Inspection on 17/07/06 for Bellegrove

This inspection was carried out on 17th July 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

Bellegrove 05/11/07

Bellegrove 30/01/06

Bellegrove 01/08/05

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Bellegrove Bellegrove 100 Mickleham Road St Pauls Cray Orpington Kent BR5 2TL Lead Inspector Wendy Owen Key Unannounced Inspection 17th July 2006 09:30 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 Bellegrove DS0000063945.V297631.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. Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bellegrove Address Bellegrove 100 Mickleham Road St Pauls Cray Orpington Kent BR5 2TL 020 8300 0108 020 8309 7043 bellegrove@shaw.co.uk 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) Shaw healthcare Ltd Margaret Rolls Care Home 58 Category(ies) of Dementia - over 65 years of age (28), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (29) Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 place registered for service user category MD for named service user only. 1st August 2005 Date of last inspection 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. The fees are £371.05 -£488 per week. The fees include accommodation, food and staffing. Toiletries, clothing and personal expenditure such as hairdressing and private chiropody etc are not included. Information regarding the care provided is available on request from the home and also available in the reception area. A copy of the latest CSCI inspection report is available on request. Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection included feedback written and verbal from residents and residents; verbal feedback from a health professional, care staff and management. The Inspector also viewed records, observed practices and toured parts of the home. 5 comment cards were received from relatives and 14 from residents. What the service does well: Bellegrove provides good care to the residents. “My husband is always well looked after. His every need is catered for.” “Staff are organised and there appears to be good rapport between individuals. “Staff are caring and seem competent in their management of residents.” Shaw Healthcare ensures staff are trained and competent with core training updated regularly and over 50 of staff qualified to NVQ 2 or above. “I know they (staff) attend training and that their manager has a good knowledge of their work.” one relative said. The home is well managed by a Manager who is qualified and experienced and ensures staff are supervised and supported as well as ensuring the health and safety of the residents and staff. The Manager and staff have a willingness to learn, take advice and seek to ensure the home meets the standards and Regulations. The medication practices are satisfactory and the healthcare needs of residents are being met, although improvements are required in the records maintained. All relatives who provided feedback said that the home communicates well if there are any problems or issues. Bellegrove has robust complaint and adult protection procedures, which are implemented by the home when the need arises. This ensures residents are protected and any concerns listened to. Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 6 The Manager implements the quality assurance developed by Shaw to ensure residents’ needs are being met and the service is continually looking to improve. All relatives who provided feedback stated that visiting is open and flexible and that, they are made very welcome by the Management and staff. When asked “Do staff make you feel welcome?” one relative wrote “Yes, very much so.” What has improved since the last inspection? What they could do better: The main concern raised during this inspection relates to the standard of the environment. There is a need for significant improvement in a number of areas to ensure residents are provided with a well maintained, well decorated and furnished environment which is comfortable and homely. The poor standard of the environment has a negative impact regarding the standard of cleanliness. One relative said “….continuous improvement is required.” Whilst another relative said that the toilets could be cleaned more regularly throughout the day. Whilst there is some evidence that pre-admission procedures ensure prospective residents are assessed prior to admission, the lack of formal assessment records, in some cases, means that staff do not have the full information to ensure residents needs will be met. Nor do all the residents benefit from signed terms and conditions of residency. Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 7 The care planning documentation did not reflect the individual needs and such gaps in information means residents’ needs may not be fully met. The medication practices are generally satisfactory, although some improvements still require improvement. Residents and relatives feedback shows that the activities provided could be improved upon. One resident said, “ I would like more activities arranged by the home” whilst a relative felt that more activities in smaller groups or one to one would benefit the residents, especially those who do not like big groups. Previous comments in the summary show that staff are provided with comprehensive training. However, further training in more specific age related diseases would be beneficial to ensure staff have a full understanding of the residents’ needs. Eg Parkinson’s Disease and epilepsy. Shaw have robust procedures to ensure service users’ monies are well looked after. However, there are some concerns regarding the residents’ accounts being non-interest bearing and the need to improve some practices to ensure the monies received by the home are well recorded and accounted for. 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 DS0000063945.V297631.R01.S.doc Version 5.2 Page 8 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 Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 9 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): 1,2,3,4 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service have some information about the home in order to make an informed decision about whether the service is right for them. The variability of the assessment process means that staff do not always have the information they require to plan how they can fully meet the needs of individuals. EVIDENCE: Shaw have comprehensive procedures to determine the appropriate ness of placements and admissions to the home. Written feedback showed that the majority of residents had information on the home prior to admission. One relative told the Inspector that home had assessed resident and asked for information about their needs before being admitted. The relative has visited the home before being admitted. The Manager also spoke of assessing a resident in another home before agreeing admission to Bellegrove. Two residents’ files were viewed. One of these was a resident admitted from another Shaw, there was no assessment record on the file despite the Manager Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 10 remembering making the visit and assessment. Nor was there a Care Manager assessment. The second file did contain both the home’s assessment and Care Manager assessment. Shaw have developed comprehensive terms and conditions of residency which must be completed for all residents on admission. Written feedback showed that the majority of residents were not able to answer the questions. Viewing of five residents’ files showed that the provision of a contract was variable especially those that that had been signed and dated by the resident or their representative. The files of the two most recent admissions did not contain a placement agreement agreed by the Local Authority. (See requirements 1 & 2) Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 11 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 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is adequately meeting the healthcare needs of individuals. However, the mixed standard of care plans means there is variable practice and not all service users can be sure that their care needs are fully met. EVIDENCE: Four residents were case-tracked and all resident’s files viewed had a care plan developed. However, these were of a variable standard. Most were adequately completed. However, in some cases the care plans contained basic information on their care needs and there was a lack of any interventions required especially in relation to mobility, catheter or continence and personal care, although this was evident in the activity of daily living assessment. The files contained a number of risk assessments. However, once again some did not contain information in relation to the interventions required where risks were identified. Examples of this include pressure care risk and nutritional risk assessments, which had no corresponding care plan entry. Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 12 Senior staff have attended care planning training organised by Shaw and are now awaiting the delivery of the new documentation. The inspector received positive feedback from staff who feel they understand the care planning process much better. (See requirement 3) Assessments in relation to healthcare were also variable and, in some cases, limited. There were limited risk assessments in relation to challenging behaviour and physical health risks. The feedback received from the questions “Do you receive the care and support you need?” And “Do staff act and listen to what you say?” showed that the majority of the residents feel they do. Two relatives spoken to were very happy with the care provided and felt the staff understood their relative’s needs. (See requirement 4) The supporting documentation showed that there are good records in relation to the home accessing healthcare for residents. All residents are registered with a GP who also provides District Nurse services. The home has a visiting chiropodist, private and NHS; visiting optician and dentist, when required. A Occupational Therapist who had the opportunity to provide feedback told the inspector that she had observed good care practices and staff interacted with residents in a caring and friendly manner. She informed the inspector of the reasons for her visit and that of the physiotherapist. The home also benefited from the support of a Parkinson’s Disease nurse visiting service users. The District Nurse service is responsible for the administering of insulin to diabetic residents. However, it is a concern that there is a lack of information regarding the dietary needs of one of the residents who is an insulin dependent diabetic. Written and verbal feedback confirmed that the home communicates well with relatives whenever there is an issue relating to their health and well-being and one member of staff spoken to told the inspector how she relates the residents progress to the family member whenever the relative is in the home. (See requirement 4) Medication records were viewed for those resident who were being case tracked. In general these were found to be satisfactory with a few improvements required. The records were generally well completed, although there was a lack of allergies recorded on some, and whilst medication had been signed and counted as received, the date had been missed in all cases. For one medication record there was no evidence of the medication counted, signed for or dated as received into the home. The home should also be aware that the practice of using printed labels on medication records must be discontinued and where there is any hand-written medication there should be two signatures countersigning the record. (See requirement 5 and recommendation 3) Observations throughout the day provided evidence of staff treating residents with respect and courtesy and interacting in a warm and friendly manner. Residents’ privacy is respected with staff calling residents by their preferred name and ensuring they knock on the doors before entering the room. Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 13 Bellegrove has only one double room which has a screen placed around the wash-basin for privacy. Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 14 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 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The quality of food is satisfactory, although variable at times. The activities within the home and community mean the service users have a range of opportunities to participate in stimulating and motivating activities. EVIDENCE: The home has a schedule of activities which are provided by the Activity Coordinator. The written feedback showed a mixed response on how people view this provision. With the number of residents it is difficult to have small groups or one-to ones on a regular basis which suits some residents. There was evidence of a quiz and bingo being held and preparations were being made for the Summer fete taking place at the weekend. There was also some evidence of entertainment taking place. Since the last inspection last inspection there has been an improvement in the records maintained for each individual in relation to participation in activities. (See recommendation 4) Meals were also variable as highlighted in the monthly Provider reports. The organisation aims to improve the standards over the next few months by installation of a re-generation kitchen. The kitchen area used at present is of a Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 15 poor standard, as is the standard of carpeting in the area directly leading to the kitchen. With a re-generation kitchen the home will be able to plan menus in the home and ensure meals are of an adequate temperatures. (See requirement 8) The day centre located in the home is due to be closed in the next few months which means this area will be used as a large dining room for the ground floor, relieving much needed lounge space. The Manager has started to hold residents and relatives meetings as indicated n the last report. The home also enables residents to bring in their property, possessions and mementoes to ensure their private spaces are comfortable and homely. However, there is a need to ensure that any property brought in is safe and an accurate record made. There was no record of property brought into the home in the case of one resident but records in respect of another. Bellegrove welcomes visitors to the home throughout the day. There are no restrictions. The feedback shows that the home has good communication between themselves and relatives. This is demonstrated in the recent collaboration for the Garden fete. Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 16 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): 16,17 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel safe and listened to. Formal processes and procedures are available, understood and consistently applied. EVIDENCE: Shaw have comprehensive complaints and adult protection procedures in place. The procedures are implemented effectively by the Manager. The home keeps a record of the complaints, written and verbal, the responses with action undertaken to address the issues. Two relatives spoken to told the inspector they would take any concerns to the Manager, who is very approachable and listens to their concerns. This was apparent from the observations made during the course of the inspection. The complaints log showed complaints that had been dealt with by the home and were dealt with appropriately. There were no complaints received by the Social Services complaints department in the last six months. Nor has the Commission been made aware of any concerns. The Protection of Vulnerable Adults from abuse is discussed with all new staff during the induction training. The organisation’s procedures are comprehensive and detail the action to be taken in the event of any allegation, including the referral to the relevant agencies. The Commission is aware that where necessary, the procedures have been implemented effectively. Discussions with staff showed that they have a basic understanding of types of abuse and what they would do if they were aware of any incidents. All stated Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 17 that they would refer to the line manager. However, more comprehensive training would benefit staff to ensure they have a better understanding of the roles of various agencies. (See recommendation 5) All residents are entered onto the electoral register with residents take part in the voting process either through postal voting or a visit to the polling booth at election time. Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 18 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): 19,20,21,23,24,25 & 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The environment would benefit from redecoration, maintenance and repair work in many areas. This would ensure that residents live in a safe, well maintained and comfortable environment. EVIDENCE: Previous reports have highlighted the need for redecoration and refurbishment of a number of areas. Whilst there is some evidence of bedrooms being redecorated, the standard of the communal areas remains poor. The home looks tired and shabby. It gives the appearance of not being cleaned to a good standard due to the negative effect of the décor and furnishings. The Manager made the Inspector aware of the plans for the home, including a complete redecoration of the first floor dining room area and new carpets; the refurbishment of the kitchen with a regeneration kitchen; the redecoration and Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 19 refurbishment of the day centre to make a dining area for the ground floor residents once the day centre has been closed. No timescales were provided. The home is also in need of new baths due to the glazing cracking on the bath surfaces. The Manager is aware of two baths being ordered but not more than that. Window frames are also of a poor standard and either need replacing or paintwork stripped and re-painted. It is positive to note that since the last inspection all but one of the bedrooms are single rooms and all beds have been replaced with safer wooden framed beds. The light fittings also require changing due to overheating at times. These are in the process of being changed. It is difficult for the home to look clean and fresh due to the poor décor and furnishings. However, it is of an adequate standard. The home has a good supply of personal protective clothing for staff and well-resourced hand washing facilities are located throughout the building in appropriate places. Infection control procedures were in place in the required areas and staff spoken to had a good understanding of hygiene procedures. The laundry area is small and cramped with no space for the separation of dirty laundry. The drying area was in need of urgent redecoration. (See requirements 6-9) In a recent survey undertaken by the home it is evident that the main concerns relate to the standard of the environment. Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 20 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is adequately staffed and generally well trained. Recruitment procedures require a little more improvement to ensure the safety and protection of residents. EVIDENCE: It is evident from the feedback received from relatives and residents that they feel staff provided a good quality of care. They not only provide a warm and friendly environment but also ensure that their care needs are being met. There is comprehensive training available and staff spoken to stated that there is always training available. Initially, staff are inducted into the organisation with a four-day induction course and familiarisation of the home and its procedures. Statutory training such as moving and handling; food hygiene, adult protection and infection control training is provided during this induction period. Shaw also provides other training such First Aid and dementia as well as more specific training geared to the role of the individual. Staff also benefit from Bromley consortium training and those spoken to spoke highly of the training provided. It is also positive to note that team leaders will also be able to undertake the Registered Managers award to support them in their development. The home is also developing staff in the achievement of the NVQ qualification with over 50 having achieved at least NVQ 2 or above. Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 21 Discussions with staff and viewing of the resident’s files show that there is a need to provide more training specific to the needs of those with epilepsy or Parkinson’s Disease. (See recommendation 6) The home maintains good records of training undertaken by staff and each member of staff has their own portfolio and certificates. Four staff files were viewed to determine the standard of the recruitment practices. Many of the required checks and documents are held centrally at the Head Office. These were obtained by the Manager and were found to be adequate with references, proof of identity, POVA and Criminal Records Bureau checks in place. There were some gaps such as written verification as to why the individual left their previous care employment and lack of evidence of qualifications. (See requirement 10) Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 22 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): 31,32,33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed well with the health and safety of residents maintained. Systems used to monitor practice and improve the quality of care are implemented. EVIDENCE: The Manager is experienced and well qualified to manage Bellegrove. Feedback from residents, relatives and staff show that she is approachable and willing to listen and that she takes time to ensure staff are provided with the support and guidance required. The home is well run and managed well. She has recently commenced relatives’ and residents’ meetings to ensure the home is meeting the needs of the residents. Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 23 The organisation has its own quality assurance system requiring the Managers to audit the procedures regularly. These audits are undertaken by Managers from other homes to provide a more independent view. There is evidence of recent audits taking place which include resident and relative questionnaires. The Manager has yet to collate these but on doing so will ensure the Commission is sent a copy of the report detailing the outcome and proposed actions to ensure the shortfalls, if any, are addressed. The Manager and staff are willing to take advice and guidance and implement any requirements raised through the inspection process if is within their remit. There has been some improvement in the Provider undertaking monthly Regulation 26 visits although the reports were not always available in the home or sent to the Commission. Those viewed were generally reflective of the current situation in the home and the findings of the inspection. On viewing records and discussions with staff there was evidence that they benefited from formal supervisions taking place and staff spoke of informal supervision and mentoring by staff. The Manager ensures the health and safety of residents, visitors and staff though the regular servicing and checking of the equipment used and ensuring risk assessments are in place where required. All staff attend core training each year including moving and handling; food hygiene and infection control. Staff are also updated in First Aid with the Appointed Person certificate. This means that there is always a trained person on duty in the home. Staff spoken to had a sound understanding of what to do in the event of a fire and where accidents occur. The home maintains good systems for managing residents’ monies although the recent audit shows there are still some improvements required. The inspector also recommends that a system for the receipt of monies from relatives etc is developed to ensure receipts are given out, an accurate record is maintained and monies are kept safe until the administrator returns to the office. The Inspector is also concerned that all monies, above and beyond what is held in the home, are held in one bank account. This is a non-interest bearing account and in one case a resident has approximately four thousand pounds deposited with other residents’ monies. The resident is not receiving any interest on this and this is considered unsatisfactory. (See requirement 11) Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 24 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 2 2 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 2 2 2 2 2 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14 Requirement The Registered Person must ensure that the home maintains records of the assessments completed and associated records including property lists. The Registered Person must ensure all residents are provided with contracts of residency which are completed in full, signed and dated. The Registered Person must ensure care plans reflect the health social and personal care of residents. The previous timescale expired 1/4/06. The Registered Person must ensure risk assessments are completed where there are identified risks and include any actions required to minimise the risks. The previous timescale expired 1/4/06 The Registered Person must ensure that all medication records include the amount, the signature of the person receiving the medication and the date the medication is received into the home. DS0000063945.V297631.R01.S.doc Timescale for action 01/09/06 2 OP2 5 01/09/06 3 OP7 15 01/10/06 4 OP8 15 01/09/06 5 OP9 13 01/09/06 Bellegrove Version 5.2 Page 26 6 OP19 16 & 23 7 OP19 23 The Registered Person must 01/09/06 provide the Commission with an action for the replacement of worn carpets throughout the home. Some new carpets have been fitted. This progress must be continued. The timescale for this requirement expired 1/10/05 The Registered Person must 01/09/06 provide the Commission with an action plan for the re-decoration of communal and private areas. This is outstanding from the last inspections. No work has been completed to date. Please provide the Commission with an action plan for the required work. Timescale expired 1/4/06 The Registered Person must provide the Commission with the action plan for the installation of a re-generation kitchen and the redecoration of the day centre to provide suitable dining arrangements. The Registered Person must provide the Commission with an action plan for the work required to the window frames. The Registered Person must ensure that the required checks are made on newly appointed staff. Timescale expired 1/3/06 The Registered Person must review how residents’ monies are received by the home and held in non-interest bearing bank accounts. 01/09/06 8 OP19 23 9 OP19 23 01/09/06 10 OP29 17 & 19 01/09/06 11 OP35 17 01/10/06 Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 27 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 OP8 Good Practice Recommendations The home should ensure that service users are weighed on admission to the home and that the nutritional assessment is used correctly. Any medication carried over to the next month should have the amount recorded and allergies should be recorded on the medication record. Hand written medication records should have two signatures to ensure the accuracy of the person making the transcription. The use of printed labels should be discontinued. The home should investigate ways in which they could provide more activities to residents in groups and individually. Staff should be provided with more in depth adult protection training and guidance on how to protect vulnerable adults from abuse. Staff should be provided with training in epilepsy and Parkinson’s Disease. 2. OP9 3 OP9 4 5 6 OP12 OP18 OP30 Bellegrove DS0000063945.V297631.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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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