CARE HOMES FOR OLDER PEOPLE
Bellegrove 100 Mickleham Road St Pauls Cray Orpington Kent BR5 2TL Lead Inspector
Wendy Owen Unannounced 01 August 2005 00:00 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. Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Bellegrove Address 100 Mickleham Road St Pauls Cray Orpington Kent BR5 2TL 020 8300 0108 0208 309 7043 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) Shaw Healthcare Ltd Margaret Rolls CRH 58 Category(ies) of DE(E) 28 registration, with number OP 30 of places Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 28/02/05 Brief Description of the Service: Bellegrove is a detached purpose built two-storey building situated in a residential area close to the local library, health centre and a parade of shops. The Home is registered to provide care to 30 older people and 28 older people with dementia. There is also a day centre for 20 clients on the ground floor. This is not part of the registered premises. The Home is separated into two units with the ground floor providing care to service users with dementia and the first floor, caring for older and frailer service users. The local bus stops outside the home and there is parking at the front of the building and a small, enclosed garden at the rear of the home. Shaw Healthcare have recently taken over the provision of the Local Authority contract and are responsible for the management and staffing. Staffing arrangements provide twenty-four hour care to service users living in the Home. The building is leased from the London Borough of Bromley and recent reports have identified a need for refurbishment and redecoration throughout. Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over one day with two inspectors undertaking the inspection. The inspection included viewing records; tour of the home; discussions with service users; staff; relatives and the manager. The Commission received verbal feedback from one relative and two residents and written feedback from five relatives. What the service does well: What has improved since the last inspection?
Since the last inspection the home now has only four double rooms remaining with the remainder being single bedrooms. Care plans were not viewed on this occasion and therefore no judgement has been made on their improvement. The manager now monitors the accidents in the home monthly with action taken to minimise the risks. Fire drills are now taking place at appropriate times and a fire risk assessment has been completed. The servicing of the gas equipment has also been completed. Night-time staffing is being reviewed to increase the waking staff from three to four and is currently being addressed through recruitment procedures. Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.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. Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.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 Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.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) 1 The Statement of Purpose is not up to date and therefore does not give full and accurate information to residents and relatives and therefore they can not make an informed choice on the suitability of the home. EVIDENCE: The organisation has developed a Statement of Purpose and draft Service Users’ Guide. Since the production of these documents there have been some changes to the number of bedrooms and therefore the number of residents it is able to care for. The Statement of Purpose and Service Users’ Guide needs to be amended to reflect these changes. (See requirement 1) The last inspection required the home confirm in writing to residents or their relatives, that, after assessment, they are able to meet the individuals’ needs. (See requirement 2) Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.doc Version 1.30 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 standard(s) 9 & 10 The staff treat residents privacy and dignity are maintained ensuring the rights of residents are respected. Medication procedures require improvement to ensure the potential risks to residents’ health are minimised. EVIDENCE: The organisation’s aims and objectives include the right to privacy, dignity and respect. The Statement of Purpose provides a statement of how this will be met though training, care practices and codes of conduct. Feedback indicates that the practice does meet these needs, including knocking on doors before entering the rooms, using preferred names and ensuring privacy and dignity during personal care. The organisation has also reduced the number of shared rooms in the home to one. Therefore all but two residents have private rooms. Medication is stored in a combined hairdressing/treatment room in two trolleys, one for each unit. Standard 26 comments on the standard of cleanliness and tidiness throughout the home and includes the poor cleanliness in this room, which is also used as a hairdressing room Records of medication returned had been left lying around, leaving a state of untidiness but also risk of mislaying these records. Controlled drugs were checked and whilst
Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.doc Version 1.30 Page 10 medication corresponded to the amounts recorded, there were gaps in the records, including second signatures and accurate records of medication received were missing for a number of residents. There was no up to date review of those residents self -medicating and no indication on medication records that this was the procedure; not all medication had been signed as being received into the home or dated. Ensure food supplements were being used, even though out of date and not prescribed for any particular resident. Fridge temperatures were recorded but not the temperature of the room which may result in medication being stored incorrectly. (See requirement 3) Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.doc Version 1.30 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 standard(s) 12, 13 & 15 Meals provided are not nutritious or varied enough to provide a healthy and balanced diet for residents. Whilst there is an activity schedule in place, not all individuals benefit from regular involvement to ensure residents are stimulated and interest maintained. EVIDENCE: The main meals are provided by another residential home, Manorfields and supplied to the home in hot trolleys. Previous reports and feedback on the day have identified a need to improve the quality of food provided. The menu viewed on the day showed a very basic standard of food and poor choice provided, which was born out by the days main meal of fishfingers or mince and vegetables. The cauliflower served was greyish in colour and looked very unappetising. One of the desserts offered was a packet mousse prepared by the staff. The Service Users’ Guide states that there is a team of catering staff taking instruction from the manager and later state that catering staff throughout the day will meet all reasonable personal requests for alternatives or snacks. The home does not have a catering team and any other snacks, including the hot evening meal being prepared by the care staff. This is not acceptable not only does the food not meet basic standards but support staff are also undertaking tasks required of kitchen assistants. There
Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.doc Version 1.30 Page 12 is no record of what food is provided to each resident in order that nutritional intake may be monitored. (See requirement 4) The feedback from relatives indicate that the home could do more to provide a more stimulating environment for residents. The Service Users’ Guide and Statement of Purpose state a wide range of activities but this is not evident for many residents. The home must also note the inappropriateness of displaying Christmas photos on walls on the dementia unit at this time of year. This may be confusing to residents who are already struggling with cognitive impairment. (See requirement 5) Consideration should also be given to ensuring the accuracy of the information provided in the Statement of Purpose. It currently indicates that the home has its own hairdressing salon. However, this may be misleading as the same room is used for medication storage. Visitors are welcome into the home at any reasonable time of the day. This was evident by the number of visitors and seen to be coming and going. The Service Users’ Guide confirms that visitors are welcome throughout the day in residents’ individual rooms or communal areas. Visitors did not express any concern regarding lack of separate accommodation for this. Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.doc Version 1.30 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 standard(s) EVIDENCE: Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.doc Version 1.30 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 standard(s) 19, 20, 21, 23,24,25,26 There has been little progress in the redecoration of communal areas nor have thermostatic valves been fitted. Therefore the home does not provide a homely environment but due to the poor standards of cleanliness, there are potential risks of infection to residents. EVIDENCE: The standard of decoration throughout the home has progressed little since the last inspection. Whilst a few bedrooms have been redecorated and carpeted many of the rooms and communal areas are in great need of redecoration. Many of the rooms do not contain the furniture detailed in the standard with one room having only a commode as “comfortable seating” for the resident. The standard of cleanliness was also poor despite the home’s “Guide” stating that, “your room will be cleaned thoroughly once a week” and “tidied and spot cleaned everyday”. The bed-linen on beds made that morning were found to be very soiled, crumpled and of poor standard, even though the home’s information said these would be changed regularly. Flannels had been made
Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.doc Version 1.30 Page 15 out of torn up towels and other towels were torn or badly frayed. The inspectors were informed that laundry staff only work until 12 or 1 and there is a vacancy of 27 hours for this team and there are no domestic staff after 2pm. The situation has been exacerbated by the handyman, who undertook regular carpet cleaning, having been on long-term sick. Some of the carpets are now beyond improvement through cleaning. Support staff are undertaking afternoon laundry tasks with a risk of cross infection occurring with mixing kitchen, personal care and laundry tasks. Table linen was also placed on tables without being ironed, made more difficult not only by lack of staff but also equipment specific for these chores. The home must review the staffing and tasks of support workers; domestic and laundry staff to ensure the appropriate staff are available to undertake dedicated tasks throughout the day. One resident has MRSA and although there is protective equipment available these were kept in the individuals wardrobe with clothing and personal possessions. This is not the ideal place and needs to be more prominently placed (See requirements 6-11) Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.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) 27 & 28 The mix, number and deployment of staff must be reviewed to ensure key staff are available during key times of the day and provide sufficient care to residents. EVIDENCE: Previous comments have identified concerns regarding the staff mix within the home. The “Guide” states that, the home will be led by a team leader during the morning and afternoon and at night “on call”. The Guide also states that the manager will be supernumary and the staffing will meet the London Registered Guidelines. There is no mention of the position of the deputy manager. This leads to concerns as to how the home will provide the management hours, especially where team leaders are heavily involved in medication tasks and other chores. The London Guidelines require management hours to be provided at the weekend as well as the week. A review of the whole staffing must be undertaken to ensure there are adequate staffing at all levels and mix, throughout the week and at core times. (See requirement 12) The Commission received mixed feedback regarding the knowledge, skills and understanding of some of the staff. The feedback indicates that some staff are unable to communicate to a basic standard in either the verbal or written form. This means vital information may be lost and potentially residents put at risk. (See requirement 13) Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.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) 33 &38 Lack of monitoring procedures do not ensure the quality and standards of care are maintained or improved upon and also leaves residents are potentially at risk. EVIDENCE: Discussions with the Manager and staff confirm the high amount of training being provided by the new provider. For the Manager, in particular, this has meant a great deal of time being spent out of the home. The poor standards in some areas may be a result of the lack of time to monitor and audit procedures. However, auditing and monitoring are integral to good management and must be evident. This includes the undertaking of monthly visits by the delegated responsible person. The Commission has received no reports over the last few months nor could the home locate their copies of the report. (See requirement 14) Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.doc Version 1.30 Page 18 A sample of service contracts were viewed and a shortfall identified in the following areas; the up to date chlorination certificate and fixed wiring certificate. The latter was sent to the Commission a week after the inspection. All staff have, or will receive, the company’s four day induction which includes COSHH; health and safety; fire training; moving and handling and risk assessment. First aid training is also in place for a number of staff. The safety of residents in the home is supported with an alarm system in private and communal areas. However, safety is compromised where practice such as placing a disposable glove over a smoke alarm occurs. The Commission receives notification of incidents as required under regulation 37. Accidents are monitored each month by the manager. (See requirements 15-18) Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.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 2 x x 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2
COMPLAINTS AND PROTECTION 2 3 3 x 2 2 2 2 STAFFING Standard No Score 27 2 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 2 x x x x x x 2 Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.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 1 4 Regulation 4&5 14 Requirement The Registered Person must amend the Statement of Purpose and Service Users Guide. The Registered Person must confirm in writing to the resident or relative, that the home is able to meet indiviudal needs. This is outstanding from the last inspection The Registered Person must ensure that medication procedures are safe. Specifically, All medication reocrds must be kept secure within the home. An accurate record of controlled drugs must be maintained. Residents who self-adminster must have their risk assessments reviewed regularly. All medication must be recorded into the home with the date of receipt and the signature of the person making the reocrd. The home must not use medication which is out of date. The Registered Person must provide residents with food that is nutritious and adequate in quantity. The home must maintain records of meals
Version 1.30 Timescale for action 1/12/05 1/12/05 3. 9 13 1/09/05 4. 15 16 1/12/05 Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.doc Page 21 5. 12 16 6. 19 16 & 23 7. 19 23 8. /26 13 9. 10. 23 23 16 16 11. 19 23 12. 27 18 13. 28 18 provided to individuals. The current system must be reviewed. The Registered Person must provide an action plan on how the home meets the individual social interests and needs of residents. The Registered Person must provide the Commission with an action for the replacement of worn carpets throughout the home. This is an outstanding requirement from the last inspection. The Registered Person must fit individual thermostatic valves to radiators throughout the home in order that residents are able to control temperatures. The Registered Person must ensure that the home is maintained to an adequate standard of cleanliness. The Registered Person must provide adequate furniture in residents bedrooms. The Registered Person must provide residents with clean bedlinen, flannels and towes which are renewed regularly. The Registered Person must provide the Commission with an action plan for the redecoration of communal and private areas. This is outstanding from the last inspection. The Registered Person must review the staffing level and mix to ensure adequate staffing is provided at all times. The Registered Person must ensure that all staff are able to comminicate effectively to residents, staff, relatives and any other agencies involved in the care fo the resident.
Version 1.30 1/12/05 1/10/05 1/12/05 1/09/05 1/10/05 1/09/05 1/10/05 1/10/05 1/10/05 Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.doc Page 22 14. 31 24 15. 38 24 & 26 16. 38 23 17. 38 23 18. 38 23 The Registered Person and Registered Manager must ensure adequate auditing and monitoring of practice and quality of care is undertaken regularly. Copies of Regulation 26 visits must be supplied to the Commission and to the Registered Manager. The Registered Person must complete the work require identified in the Periodic Electrical Installation Inspection report (fixed wiring) dated 15/07/04. Please provide an action plan for the completion of this work. The Registered Person must provide the Commission with details of the up to date chlorination certiifcate. The Registered Person must ensure that the fire alarm system is regularly tested from different call points The Registered Person must ensure that smoke detectors are not covered. 1/09/05 1/09/05 1/09/05 1/09/05 1/09/05 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 Good Practice Recommendations Bellegrove G51G01s63845Bellegrove.v233234.01.8.2005stage4.doc Version 1.30 Page 23 Commission for Social Care Inspection Riverhouse 1 Maidstone Road Sidcup Kent DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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