Inspection on 30/01/06 for Bellegrove

This inspection was carried out on 30th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 17/07/06

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 Unannounced Inspection 30th January 2006 13:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 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 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.V275282.R01.S.doc Version 5.1 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. Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by two inspectors and took place over one afternoon. The inspection included a tour of the home; discussions with staff, the Manager and residents; viewing of records and observation of practices. What the service does well: What has improved since the last inspection? The home has improved in a number of areas since the last inspection. The hallway and reception area has been redecorated and new carpet fitted. Thermostatic valves have also been fitted throughout the ground floor. This now means residents are able to control the temperatures individually. The home now writes to prospective residents or their representatives after their assessment, confirming that their needs can be met. The home appeared clean throughout with the concerns of the last inspection now addressed. There was no evidence that smoke detectors were being used inappropriately. The home has provided the Commission with an amended Statement of Purpose and Service Users’ Guide. Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 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 DS0000063945.V275282.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 The pre-admission procedures need to be improved to ensure information is available to staff on how the individual’s needs are to be met. EVIDENCE: The last inspection required the Manager to update the Statement of Purpose and Service Users’ Guide. This has now been completed. The organisation’ procedures require the home to assess any prospective residents prior to admission as well as obtaining the Care Manager assessment. There personal files viewed provided was evidence of the Care Manager’s assessment and the home’s assessment. There was evidence that the home now confirms in writing that they are able to meet the resident’s needs. The Statement of Purpose states that “a senior member of staff from the home will visit potential service users and significant others in their current surroundings to gather relevant information”. The document did not reflect the organisation’s actual admission and assessment procedures. Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 9 Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 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): 7,8,9 & 10 Care plans and risk assessments do not fully reflect individual needs. Medication procedures also require further improvement. Without the full and complete information residents’ health, safety and welfare are potentially at risk. EVIDENCE: Three care plans were viewed to identify whether these adequately reflected the care required by the residents. The care plan format did relate to the needs highlighted in standard 3.3 All three care plans included information regarding service users preference to time of going to bed and rising and the staff input required to undertake these tasks i.e. one member of care staff. Records pertaining to one resident, in particular, provided staff with guidance regarding observations to be made that would possibly necessitate there an emergency admission to hospital. In all three care plans needs had been identified, however there was no guidance provided for staff on the action and process required to address the need. Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 11 Service users wishes in respect of action to be taken following death had been recorded in care plans seen. Information was recorded regarding service users preferred time of day for bathing, however daily records did not indicate that baths were occurring. The inspector was informed that this information was kept in a separate Bath book this book indicated for two service users, that they had received only two baths since the first day of January. Staff spoken to felt that this was inaccurate and that staff had simply forgotten to complete the book. One resident with MRSA was not having a bath but according to the member of staff was receiving a “bed bath” although her care plan did not reflect this. Care plans also contained conflicting information such as being partially sighted in one part and blind in other records or one resident needing two sticks to walk whilst in another area requiring a zimmer frame. One of the headings in the care plan refers to privacy and in response to this a member of staff had written not fussed. Two of the three care plans indicated the service users preference in relation to the preferred gender of the carer. (See requirement 1) In relation to pressure care risk assessments, documentation required staff to assess service users BMI score which stated this was done by height x bodyweight. However, there was no record of residents’ height on documentation seen. Although, entries were seen to be made at a later date, there was no record of weight for two service users at the point of admission. (See recommendation 1) Records recorded one resident as having diet-controlled diabetes. However this was not recorded as part of the water low assessment. Whilst another resident’s initial assessment indicated that the residents needed encouragement with eating, records indicated that whilst she would generally have breakfast she would possibly need encouragement with lunch. It would be therefore expected to see entries made in the daily record to indicate that staff have offered food on further occasions through the day. However, this was not the case. In all cases dietary requirements such as likes and dislikes had not been completed. (See requirement 2) The Manager had assessed some care plans as part of her monthly audit and had highlighted to staff the need for action to be taken to address shortfalls in the care plan system. Discussion took place regarding the need for staff to have opportunities to attend additional training when assessed as necessary with the Manager stating that this would be possible. Records seen indicated that residents receive good health support, with records kept of visits by the GP, District Nurse and any action required by staff. Records indicated that residents are assisted to attend routine health checkups eg: a hospital audiology appointment. Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 12 District Nurses and the hospice team are currently being providing advice and support for one service user. A full audit of the medication practices was undertaken at the last inspection and therefore this inspection concentrated on the requirements raised at that time. There continues to be a lack of risk assessments and clear guidance for staff in relation to residents who self- administer (albeit only part of their medication). The recording of controlled drugs requires improvement to ensure there is clarity in relation to the amount of medication being received by the home with the corresponding two signatures. The medication records also showed a number of “as required” and “as directed” medications. There must be clearer guidance for staff as to the circumstances when the medication should be administered, including amounts and maximum doses. “As directed” medication also requires further administration guidelines such as in the cases of cream, where, when and amount. (See requirement 3) The medication records were, in the main fully completed, with the exception of allergies. To ensure there is accurate accounting of medications in the home the home should introduce a system where any remaining medication for each month remaining in the home for the residents is counted and the number carried forward. (See recommendation 2) The home, in the main ensures any medications hand transcribed have two signatures to confirm accuracy and there was no evidence of out of date medication in place. Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 13 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 &14 Routines within the home are flexible and residents are provided with care which meet their individual needs. The residents are not at present provided with continuity in the activities organised and provided. This leaves some residents without any stimulation or interest during the day. EVIDENCE: A service user spoken with stated she was able to spend time how she wanted and could choose whether or not she wished to participate in activities taking place in the home. Whilst another stated that she was pleased the local vicar came to the home on a regular basis. She had also been assisted to attend the library and staff had arranged for a newspaper to be delivered each day. The inspector was provided with a schedule of activities for a four-week period. However, information regarding service users activities was very limited for two of the care plan seen. Records indicated they had only participated in that activity twice since January the first. The inspectors were informed that this information is held separately in the activity coordinators file. However, when this was viewed the activities participated by some residents, were very limited. Whilst there may be some residents who refuse to participate best practice would determine that this be recorded. However, there may be other activities or interests which a resident would enjoy. (See requirement 5) Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 14 Previous comments made in the report indicate that service users are able to express a preference in terms of rising and going to bed. This was confirmed by a service user spoken with. One care plan stated that appearance was important to her and that she liked her hair to be set weekly, her clothes should be appropriately coordinated and nails painted. This is good practice and provides information integral to ensuring the individual’s needs are being met. Service user spoken with stated that they had been able to bring in personal possessions, photos and mementos and bedrooms seen were individually personalised. The administrator stated that whilst none of the service users were able to manage their financial affairs independently, he endeavoured to involve service users when possible. Evidence was seen that service users sign records pertaining to their personal allowance when depositing or withdrawing money from their account. During the inspection process the inspectors heard good interaction between staff and residents. Residents appeared to be relaxed and comfortable in their own communication with staff members. Good interaction was observed between staff and service users. The manager stated she receives menus from Manorfields on a regular basis. This is not an ideal situation and previous reports have highlighted the issues. The format is not service user friendly and therefore the Manager has to type the menus up herself. There has also been an incident recently when Manorfields had provided alternative food to the menu causing a lot confusion. (See requirement 4) The menus for one week were seen and residents are provided with a choice at each meal-time. Discussion took place regarding the description of food recorded on menus such as Navarin of lamb, tray bake and mousse. These descriptions do not provide a clear picture for older people, particularly those who have dementia. (See recommendation 3) The menu for the day is displayed on a chalkboard in the first floor unit dining room. Two service users came in to see details of the evening meal and when spoken to, both stated they had enjoyed the lunchtime meal. However a full inspection of this standard was not undertaken during this visit. Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 15 Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 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 & 18 Residents or their relatives are able to voice concerns or raise complaints with confidence that they will be listened to and issues investigated. Procedures are in place to ensure vulnerable people are protected from poor practices and abusive situations. EVIDENCE: The home has a complaints procedure in place, a copy of which is on display in the reception area. A copy is also available in the Service Users’ Guide. Complaints are recorded in a complaints folder. These showed no written complaints but recorded three verbal complaints since September 2005. Two of these concerned the laundry. These were dealt with appropriately by the manager. The home has policies and procedures in place to protect vulnerable residents. All staff are provided with information on these during induction training and the Manager also discusses this during the interviews with applicants. Adult protection is included as a core unit in the NVQ qualification. There has been one adult protection issue relating to an agency member of staff. This was referred as required under their procedures and investigated appropriately. Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 17 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, 23 & 26 Whilst progress has been made in some areas, further improvement is required to provide the residents with a comfortable, well-maintained and homely environment. This must also include reviewing the layout of the private rooms to ensure the residents have unrestricted movement and access to emergency systems. EVIDENCE: There was little evidence that redecoration or refurbishment had occurred in the communal areas or bedrooms seen. Although the hallway and reception area had been redecorated and new carpet fitted prior to the last inspection. The commission is aware through discussions with the Providers and Local Authority that action plans for the completion of redecoration and maintenance will be sent to the Commission and will highlight the areas of priority. (See requirement 6 & 7) Discussion took place regarding the bedroom of resident where the layout of the room was particularly hazardous, with only a small thoroughfare between Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 18 bed and furniture. The gentleman did not have access to an emergency call bell, which was of particular concern, as his frailty and poor communication skills means he is particularly vulnerable. (See requirement 8) The last inspection highlighted concerns regarding the standard of cleanliness in the home. The Deputy Manager stated that additional domestic staff had been recruited since the last inspection. Generally the cleanliness had improved and beds viewed were clean and in linen was in a good state. One resident spoken with commented on how nice it was to have a room regularly cleaned and not have to do this task herself. At present four service users have been diagnosed with MRSA. The care plan of one person with this diagnosis was examined and found to contain simply “barrier care with no further guidance or information for staff. There was no evidence of disposable aprons and gloves in the residents’ bedroom or bottles of antiseptic soap. The Manager stated that aprons and gloves were kept in the bottom of resident’s wardrobes or chest of drawers as she was concerned that people diagnosed with MRSA would be stigmatised. Discussion took place regarding the possibility of staff collecting appropriate protective clothing from sluice and storage areas before assisting residents or placing them discreetly in the room. This would address her main concern and reduce the risk of the infection being spread. Only one small domestic size dispenser of alcohol gel was seen in a sluice room. Discussion took place regarding the need for appropriate hand wash to be easily available in residents’ bedrooms bathrooms, toilets and sluice areas. Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 19 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 Staff are well trained, although some poor practices, including some aspects of training and recruitment, leave residents potentially at risk. EVIDENCE: The Deputy Manager has recently been promoted to Manager of another home which has resulted in internal promotion for another member of staff. Recruitment and training practices were discussed staff with one member of staff, who was completely new to caring. She indicated a good standard of training through the home’s own induction and the organisations four day induction processes. It is a good induction package with a mentoring system in place for all new employees. The staff member said that she felt well supervised throughout this period. Discussions with the Manager showed that, whilst staff are inducted, the resulting induction four day training provided by Shaw may not occur until after the member of staff had been placed on the staff roster and therefore working with residents. There are two members of staff trained to provide moving and handling training. However, this is limited and contained little practical work. More detailed training takes place on the 4-day induction. In one case a new member of staff started with the home in November 2005 but had not undertaken induction training until January 2006. This may lead to potential health and safety issues where staff may be placed in situations and not having adequate training to assist or support residents. The Manager must Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 20 review this situation especially where the newly appointed staff has had no experience or training in this area. Recruitment checks were made on two new members of staff. These contained application forms, interview schedules and health questionnaires. The application form of one member of staff contained no employment information prior to 2002, with the exception of previously living abroad until 1990. The application did not contain any information regarding one employer, even though a P60 showed them to be employed with them for a period of time. The application forms must be scrutinised more closely and any gaps or lack of clarity explored. One file contained identification and a permit to work in this country but no evidence of a Criminal Bureaus Check (CRB), whilst the other contained no identification and no evidence of a CRB. The inspector is aware that the organisation does not employ staff until clear a CRB is returned. However, the home must maintain some evidence that this is the case. (See requirement 9 & 10) The training matrix provided by the Manager showed that most staff have attended the four day induction course, which covers the areas required by TOPSS. Eleven support staff have achieved NVQ2 or above with registration of other staff also in place. The home cares for residents who have a diagnosis of dementia as well as physically frail. Dementia training is included in the core training for staff with seven staff having undertaken training to date and three more due to attend a four day training this month. The Manager has further dates on the training calendar to enable more staff to attend this vital training. Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 21 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): 31,35 & 38 The home is generally well run and well managed with systems in place to monitor the quality of care provided and to ensure the safety and well-being of the residents. However, the lack of monitoring by the Provider does not provide adequate scrutiny of these systems. EVIDENCE: The process for managing service users personal allowance was discussed with the homes administrator. Receipts are given for any money received from relatives handed to the home for safekeeping. There is a procedure in place for handling money outside of office hours. The company policy states that service users may have up to a maximum of £60 held in their own name in the home safe. Thereafter, service users money is held collectively in a company account. This procedure is satisfactory, as Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 22 long as there is a system for allocating interest, according to each individual’s monies held. A random sample of records relating to resident’s personal allowances were examined and found to be accurate, as was an audit of monies being held on their behalf. The last report highlighted the lack of regular monitoring by the Providers. There has been no improvement in this. The home has been undertaking the audits required by the organisation’s quality assurance system. This identifies shortfalls and action for improvement. However, this was not inspected in great detail on this occasion. (See requirement 11) A number of records relating to the health and safety of the home were viewed. These were generally in order with the servicing of equipment carried out within the required timescales. The last inspection raised concerns relating to the fixed wiring of the home where the last report identified it as being unsatisfactory. The Manager stated that some of the urgent work had been carried out but was unable to provide the required evidence to this effect. (See requirement 12) The recent servicing of the lifting equipment, including Parker baths, showed that cracking in some of these baths present a risk of cross infection. The contractor recommended that these be changed. (See recommendation 4). The home maintained appropriate records in relation to the servicing and checks made on the fire alarm with checks made on different call points now made each week. Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 23 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 3 X 2 X X N/A 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 2 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X x X 2 X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The Registered Person must ensure that care pans fully reflect resident’s needs in respect of their health and welfare. Timescale for action 01/04/06 2 OP8 12 & 13 3 OP9 13 4 OP15 16 The Registered Person must 01/04/06 ensure risk assessments are fully completed and contain all relevant information in relation to the resident’s health and wellbeing. The Registered Person must 01/03/06 ensure that medication procedures are safe. Specifically, an accurate record of controlled drugs must be maintained. Residents who self-administer must have risk assessments in place and reviewed regularly. All medication must be recorded into the home with the date of receipt and the signature of the person making the record. The Registered Person must 01/12/05 provide residents with food that is nutritious and adequate in quantity. The home must DS0000063945.V275282.R01.S.doc Version 5.1 Page 25 Bellegrove 5 OP12 16 6 OP19 16 & 23 7 OP19 23 8 OP23 23 9 OP29 17 & 19 10 OP30 18 11 OP31 24 maintain records of meals provided to individuals. The current system must be reviewed. This requirement was not fully inspected on this occasion. Previous timescale in place. The Registered Person must provide an action plan on how the home meets the individual social interests and needs of residents. This is an unmet requirement from the last inspection. The Registered Person must 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 Registered Person must 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. The Registered Person must ensure that the layout individual’s rooms take into account the health and safety of the person. The Registered Person must ensure that the required checks are made on newly appointed staff. The Registered Person must ensure that moving and handling training is provided to new staff, when required, prior to working with residents. The Registered Person and DS0000063945.V275282.R01.S.doc 01/04/06 01/10/05 01/04/06 01/04/06 01/03/06 01/04/06 01/03/06 Page 26 Bellegrove Version 5.1 12 OP38 24 & 26 Registered Provider 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. These have not been completed and continues to be outstanding. The Registered Person must complete the work require identified in the Periodic Electrical Installation Inspection report (fixed wiring) dated 15/07/04. The Commission is awaiting confirmation that the urgent work has been completed. 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP8 OP9 OP15 OP22 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. Menus should be amended to provide simpler descriptions of the food provided. The home should provide an action plan for the renewing of the Parker Baths. Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Bellegrove DS0000063945.V275282.R01.S.doc Version 5.1 Page 28 - 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!