Inspection on 10/01/06 for Bellefield Residential Home

This inspection was carried out on 10th January 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 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

Bellefield Residential Home 19/06/07

Bellefield Residential Home 25/08/06

Bellefield Residential Home 05/10/05

Bellefield Residential Home 13/10/04

Bellefield Residential Home 21/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Bellefield Residential Home 42 Aysgarth Avenue Liverpool Merseyside L12 8QT Lead Inspector Natalie Charnley Unannounced Inspection 10th January 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bellefield Residential Home DS0000025330.V276940.R01.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. Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bellefield Residential Home Address 42 Aysgarth Avenue Liverpool Merseyside L12 8QT 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) 0151 259 4397 bellefield@highfield-care.com Southern Cross Care Homes No 2 Limited Mrs Paula Gresham Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2005 Brief Description of the Service: Bellefield is registered to provide care for up to 31 residents within the category of old age. The home has been extended and adapted over the years to meet the needs of the residents at the home. The accommodation is arranged over two floors with the first floor being accessible by stairs and a passenger lift. The home has twenty nine single rooms, thirteen of which benefit from en suite facilities. The home has one double room that also has an en suite facility. There is a conservatory, large dining room, a main lounge and two smaller lounges situated on the ground floor. Residents have access to two bathrooms on the ground floor and one bathroom on the first floor. Bathing aids are available. There is an enclosed outdoor area with seating available. Parking is available on the road at the front of the home and at the rear of the home in a small car park. The home is situated in a residential area of West Derby in close proximity to local shops and amenities. There is access to public transport from the home. Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over a period of one day The inspector arrived at the home at 10.00am and left at 15.30 .The inspector spoke with 4 staff, the home manager, a district nurse, 2 visitors and 8 residents. The first half of the inspection was carried out with the senior care assistant on duty as the home manager did not arrive for duty until 13.50. The inspector completed the inspection by looking at the homes records, a tour of the building, formal and informal interviews and information from previous inspection reports. The inspector followed an inspection plan written before the start of the inspection to ensure that all areas that needed covering were done so. Feedback was given to the manager during and at the end of the inspection. The information was not available at the home to check the outstanding requirements and recommendations, as the previous inspection report could not be located. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that all documentation can be read and that a daily report is written about a resident on a daily basis. This is to ensure staff are clear as to any changes in a residents condition. Staff must receive training in all mandatory areas to ensure they can care for resident appropriately. Details of adult protection policies must be obtained from the local council. Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 Page 6 Staff must be made aware of their responsibility in recording and storing medications appropriately. Medications must always be stored safely. The home must maintain the maintenance programme at the home to ensure the safety for residents. Residents views need to be sought in regard to food and provision of fresh produce. This will enable the home to provide meals that are appropriate to the residents who live there. 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. Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 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 Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 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): No standards assessed EVIDENCE: Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 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 and 10 Care planning at the home is based on the individual and details how care is to be given, however some records are difficult to read and staff may find records tricky to follow. Staff need to ensure that they are familiar and trained along side the homes medication policy to ensure that medications are given out safely Privacy and dignity is maintained at all times, protecting the rights of residents who live at the home. EVIDENCE: Six care plans were sampled that showed that the home have recently changed the care plan documentation and format. This change is nearly completed and is being implemented by the manager. All plans are reviewed on a monthly basis and contain very detailed risk assessments on falls, nutrition, manual handling and continence. Social profiles are also recorded which contain information on the past history of a resident and indicates their likes and dislikes regarding hobbies and activities. The main body of the care plan is very detailed and clearly outlines what care residents need. Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 Page 10 Notes show that residents have access to a wide range of other health professionals such as GP’s (General Practitioners), specialist nurses, dentists and opticians. Staff record a daily record each shift that lists what a resident has done on that particular day and if any problems have occurred. These reports were very difficult to read because of bad handwriting. Gaps were noted from 4/1/06, 6/1/06,17/12/05 and 22/12/05. The records were intermittent and gaps meant that entries could be made at a later date, running the risk of inaccurate information being recorded. Medication records were sampled and a medication round was observed at lunchtime. Records were well recorded, with only one small error noted by staff not double signing handwritten entries. Residents, who self medicate, have special risk assessments in place to ensure that they are safe to carry out this practice. Two staff were interviewed who are responsible for giving out medication. Neither had received training or an assessment of their competence. Two pots of liquid medication and an inhaler were found in the smoking lounge. In the managers office, a box of medication labelled ‘pharmacy returns’ was found, and on discussion with staff it was noted that medications that are coming in and going out of the home are not being recorded. The keys to the managers office were found on the table in the staff room which meant that staff had access to medication and confidential information. Residents confirmed and it was observed that staff treat residents with dignity and respect. Staff were noted to be addressing residents in a polite way and knocking on doors before going into bedrooms. One resident stated “staff are very respectful” and went on to say “staff have to carry out some very personal things for us but they just get on with it, and always make sure we are ok”. Staff also confirmed that visits by doctors or other heath workers are done in the privacy of residents bedrooms. Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 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): 14 and 15 Many residents do not enjoy their meals and feel that they are not appropriate to their needs; this leaves them at risk of malnutrition and does not demonstrate choice. EVIDENCE: Residents spoken to confirmed that they are supported to make choices on an individual and daily basis. Examples given were regarding residents being able to get up and go to bed when they please and eat meal where they chose. One resident commented, “ We chose what to do here and when we want to do it”. A sample of residents bedrooms were looked in and showed that residents are encouraged to bring in items of furniture and belongings with them that remind them of home. Many residents chose to have photographs put up on the walls and have brought in their own bedding. The home use a four week rotating menu. Residents were observed having lunch and comments were made such as “we don’t get much fresh food here”, “we have to eat what is on the menu” and “the food is ok but a bit basic”. Lunch on the inspection day was pasties, potato waffle and peas and diner, according to the menu, was going to be soup, poached egg and sandwiches. Many of the pasties served at lunch were burnt and some residents were finding it very hard to cut up. Residents can see choices of meals on the menu board, however residents stated that “choice is limited” and “we don’t like to Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 Page 12 say if we don’t like things”. One resident who stated that she is a vegetarian was served a sausage roll as an alternative to pasties at lunchtime. The kitchen was checked and the chef spoken to. Four items of food in the fridge were found to be opened but not labelled as to what they were or dated when opened. Very little fresh food was found in the storage areas. The home were not recording temperatures of foods that were being served because “the record book has run out in December”, chef commented that visual checks were being done, but was advised this was not appropriate to ensure the safety of residents. Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 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): 18 Staff have a poor knowledge of adult protection procedures, which leaves residents at risk from harm. EVIDENCE: Staff files showed that all staff working at the home under go a police and POVA (protection of vulnerable adults) check before starting work, this is to ensure that they are suitable to work in a care home. The home manager was unable to locate the local adult protection policy and staff spoken to stated that they had not all undertaken abuse awareness training and admitted that they had had little or no knowledge of the local or home policy on adult protection. The home must address this urgently to ensure the safety of residents. Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 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 and 26 The layout, facilities and location of the home are suitable for the residents who live there. The home is clean, however some areas of maintenance need urgently addressing. EVIDENCE: A tour of the home was undertaken and highlighted some areas of maintenance work that needs attention. The toilet opposite room 4 had lino that was beginning to peel and was a potential trip hazard to residents, the bathroom opposite room 1 had a bath mat that was covered in mould and needs removing as soon as possible. The laundry area is in need of an urgent deep clean, especially behind the washing and drying machines. This area was very dusty and 3 old socks were found, that appeared to have been there some time. The home has a small smoking lounge that has no ventilation apart from when the main door is opened. This room was extremely smoky and had no fresh air, which could cause problems for the health of residents who use it. Other areas of the home were found to be clean, tidy and odour free. Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 Page 15 The home have policies in place to cover infection control and staff interviewed, demonstrated a good knowledge of this and how it is important to keep residents safe. Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 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 and 30 Staff morale is high resulting in an enthusiastic workforce that works positively with residents to improve their quality of life. Staff are not up to date with training and may not have the skills to care for residents appropriately. EVIDENCE: The home is currently recruiting one full time care assistant, a weekend cook and a handyman. The rotas show that enough staff are on duty at all times to meet the needs of residents, and that the home manager covers vacant shifts herself, rather than use agency staff who are unfamiliar with the home. Staff spoken to stated that the staffing levels are “good” and that they are never asked to do something they are not happy to do. Residents spoke highly about the staff that care for them commenting, “staff are nice”, “staff great” and “they are kind and considerate”. All residents and visitors felt that staffing is at a suitable level and a district nurse commented, “staff here are nice and they follow our guidance”. The staff training list that is up on the office wall showed none of the staff have first aid training, manual handling or dementia, only 5 have training in abuse awareness, 13 in fire safety, 5 with COSHH and 10 with care planning. Four staff interviewed stated that they had been on some training but could only identify fire training and food hygiene, they spoke about the difficulties that they have attending training that is outside of the home due to childcare Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 Page 17 arrangements. Two of the staff interviewed had responsibility for giving out medications, neither had received training or had a competence assessment. The home must address the issue of training at the home as a matter of urgency. Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 Page 18 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): 38 Many of the health and safety needs of the home are reviewed regularly and good records kept. However a lack of staff training in relevant health and safety areas needs to be developed as some of the current practices run the potential of putting residents, relatives and staff at risk. EVIDENCE: Accident records are well recorded at the home, however are not stored confidentially, and are written within a large book. Details of ‘additional factors’ were noted which detailed ‘resident has dementia’ for two residents. Discussion took place with the home manager regarding checking if these residents were within the right category of care, if this was the case. The home carry out health and safety meetings, the last of which was in November 2005. All health and safety certificates needed by the home were in date and a fire risk assessment was completed in September 2005.Staff have access to details of an ‘emergency contingency plan’ for use in the event of Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 Page 19 emergency when looking after residents. This is to ensure the safety of both staff and residents. It was noted at the start of the inspection that the last inspection report from the Commission for Social Care Inspection could not be located by the staff in charge. When the manager joined the inspection in the afternoon, she was unable to find the report. This is of concern, especially as residents should have access to this document. Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 Page 20 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 2 Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP8 Regulation 13(1) Requirement The registered person must ensure that documents in care files are clear and legible. A daily report must be written for each resident The registered person must ensure: 1. All staff who administer medication are trained and competent to do so 2. No medications are left out unattended 3. Medications coming into and out of the home are recorded 4. Medications are stored safely and in an appropriate place 5. Handwritten entries are double signed and dated The registered person must ensure that temperature checks are recorded for foods. The registered person must ensure that residents thoughts and opinions about the food at the home are sought. The registered person must Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 Page 22 Timescale for action 01/03/06 2 OP9 13(2) 01/03/06 3 OP15 16(2)(i) 13(4)(a) 01/02/06 4 OP18 18(1) 5 OP19 23(1) 6 OP30 18(1) 7 OP38 13(4) 5(1)(d) ensure that all opened food is labelled and dated The registered person must ensure staff are trained and made aware of the policies on abuse. A copy of the local council adult protection guidelines must be obtained The registered person must ensure that: 1.The mouldy bath mat in the bathroom opposite room 1 is removed 2.The toilet opposite room 4 has replacement flooring 3. The laundry must be deep cleaned, with particular attention to behind the washing machines. The registered person must ensure that all staff receive mandatory training and that records are kept up to date The registered person must ensure that all accident records protect the confidentiality of residents. The registered person must have a copy of the last Commission for Social Care Inspection report on the premises 01/03/05 01/03/05 01/04/06 01/03/06 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 OP15 Good Practice Recommendations The home may wish to consider using more fresh produce when preparing meals Bellefield Residential Home DS0000025330.V276940.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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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