Inspection on 05/11/07 for Bellegrove

This inspection was carried out on 5th November 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bellegrove 17/07/06

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 Rosemary Blenkinsopp Unannounced Inspection 5th November 2007 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.V340511.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.V340511.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 bellegrovemanager@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 54 Category(ies) of Dementia - over 65 years of age (25), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (28) Bellegrove DS0000063945.V340511.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. 17th July 2006 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 29 older people and 25 older people with Dementia. The Home is separated into two units with the ground floor providing care to residents with Dementia and the first floor, caring for the frail elderly residents. 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. The building, which the home operates from, is leased from the London Borough of Bromley and is due to close as part of the re-provision of services by Shaw Healthcare. Staffing arrangements provide twenty-four hour care to residents living in the Home. The fees are £510.51 per week for frail elderly resident and £624 for Dementia residents. 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.V340511.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted over a one day period by two inspectors. The visit was unannounced. Prior to the visit the AQAA had been completed and forwarded to the CSCI office with all information completed. Ten comment cards were received including those from residents, relative’s staff and a health professional. Comments received within the questionnaires were positive and quotes extracted from these are incorporated in to the main body of the report. The two inspectors spent time in different units observing the practice, interactions by staff and the care provided. The lunch was observed .The inspectors met with residents and relatives who were visiting. Residents were selected for case tracking and as part of this their care plans, risk assessments and other supporting documentation was selected for inspection. Medications were inspected. A selection of health and safety documentation was inspected, as was the complaints file. Staff were interviewed regarding working in the home and questioned on selected topics. Overall the findings were positive and there was evidence that the home provides a good level of service to residents who live in it. What the service does well: What has improved since the last inspection? Assessment information was completed with staff signatures and date. The care plan documentation whilst cumbersome is comprehensive. Shaw Healthcare have standard forms to address the majority of residents issues, which can assist staff in record keeping. The window frames have been assessed although work has yet to start this is under the responsibility of the London Borough of Bromley. The ground floor Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 6 dining area has undergone some refurbishment and a new carpet has been laid. 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. The summary of this inspection report can be made available in other formats on request. Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with information and opportunities to sample the service prior to admission. Information relating to the resident, is obtained prior to admission and that provides staff with a summary of needs in order for them to address the resident’s care. EVIDENCE: At the time of the inspection there were 49 residents on site of which there were three on respite care. The inspectors’ case tracked four residents as part of the site visit, two from the Dementia unit and two from the frail elderly unit. The inspector on the Dementia unit met with one of the residents involved in the case tracking and her daughter. Positive comments were received regarding the home and the service it provided. On the care plans viewed there was evidence of a base line assessment conducted by the home staff as well as assessment in relation to manual Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 9 handling and nutrition. The mental health assessment was a tick box format and more information could have been included particularly as Dementia residents usually have complex medical and physical health issues. The second care plan and assessment information was that of a resident who had been an emergency admission hence there was little assessment information to be inspected. There was the Social Services information, a service agreement and a property list. The night staff conduct a night care assessment as soon as this is possible and this is retained on file. There were comments regarding the delay in issuing of the Contacts through Bromley Local Authority. The Manager stated that this was the case and where in the past it had been about two weeks before the contracts were issues now it was a lot longer. Residents are issued with Shaw Health care contracts on admission. Residents are provided with information prior to admission including the Statement of Purpose and Service Users Guide. Opportunities for introductory and trial visits are provided should the resident wish to sample the service prior to admission. The second inspector made the following observations: An updated information pack has been developed. This provides information to people who may wish to use the service or are currently using the service. It is written in a simple manner although the document could be made available in larger print or with photographs. Most residents admitted to Bellegrove have the arrangements made by the Local Authority and therefore the Care Manager’s assessment is central to their admission. The Manager or senior staff member also completes an assessment to ensure the home is suitable for them and that they can meet their needs. Files viewed, with the exception of one, showed evidence of the home’s assessment and Care Manager’s ‘Easycare’ summary or core assessment. Obtaining the Care Manager’s assessment has been a concern in the past but the manager has endeavoured to ensure this happens prior to admission. Written confirmation, that the home is able to meet their needs, after assessment, is still not provided in all cases. Where the Local Authority is responsible for making the arrangements for moving into the home they are also responsible for providing the agreement between the home, resident and purchaser of the service. Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 10 Where the arrangement is made privately Shaw have developed a contract for the service. Residency agreements are also provided for those who are funded by the authority. Four residents’ files were viewed and found to contain Placement Agreements, contracts and residency agreements. Details of the fees payable are included in the agreement. Bellegrove DS0000063945.V340511.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health care is well addressed by staff working in the home and with the support of the multi disciplinary team. Medications are safely managed with documentation in place to evidence this. Regular audits quickly identify and areas were there are gaps and remedial action taken to address it. EVIDENCE: Of the two residents who were case tracked, on the day of the site visit, one had been admitted to hospital the other was in the home during the inspection. The two care plans were completed with good information on the physical social and psychological needs of the residents There were a number of risk assessments completed including those for nutrition, manual handling and challenging behaviour. The other risk assessments including social activities and one headed “Alzheimer’s “could Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 12 have been addressed in the care plan providing comprehensive information on how to address the issue. The actual care plan was almost identical in information repeating the information in the risk assessments. This would be very lengthy to complete, and for staff referring to these documents very time consuming to read. There were a number of other risk assessments that were relevant to the residents including use of bedrails and a falls risk assessment. The second care plan was also well completed and again there were a number of risk assessments in place and reviewed. These included manual handling, falls, use of bedrails, and nutrition. The nutrition score indicated a very high risk. The weight chart had only one entry dated 29/8/07. As the risk assessment indicated that the resident was high risk. More frequent weight checks should have been carried out and other actions to address the issue implemented. Again the care plan was reflective of the risk assessment and the information almost identical .The information contained in the care plan was to a good standard. Risk assessment and care plans should work in support of one another and some information may need to be duplicated although not all. In resident’s files there is a relatives communication sheet, which provides relatives with an avenue for inputting and communicating with staff on the care provided. Health care records detailed visits made by members of the multi disciplinary team and gave a brief summary of it. The diary is also used as a prompt to remind staff of set appointments. Shaw Healthcare provide a number of standard forms including hygiene charts, handover sheets, body maps for indicating injuries etc. Staff confirmed that equipment was available and that recently more manual handling aids had been purchased. There was evidence of equipment in use during the site visit. Comments received from visiting professionals included the following “ I found the team leaders to be very responsive to suggestions and actions that I recommend “. The second inspector sampled three other care plans of residents on the first floor and her findings were as follows: Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 13 Discussions with two residents on the first floor who were more than happy with the care provided by Bellegrove staff. Their “down to earth approach” suited them very well. The resident also told the inspector that the staff treated her well and that she was generally happy. Two care plans were viewed and found to contain very comprehensive information about the individual. However, much of this information was repeated throughout and meant the files were not very user friendly. The files viewed were up to date, although the signing and dating of records was variable. Risk assessment, assessment of daily living and care plans had all been developed for each person. There was a lack of information on some personal care, in particular bathing routines and social care. There were also gaps regarding individuals’ pressure sore care and diabetes. There was information on these areas but it was limited, particularly regarding the District Nurses action and care required in respect of nutrition, foot care and optical care. It was evident from the records viewed that appropriate healthcare is accessed, other than information on optical visits being limited the records are good. As stated previously a number of assessments are completed for falls, pressure care, nutrition and continence care. These were generally well monitored and action to reduce the risk is documented and up to date. One exception to this was where a resident was deemed, after assessment, to be overweight, there was no care plan detailing the action being taken to address this or if not action to be taken the reason for this. Medications. Within the care plans there was self-administration consent form. In addition there was information in respect of the medications and their side effects, which is beneficial for staff. The medications were inspected on the Dementia Unit. The medication policy was available. There were records of the daily fridge temperatures. The records relating to those medications returned to pharmacy were completed with the receiving pharmacists signature. Dates of opening were on eye drops Only one medication is stored as a controlled drug and the supporting records for this were in place. Records relating to medication audits for October and November were on site. Medications are checked weekly by a team leader. The medication charts were completed wit no gaps evident. Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 14 There was a current BNF, which is a drug reference book, available for staff to use. Medications first floor. All prescribed medication is recorded on pre-printed medication records. Viewing of medication records and observation of practice took place on the first floor unit. For most of the medication the staff member placed the medication directly from the blister pack to the medication pot. This did not happen in the case of medication kept in packets. The carer handled these and placed them in the residents’ hands or on the table. The records viewed showed them to be generally fully completed with photographs of the individual attached. Some records had gaps in the allergies section, where allergies are not known, this should be recorded. Where there were hand transcriptions some of them did not have any signatures whilst others had one. Two signatures must be in place for confirming the accuracy of the transcription. Records of receipt were in place, which were signed and dated. Those medications, which were to be administered ‘as required’, should have clear administration details including maximum daily dose, duration, and length of time prior to seeking GP advice.e.g loperamide. Some medication had been stored in the fridge, including calogen, which has a timescale for use. This medication had not had the date of opening recorded. Residents in the home are not currently self-administering medication with the exception of inhalers. Where this had been identified in one of the records viewed it was clear that the records did not document this fully. The records should contain records of medication handed over to the individual and a risk assessment to ensure they are able to do this safely. Records of disposal are maintained and returned to the pharmacy. Staff are trained in medication practices in a number of ways. Some staff have received trained by the pharmacy that supplies the medication and others have undergone the distance learning safe administration of medication. Please see requirements 1 and 2. Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some routines do exist in the home although choice and individuality are promote as far as possible. The home provides opportunities for residents to engage in group and individual activities. Visiting is open and encouraged. Relatives are actively supported to participate in the home and bring forward suggestions for improvements EVIDENCE: The inspector met with one resident and her daughter. They both participated in the discussion and completed questionnaires. In the main they were happy with the care provide and the daughter felt she was made welcome offered a hot drink and kept informed of developments. One recent improvement had been the introduction of a newsletter, which she felt kept them abreast of developments. She also enjoyed the relatives meetings, which provided a forum for open expression of her views. The food had improved recently although the resident felt that “ there is a lot of waste”. Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 16 Relative’s meetings are held every three to four months and all relatives are invited. The resident herself stated that she enjoyed the TV particularly the “soaps” and had visitors regularly. There was music playing in the lounge were we sat and she commented that “ it is better than pop music “. The home has an activities programme that incorporates regular sessions, entertainers and festive activities. The relatives with whom the inspector met expressed their anger at the closure of the home and felt this would be to the detriment of their loved ones. During the lunchtime period the tables were laid in preparation, and three choices of juice were offered. The meal itself was nicely presented and staff were assisting residents with their food. Amongst the residents in the lounge there were signs of well being. Residents were talking amongst themselves to staff and making their needs known. Residents looked well presented and dressed appropriately. Mugs of tea and biscuits were served at approximately 10:45. There is a hairdresser, which visits the home regularly. There is a residents committee in operation, which gives feedback on the service. Feedback from relatives included the following statements: “ I always get a friendly reassuring answer -------I am kept informed with all things important the staff are very open and supportive “. Another relative commented with the following “ When I leave Bellgrove I am confidant resident X is being well cared for and I can have peace of mind”. Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information on how to make a complaint is available to residents and relatives. External avenues for referral of such are included in this information. Complaints are acted upon and taken serious. Staff had a working knowledge of adult protection and whistle blowing and the reporting of such matters. EVIDENCE: The home has a complaints procedure on display and this is incorporated into other documents. There are supporting policies and procedure for complaints. Guidance on adult protection and whistle bowing are also available. The CSCI has received no complaints regarding this service since the last key inspection. Within the home’s complaints log there needs to be clearly stated whether the complainant is satisfied with the outcome as currently this is not specified. Staff with whom the inspector met demonstrated a working knowledge of abuse and the need to report such matters immediately. They were aware of Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 18 where to find the information and the senior personnel in the company to whom such matters could be referred. The staff were also asked about the term whistle blowing and again the understood the term and how it would be addressed in the working environment. A complaints register was in place where complaints or concerns are recorded. Since January 2007 there have been nine complaints logged. The records were viewed and no apparent themes emerged. Records were in place for some complaints, although not all had full investigation details or record of the outcome and whether the complainant was satisfied with the outcome. The Manager has an open and inclusive approach to managing the home and is very approachable. Two relatives and one resident spoken to said that if they had any problems they would speak to the Manager. In fact one of the relatives said they generally spoke to the Manager whenever they were in the home and felt that her approach and ‘visibility’ helped in this way. The organisation has thorough and comprehensive procedures in place for safeguarding adults. The organisation also has a history of managing and investigating allegations made. Adult protection guidance is also included in the induction training to ensure staff are aware of their role as well as what constitute abuse and in NVQ qualifications. Please see recommendation 1. Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides satisfactory accommodation for residents to live in. Improvements have been made in the home to the fabric and fittings although areas such as window repair replacement remain outstanding. EVIDENCE: The inspectors toured the areas on the two floors including the individual bedrooms and the communal areas. It was evident that some redecoration had taken place and other areas were due for such. There was evidence throughout the home that efforts hade been made to promote orientation for residents pictorial signs were located on bathroom and toilet doors. Other orientation aids included clock and calendars, which were in use. Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 20 Those bedrooms inspected were personalised clean and tidy although in terms of redecoration the standard was mixed. The windows were open in some bedrooms and this made the room feel cold. Staff must ensure that they keep rooms at the optimum temperature for residents to use. In the ground floor dining areas this area was due for refurbishment, which will include new carpet blinds and redecoration. In most of the hot water outlets tested the water was running cool and this needs to be investigated. The smoking room was without ventilation this should be rectified. On the first floor, bedrooms were generally personalised, comfortable and homely. Some were quite cluttered and some carpets were in need of replacement. In some areas of the home updating and work is to be completed for example the dining room on the ground floor. Whilst utilising the former day centre as a dining room the transformation is not quite complete and currently gives a less than homely feel. This has, however, freed up areas in the lounge, which previously included the dining area. There is now more space for movement and armchairs can be sited in various locations. There is a small enclosed garden, which was pleasant, and had seating provided. Please see requirement 3. Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers to address the work. Training is provided and updates ensure that staff maintain their skills and are competent in their roles. Robust recruitment procedures are in place to ensure that resident are in safe hands at all times. EVIDENCE: The staffing levels in the home are as follows five staff on the ground floor and four on the first floor during the daytime period. Four staff including one team leader cover the night duty. On both floors there is a team leader in charge of the shift with the Manager on site supernumerary. In addition the Deputy Manager has two days a week where she is supernumerary. There is a full time administrator and a number of other ancillary workers. Currently there are there full time vacancies totalling 80 hours. This includes care staff as well as a part time domestic, a kitchen assistant and 15 hours a week in the laundry. Recruitment is underway but so far there has been little response. In addition there are some shifts where agency staff are employed. This had been the case recently as one resident had required increased levels of supervision. Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 22 The Manager stated that all staff who worked on the Dementia unit had received some training on the topic. The inspectors spoke to staff throughout the site visit. One care assistant confirmed a four-day induction covering the statutory topics. Training had included a two part Dementia course updates on manual handling, fire, health and safety. She had a good knowledge of infection control procedures and those precautions necessary when dealing with MRSA. A second staff member was interviewed she had been in post for several years and was NVQ 3 trained. In addition she had completed the D32/33 NVQ assessors course. There are four manual handling trained instructors in the home of which she was one. Two staff are also fire training instructors. She confirmed that she received supervision every eight weeks and that an annual appraisal was conducted. She felt the company provided good support and on going training. The induction provided by the company meets the common induction standards. The home facilitated various forums for staff to meet including separate team leader meetings. This provides an opportunity to review the work, record keeping residents needs and staffing levels. Recruitment records viewed were generally satisfactory. No individual is employed to work in the home until the Criminal Records Bureau check and references have been received. Proof of identity is also obtained as well as copies of training certificates and qualifications. Files viewed also contained records of interviews. The concern the Commission has, is the reliance on the Head Office to make sure the checks are available and there are instances where the Manager cannot be sure that the required checks and documents are in place. During this inspection the process was found to have its flaws with some discrepancies in the information and some information lacking. The Manager must ensure, through written confirmation by the employer, that they have undertaken the checks required. Records show that all new staff undergo a four day induction arranged by the organisation as well as the home’s induction. Staff are also expected to complete the induction workbook. Please see recommendation 2. Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 23 Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is trained and experienced in managing such a service. Shaw Healthcare provides additional support in the management arrangements. Quality assurance measures are in place to take account of the views of residents, staff and relatives. This is enhanced by an open door philosophy. Health and safety measures are in place to ensure the home is safe to live in and staff to work in. EVIDENCE: The Manager is registered, qualified and well experienced. Her style of management is open and inclusive. Staff, residents and relatives stated that she was approachable and always had an open door policy. Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 25 A sample of service agreements and contracts were viewed including those for gas and electric. Lifting equipment has also been recently serviced. The measures in place for fire safety were inspected and overall these were found to be satisfactory. Evidence of regular fire alarm testing and servicing of the system and equipment were on site. Records detailing regular fire drills were available. Quality assurance systems were in place with audits on various procedures that incorporated surveys of residents and relatives. In addition clinical areas had been audited including infection control, care plan and medication. The environment and health and safety procedures are also subject regular audits. The Manager has commenced residents/relatives’ meetings as recommended previously. This has worked well and ensures that the people can discuss everyday issues, concerns and is a forum for informing people about what is going on. Monitoring visits are now being undertaken at more regular intervals. Resident’s monies were checked. These are retained by the administrator. Residents have an individual balance sheet and two staff sign for all expenditure and money received in to the home has one staff signature. Two staff signatures should be in place for all transactions to reduce the margin for error. Shaw healthcare conduct a number of audits undertaken by both staff in the home and those external to the home. Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 27 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 Manager must ensure that care plans are updated to reflect the current needs of the residents. Previous time frame for action 1/4/07. Some improvement in care plans evident. 2. OP9 13 The Registered Manager must 01/02/08 ensure that the medication records detail the instructions for “as required” medications. Those residents self-administering must have risk assessments and supporting records. Hand transcriptions must be confirmed by two staff signatures. The Registered Manager must ensure that hot water is at an appropriate temperature and also room temperatures are maintained at an optimum. 30/12/07 Timescale for action 01/04/08 3 OP19 23 Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 28 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 OP16 2. OP29 Refer to Standard Good Practice Recommendations The Registered Manager should ensure that all records relating to compliant investigations are retained and whether the outcome has satisfied the complainant. The Registered Manager should investigate ways in which she could be more involved in the recruitment of staff. Bellegrove DS0000063945.V340511.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V340511.R01.S.doc Version 5.2 Page 30 - 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!