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Inspection on 05/10/05 for Bellefield Residential Home

Also see our care home review for Bellefield Residential Home for more information

This inspection was carried out on 5th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Prospective residents receive an appropriate assessment before they come to live at the home and are encouraged to visit the home to ensure that it is suitable. Detailed care plans are provided so that staff are aware of how to meet the health and personal care needs of residents. The daily routines at the home ensure that the preferences of residents are respected. Visitors are encouraged and community links are promoted. There is a clear complaint procedure and evidence that complaints are dealt with appropriately. The home provides a comfortable and pleasant atmosphere. The home is clean and generally well presented. Residents are protected by the recruitment practices in operation at the home. The management and administrative systems promote the wellbeing of residents.

What has improved since the last inspection?

There have been improvements to the decoration at the home and to record keeping in accordance with requirements and a recommendation made at the last inspection.

What the care home could do better:

The timescale for completing the contracts/terms and conditions could better support the interests of residents. Improvements need to be made to the decoration of some of the communal areas of the home.

CARE HOMES FOR OLDER PEOPLE Bellefield Residential Home 42 Aysgarth Avenue Liverpool Merseyside L12 8QT Lead Inspector Beate Roth Unannounced Inspection 10:00 5 October and 13 October 2005 th th 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.V257069.R01.S.doc Version 5.0 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.V257069.R01.S.doc Version 5.0 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.V257069.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th October 2004 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.V257069.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days and lasted for 6 hours. During the inspection time was spent in the office examining records and policies and procedures and talking to the manager. A tour of the home was undertaken. Staff were observed delivering care to residents. The inspectors spoke to residents, relatives and to staff. What the service does well: What has improved since the last inspection? What they could do better: The timescale for completing the contracts/terms and conditions could better support the interests of residents. Improvements need to be made to the decoration of some of the communal areas of the home. Bellefield Residential Home DS0000025330.V257069.R01.S.doc Version 5.0 Page 6 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.V257069.R01.S.doc Version 5.0 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.V257069.R01.S.doc Version 5.0 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): 1, 2, 3 and 5 New residents are fully assessed before they are admitted to the home in order to ensure their needs are met. Residents’ benefit from being able to visit the home to assess if it will be suitable. The timescale for completing the contracts/terms and conditions could better support the interests of service users. EVIDENCE: A statement and purpose and a service user guide were not available for prospective residents at the time of the inspection as these documents were being revised. All current service users have received a copy of the previous service user guide. Each resident is provided with a contract after a period of settling in, usually within 4 weeks of admission. The contract contains all the required information. Extra charges are made for hairdressing, newspapers and chiropody. A sample of residents’ records were examined and indicated that Bellefield Residential Home DS0000025330.V257069.R01.S.doc Version 5.0 Page 9 one resident had been living at the home since February 2005 and did not have a completed contract. A sample of new residents’ files were examined. There was evidence of appropriate assessments being carried out before new residents move to the home. There was also evidence that information is gathered from social workers and health professionals to inform the assessment. The manager or deputy undertake the initial assessment of prospective residents using a holistic assessment tool that provides the basis for ongoing care planning. Inspection of records and discussions with residents, relatives and the manager confirmed that residents are able to visit the home prior to them being admitted. Residents are admitted to the home following a four-week trial period where the placement is formally reviewed. Bellefield Residential Home DS0000025330.V257069.R01.S.doc Version 5.0 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 the following standard(s): 7, 8 and 11 The health and personal care needs of residents are well supported by the care planning processes and procedures in place at the home. EVIDENCE: A sample of residents’ records were looked at and indicated that residents have a detailed care plan in place. Assessments are undertaken in relation to: physical and social well being, pressure sores, manual handling, dependency, nutritional needs, continence, falls and individual assessments associated to the residents needs. Where a need is identified through the assessment process a care plan in relation to this need is devised. It is evident that care plans are being reviewed at least monthly and a written comment is provided in relation to the review. Care staff reported that they have ongoing access to care files and care plans and that they are able to contribute to the care planning review arrangements for residents they key work. There was evidence in the records that the views of residents and their relatives are obtained. Bellefield Residential Home DS0000025330.V257069.R01.S.doc Version 5.0 Page 11 The records at the home indicated that referrals are made to health professionals in accordance with the needs of service users. A record is made of visits by health professionals and the outcome is documented. Observations and a discussion with staff indicated that care and comfort are provided to residents who are dying and they and their relatives are treated with sensitivity and respect. The homes written procedures for handling dying and death would ensure that the staff promote the well being of the resident at all times. Bellefield Residential Home DS0000025330.V257069.R01.S.doc Version 5.0 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 the following standard(s): 12 and 13 The daily routines at the home ensure that the preferences of residents are respected. The home ensures that the social and emotional needs of residents are promoted by maintaining community links and encouraging visitors. EVIDENCE: Discussions with residents indicated that daily life at the home meets their preferences. Activities are provided, residents considered that in general there is enough for them to do and that they are consulted about planned activities. There is currently a vacancy for an activity co-ordinator. The manager and staff reported some difficulties in providing activities at present due to not having an activities co-ordinator and having staff vacancies. This staffing shortfall is actively being addressed. Records indicate the interests of residents, which inform the activities offered. A record is made of any activities a resident takes part in. There are no restrictions in relation to visiting the home at reasonable times. There are adequate facilities for residents to receive visitors in private or in one of the communal lounges/dining area. During the inspection a number of residents were receiving visitors and discussion with residents and visitors indicates that the home actively encourages and facilitates visiting. The home Bellefield Residential Home DS0000025330.V257069.R01.S.doc Version 5.0 Page 13 maintains a number of links within the wider community including the local parish centre and community hall. Bellefield Residential Home DS0000025330.V257069.R01.S.doc Version 5.0 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 the following standard(s): 16 The home has a satisfactory complaints system with evidence that the views of residents and their representatives are listened to and acted upon. EVIDENCE: The home has a corporate written complaints procedure that states complaints will be responded to within 28 days. The complaints procedure is displayed in the reception area and is contained in the service users guide, all existing service users have a copy of this document. Residents reported that if they wished to raise any issues about the standards of the service provided they would speak to the manager or deputy manager. No complaints have been made to the CSCI since the last inspection. There had been one complaint to the home since the last inspection. The records relating to this indicated that the issues raised were appropriately dealt with. Staff have received training around the homes complaint procedure. Bellefield Residential Home DS0000025330.V257069.R01.S.doc Version 5.0 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 the following standard(s): 19 and 26 The home is generally well maintained and there is a good standard of cleanliness, providing residents with a pleasant environment to live in. EVIDENCE: The home is generally well maintained. A handyman is employed to undertake maintenance tasks although contractors are used where appropriate. Since the last inspection, most of the requirements relating to the decoration and maintenance of the premises have been addressed. The requirements to provide adequate attention to the floor tiles in the conservatory and to the heavily stained carpet in the small lounge nearest the dining room have not been addressed. At this inspection it was identified that attention is needed to the carpet in the other small lounge, which has several cigarette burn marks. A risk assessment for the sinks in the bedrooms with en-suite facilities indicated that the water can exceed 43 degrees centigrade and presents a risk to residents. The manager was advised to revise the risk assessment as the steps taken to minimise the risks were not sufficient and did not promote residents rights to have control over their day to day personal care, where Bellefield Residential Home DS0000025330.V257069.R01.S.doc Version 5.0 Page 16 appropriate. During the inspection this matter was addressed as thermostatic mixing valves with adjustable temperature controls were fitted to all the sinks identified. A tour of the home indicated that the home was clean and malodour free. There are adequate policies in place in relation to the control of infection and clinical waste. The home employs sufficient domestic staff. Bellefield Residential Home DS0000025330.V257069.R01.S.doc Version 5.0 Page 17 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 and 29 The needs of residents are met by the numbers of staff. The recruitment practices at the home safeguard the welfare of residents. EVIDENCE: The rota and a discussion with the staff and the manager indicated that there are sufficient numbers of staff to meet the needs of the residents living at the home at the time of the inspection. There is a clear staff structure in the home that includes the manager, deputy manager, senior care staff, care staff and ancillary staff. There is currently a vacancy for two full-time care assistants, a night care assistant and an activities co-ordinator. The manager has taken steps to address this shortfall. In the interim the existing staff team and agency staff are covering the vacancies. Of the thirteen care staff employed five staff have achieved NVQ level 2 and a further five staff are undertaking the NVQ level 2 qualification. A minimum of 50 of staff are to hold an NVQ qualification or equivalent by 2005. One new member of staff has been employed since the last inspection. The records of recruitment in respect of this member of staff were examined and contained all the required information. Evidence of a CRB check was also available for the staff identified at the last inspection as not having received a CRB check. Bellefield Residential Home DS0000025330.V257069.R01.S.doc Version 5.0 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 The management and administrative systems in place at the home support the best interests of the residents. EVIDENCE: The registered manager is currently undertaking NVQ level 4 in management and care. The manager has managed the home for a number of years and undertakes periodic training to update her knowledge and skills. The manager is to obtain an NVQ Level 4 (or equivalent) in care and management by 2005. Bellefield Residential Home DS0000025330.V257069.R01.S.doc Version 5.0 Page 19 Bellefield has a number of quality monitoring systems in operation. Southern Cross implement a range of quality monitoring processes including monthly and bi –monthly audits of different areas of operation at the home, such as medication and finances. These are carried out by the manager and regional manager. Action plans of these audits were available for inspection. The regional manager undertakes monthly regulation 26 visits which includes discussions with the staff and residents. A copy of the report of this visit is forwarded to CSCI. Residents’ questionnaires are available for completion providing further opportunities for residents to comment on the services provided. The home looks after the personal allowances for some residents. Records in relation to residents’ personal monies were inspected and were appropriately maintained. Regular auditing of residents monies takes place. The home has appropriate secure storage facilities for residents’ personal monies. The records of fire safety checks, electricity and gas were in order. Recommendations following the inspections of the fire alarm and electrical lighting had been undertaken. Training records and a discussion with staff showed that staff are given appropriate training in safe working practices. Bellefield Residential Home DS0000025330.V257069.R01.S.doc Version 5.0 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 2 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Bellefield Residential Home DS0000025330.V257069.R01.S.doc Version 5.0 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 2 3 Standard 1 2 19 Regulation 4,5 5 23 Requirement Timescale for action 13/11/05 A revised statement of purpose and a service user guide must be made available to the CSCI. A contract must be available for 13/10/05 each service user on admission to the home. 13/11/05 The registered person must ensure that adequate attention is undertaken in relation to the following: A number of conservatory tiles are cracked • The small carpet to the small lounge is heavily stained (Previous timescale of 13/12/04 not met.) • 4 19 23 13/01/05 The registered person must ensure that adequate attention is undertaken in relation to the lounge carpet that has a number of cigarette burns. Bellefield Residential Home DS0000025330.V257069.R01.S.doc Version 5.0 Page 22 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 Refer to Standard 28 31 Good Practice Recommendations A minimum of 50 of staff are to hold an NVQ qualification or equivalent by 2005. The manager is to obtain an NVQ Level 4 (or equivalent) in care and management by 2005. Bellefield Residential Home DS0000025330.V257069.R01.S.doc Version 5.0 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. Extracts may not be used or reproduced without the express permission of CSCI Bellefield Residential Home DS0000025330.V257069.R01.S.doc Version 5.0 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. 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!