken to during the inspection demonstrated awareness of adult protection and action they would take if abuse were suspected. All residents spoken to said that they felt safe, one resident said “I feel very safe here, I’ve never given it a thought until you asked”. Belle Vue Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 Page 15 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) EVIDENCE: The above standards were not inspected, however a requirement highlighted at the last inspection in September 2004 was re-visited. It was highlighted that all water temperatures in baths sinks and showers must be taken and recorded on a regular basis and that the action must be taken to address the problems of the water temperatures in the bathrooms. Records examined during this inspection identified that staff at the home are now recording water temperatures in resident areas. Despite intervention from a plumber, since last inspection, some of the bath temperatures were observed to be a little cool and require further attention. The Manager said that she would address this immediately. Belle Vue Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 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 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) 29 The homes recruitment and selection process is robust and as such ensures that residents are protected. EVIDENCE: Four staff files were examined at random during this inspection, all of which contained two written references, which had been received prior to the commencement of employment. It was observed that the Manager is now exploring any gaps in employment. Files examined contained evidence that the home is carrying out appropriate POVA and Criminal Record Bureau Checks. Files examined did not contain a photograph of the staff member. The homes reference request was observed to only ask closed questions and did not give the person completing the reference the opportunity to comment on the staff member. A discussion took place with the Manager at the time of the inspection in respect of this. Appropriate policies and procedures in respect of recruitment were in place. Belle Vue Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 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) 34, 35, 36,38 The home ensures that the health, safety and financial wellbeing of residents is safeguarded and protected. Current systems in the home do not ensure that staff receive regular supervision to support their role EVIDENCE: The home operates a rolling programme of servicing appliances and equipment. Records examined at random confirmed that the homes fire extinguishers, fire alarm and emergency lighting are serviced on a regular basis. The Manager at the time of the inspection was unable to locate the homes certificate to confirm that the servicing of the central heating system and boilers was up to date. The Manager said that she would take immediate action to address this. Belle Vue Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 Page 18 A telephone call was made to the home following the inspection to confirm that the servicing had taken place; the Inspector was informed that the service had been carried out and that the certificate will to be forwarded to the commission for Social Care Inspection. Mandatory training is provided to staff working at the home on a regular basis. The home has recently undergone a fire inspection and is in the process of actioning recommendations made. Documentary evidence of the home’s financial viability and budgets were available, appropriate public liability insurance was in place. The home operates an effective system in which they look after the personal allowance of a number of residents. Accurate records of transactions and receipts were available for examination. It was highlighted at the last inspection that care staff should receive supervision at least six times yearly. Records were examined during this inspection to confirm that supervision was taking place but not as often as it should be. Belle Vue Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 x 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 2 x 3 x x x 3 3 2 x 2 Belle Vue Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 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. 2. Standard OP7 OP16 Regulation 14, 15 22 Requirement Care plans must be evaluated on a monthly basis The Manager must develop a system in which to record residents complaints individually in order to ensure confidentiality and data protection (Previous timescale of 30th October 2004 not met) The Registered Person must take action to address the water temperatures within bathroom areas Staff files must be updated to include a recent photograph Timescale for action Immediate 31st July 2005 3. OP25 13 Immediate 4. OP29 19 31st July 2005 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. Refer to Standard OP7 OP29 OP31 Good Practice Recommendations The Manager should develop a system for residents and their families to sign when developing or reviewing the plan of care The homes reference request should be developed further to seek more written information about the staff member. The Manager should continue to work towards achieving B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 Page 21 Belle Vue Nursing Home 4. OP36 her NVQ Level 4 in Management Care staff should receive supervision at least six times per year Belle Vue Nursing Home B51-B01 S146 Belle Vue Nsg Hme V225684 070605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Unit B, Advance St Marks Court Teesdale Stockton-on-Tees TS17 6QX 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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