Inspection on 25/08/06 for Bellefield Residential Home

This inspection was carried out on 25th August 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

Bellefield Residential Home 19/06/07

Bellefield Residential Home 10/01/06

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 25th August 2006 09:00 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.V298245.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. Bellefield Residential Home DS0000025330.V298245.R01.S.doc Version 5.2 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 None 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.V298245.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10/01/06 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. It costs £307.50- £425.00 to live at the home Bellefield Residential Home DS0000025330.V298245.R01.S.doc Version 5.2 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 09:00 and left at 15:00.The inspector spoke with 6 staff and 10 residents and the home manager. No visitors were available for comment. Surveys were sent to the home for visitors and residents to complete. 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 using all information held on file at Commission for Social Care Inspection regarding the home, to ensure that all areas that needed covering were done so. Feedback was given to the person in charge during and at the end of the inspection. This report is based on pre inspection information provided by the home as well a site visit. A number of outstanding requirements from the last report have not been addressed by the home. What the service does well: What has improved since the last inspection? The standard of records in the kitchen have improved. More fresh produce is now being used. An inspection folder is being developed which worked well during this inspection and made finding evidence to support the home easier. New care documentation is now fully implemented into the home Bellefield Residential Home DS0000025330.V298245.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. Bellefield Residential Home DS0000025330.V298245.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 Bellefield Residential Home DS0000025330.V298245.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 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to the service. Information gathered by the home before resident moves in, ensures that they can care for residents appropriately. EVIDENCE: Four residents were case tracked as part of the inspection process; this involved looking in detail at all of their care documentation. All residents had a pre admission assessment completed by the home manager, which detailed what a resident can and can not do for themselves. Assessments also include information on any risks that a resident has or undertakes as part of their daily lives. Assessments were of a high standard and were used as a basis to develop the residents care plans. Bellefield Residential Home DS0000025330.V298245.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 and 10 Quality outcome in this area is poor. This judgement has been made using available evidence including a visit to the service. Care plans and risk assessments are detailed, however they have not been made in collaboration with the resident. Residents have their dignity maintained at all times. Medication practices are poor and leave residents at risk. EVIDENCE: Care plans sampled were very detailed and showed that they are reviewed on a monthly basis by staff. Residents have a ‘social profile’ completed, which includes a life history and what activities that they like to join in with, this helps staff to get to know residents and what they like. Care plans link very well with the risk assessments, and shows that staff are ensuring that residents risks are checked on an ongoing basis. One residents care plan showed that she had a diagnosis of dementia, however this was in the early stages. There was limited information about how the residents displays symptoms of this illness, with the only reference being made to ensuring the resident doesn’t become socially isolated. The home must ensure that they can demonstrate that they can meet the needs of this individual. None of the care Bellefield Residential Home DS0000025330.V298245.R01.S.doc Version 5.2 Page 10 plans looked at had a signature from a resident or a family member to state that they had read or agreed to their care plan, which must be carried out. Records show that the home has links with and uses a wide variety of health professionals such as district nurses, opticians and dieticians. Residents confirmed that they are seen by these people in the privacy of their own bedrooms. Nutritional screening takes place for all residents, and is reviewed on a regular basis along with regular checks on their weights. Residents stated that they felt that staff were respectful and maintained their dignity. Comments were made such as “staff knock before coming into my room” and “staff here are nice and I always feel that they treat me well”. Medication administration records (MAR charts) and medication storage areas were checked during the inspection. The records for controlled drugs showed on 2 occasions, only 1 member of staff had dispensed and signed for medication, instead of 2. This is very serious, and could leave residents at risk and was discussed with the home manager to implement urgent action. It was identified that some residents were on a drug called ‘Fosamax’. This drug has very specific ways in which it needs to be administered. This information was not available on the MAR chart and staff were not aware of the way this drug needs to be given, staff need to be informed of this information to ensure the drug is given correctly. One resident who was on this drug had been given it for 13 days, instead of once a week according to MAR charts, which could put them at risk. 118 doses of medication had not been given to residents, according to the MAR charts and the balance of one residents box of paracetamol was checked. 36 tablets should have been in the box, but 55 were present when counted. It was also noted that when staff are handwriting MAR charts, they are not double signing them to ensure they are accurate. The manager must submit a plan to Commission for Social Care Inspection to state how the home are going to address these failings in medication management. Bellefield Residential Home DS0000025330.V298245.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 and 15 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to the service. The provision of activities could be improved to suit individual needs. Residents are encouraged to make personal choices and meals provided are wholesome and nutritious. EVIDENCE: The home has a weekly plan of activities which is displayed around the home, for residents to read. The planner is colourful and bold, with pictures that allow residents to clearly see what is available each day. Individual records are kept by the activities co-ordinator listing what residents have joined in with; this is then linked into their care plan. Discussions with the activity co-ordinator showed that cover for activities are provided from 9-5 on Tuesdays and Fridays, at other times, care staff supervise activities. The co-ordinator was not aware that she has a small budget and felt that raising money was hard through various fundraising events. Residents stated that they enjoyed the activities on offer, however 6 residents felt that on some days, staff were too busy to do activities. Comments were made such as “ sometimes there is not much to do, but I like it when I go out shopping” and “ they play ball games with us, but not much else sometimes”. One resident made comment that she felt that activities were Bellefield Residential Home DS0000025330.V298245.R01.S.doc Version 5.2 Page 12 sometimes aimed at the “more able” residents and that she felt that those who were less active sometimes got left out. These comments were discussed and fed back to the manager, who needs to review the provision of activities. Residents stated that the home has an open visiting policy and that they can meet relatives in any parts of the home. No visitors were at the home at the time of the inspection. Residents were observed to be given choices by staff during the day in a variety of aspects of their daily living. The kitchen area was checked during the inspection. It was found to be clean and tidy and to have good stocks of fresh foods. Chef commented that he felt the menus were liked, and this was confirmed by the residents. Lunchtime was observed and found to be a social and unhurried occasion, enjoyed by all. The inspector sampled the food, which was tasty and hot. The home does not currently have a cook at the weekend. The home manager or her deputy usually fulfils this role, as recruiting the position has been difficult. Temperature and cleaning records were checked and found to be completed well. Bellefield Residential Home DS0000025330.V298245.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 and 18 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to the service. The home has a complaints procedure, which is easy for residents or families to use. Staff have a good knowledge of adult protection procedures, which protects residents from abuse. EVIDENCE: The home has an up to date complaint procedure in place, details of which are displayed around the home for residents to read. Policies are also in place to protect staff including a policy on equal opportunities, bullying and harassment, whistle blowing and sexual harassment. The home has had 1 recorded complaint since the last the last inspection, which was dealt with appropriately. Staff interviewed demonstrated a good knowledge of adult protection issues and stated that they had received training on the subject, this included staff that do not give hands on care. The home has a variety of policies on abuse, including a copy of the local authority guidelines. Bellefield Residential Home DS0000025330.V298245.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 and 26 Quality outcomes in this area are adequate. This judgement has been made using available evidence including a visit to the service. The home is suitable for the residents who live there, creating a homely environment. All areas are clean and tidy. Not all fire doors were being used correctly, which could leave residents and staff at risk. EVIDENCE: A full tour of the home was carried out. 3 fire doors were found to be wedged open (kitchen, kitchen store and dining room). This was rectified during the inspection by the manager, however must be kept under review to ensure the safety of residents. Residents can smoke in the conservatory area of the home. Residents Felt that this was acceptable and didn’t cause any distress to those who didn’t smoke. Bedrooms and communal areas were clean and tidy. The domestic informed the inspector of what her day comprises of and stated that she has sufficient equipment and supplies to carry out her job. Staff and residents felt that the Bellefield Residential Home DS0000025330.V298245.R01.S.doc Version 5.2 Page 15 standard of cleanliness at the home was high and that furnishings were of a good standard. Staff at the home have received some training in COSHH (control of substances hazardous to health) and infection control. Policies are also in place regarding the control of infection at the home. Bellefield Residential Home DS0000025330.V298245.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 and 30 Quality outcomes in this area are adequate. This judgement has been made using available evidence including a visit to the service. Staffing levels are sufficient to operate a safe home, but training records do not reflect the training that staff have undertaken. Residents like the staff that care for them, but the home falls short of providing the 50 of staff holding NVQ (national vocational) qualifications. EVIDENCE: The home employs a variety of staff to care for residents. Staff rotas show that staff numbers are sufficient to meet the needs of the people who live at the home. Residents commented that staff are “very nice” and “caring and supportive”. All residents felt that there are enough staff around to help them if they needed it. Relative surveys used as part of the home quality assurance scheme had the following comments about staff- “The staff at Bellfield are most caring and attentive” and “staff are great”. 4 staff files were sampled, including the 2 most recently employed. Files showed that police checks and references had been carried out to ensure staff are suitable to work with vulnerable adults. Staff discussed recent training that had been carried out on manual handling, food safety, first aid and medication management, however training records did not reflect this. These records showed 22 staff needing first aid training, 16 needing manual handling training, 5 needing fire safety training and 1 needing basic food hygiene training. The manager must ensure that training records reflect the courses undertaken by staff. There are 16 care staff employed at the home, only 25 Bellefield Residential Home DS0000025330.V298245.R01.S.doc Version 5.2 Page 17 of these staff have a NVQ qualification, which falls short of the required 50 . The manager must put a plan in place as to how this is to be addressed. Bellefield Residential Home DS0000025330.V298245.R01.S.doc Version 5.2 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): 31,33,35 and 38 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to the service. Management of the home is clear and effective and quality monitoring well organised. Financial arrangements safeguard residents. EVIDENCE: The home manager is currently coming to the end of her NVQ level 4. The manager has worked at the home for several years and is well thought of by her staff, who felt they were given good support. The manager holds a weekly surgery for relatives and residents to come and speak to her in private. Annual questionnaires are sent to relatives for their comments, details of which have been included in this report. Resident and staff meetings take place on a regular basis, offering further opportunities to give opinions on the service. The manager keeps policies and procedures under regular review and an annual development plan is available for the home, showing areas for improvement. Bellefield Residential Home DS0000025330.V298245.R01.S.doc Version 5.2 Page 19 Financial records were sampled, which were well recorded. Records showed all monies that are held on a residents behalf and all monies given to individual residents. Large amounts of money are returned to families or put in residents bank accounts in order to ensure money is kept safely. Safety checks have been carried out at the home to ensure it is safe and accidents are recorded and monitored by the manager for any ongoing problems. Regular fire drills are completed by staff and emergency evacuation procedures are available for staff to follow. Bellefield Residential Home DS0000025330.V298245.R01.S.doc Version 5.2 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Bellefield Residential Home DS0000025330.V298245.R01.S.doc Version 5.2 Page 21 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(1) Requirement The registered person must ensure that care plans are formulated along side the resident and or their representative. The registered person must address how they are to meet the needs of the resident identified who is in the early stages of dementia. 2. OP9 13(2) The registered person must ensure that: 1.Handwritten entries are double signed and dated (remains outstanding from previous inspection) 2.Controlled drugs are signed by two members of staff 3.MAR charts contain the information needed by staff to safely administer the medication 4.All medications are given as prescribed 5. The manager provides Bellefield Residential Home DS0000025330.V298245.R01.S.doc Version 5.2 Page 22 Timescale for action 31/10/06 25/09/06 3 OP12 16(2)(m) 4 OP19 23(1) 5 OP28 18 6. OP30 18(1) Commission for Social Care Inspection with a plan of improvement for the administration of medication The registered person must review the provision of activities at the home to suit the needs of individuals. The registered person must ensure that: The toilet opposite room 4 has replacement flooring (remains outstanding from previous inspection) Fire doors are not wedged open The registered manager must ensure that a plan in put in place to address the shortfall for staff who hold NVQ qualifications The registered person must ensure that all staff receive mandatory training and that records are kept up to date (Remains outstanding from previous inspection) 01/12/06 01/09/06 01/10/06 01/11/06 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 OP12 Good Practice Recommendations The inspector strongly recommends an increase in the staffing hours for activities Bellefield Residential Home DS0000025330.V298245.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Bellefield Residential Home DS0000025330.V298245.R01.S.doc Version 5.2 Page 24 - 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. 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