Inspection on 12/08/08 for Bellevue Court

This inspection was carried out on 12th August 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bellevue Court 30/01/09

Bellevue Court 25/09/07

Bellevue Court 30/01/07

Bellevue Court 30/10/06

Bellevue Court 10/03/06

Bellevue Court 02/11/05

Bellevue Court 13/12/04

Bellevue Court 09/08/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Bellevue Court Bellevue Court Woodcross Street Woodcross Wolverhampton West Midlands WV14 9RT Lead Inspector Rosalind Dennis Key Unannounced Inspection 12th August 2008 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 Bellevue Court DS0000039462.V370319.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. Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bellevue Court Address Bellevue Court Woodcross Street Woodcross Wolverhampton West Midlands WV14 9RT 01902 662166 01902 672230 bellevuecourt@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Limited 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) Mrs Gail Emma Goddard Care Home 68 Category(ies) of Dementia (38), Mental disorder, excluding registration, with number learning disability or dementia (30) of places Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th September 2007 Brief Description of the Service: Bellevue Court provides care for persons with a mental illness or dementia. It is a purpose built care home located on the borders of Wolverhampton and Dudley and is a short distance away from local shops and amenities. A bus stop is located nearby. Bellevue Court operates over three floors with lift and stair access between floors. People who have a dementia related illness are accommodated on the ground and top floor (Nightingale and Lark Units) and people with a mental illness reside on the first floor, ‘Kingfisher’ unit. Bellevue Court has reduced the number of shared rooms to enable a greater number of single bedrooms to be available, which is considered to be a positive move-the total number of people who can be accommodated is now 60. Information on the fees charged by the home is included within the service user guides, where it is documented that the average weekly fees range from £450.00 to £523.00, although these fees may vary according to the needs and dependency of the individual. The reader is advised to contact the home to obtain up date information on the fees charged. People can obtain information about this service from the home’s Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk. Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was conducted by one inspector over a period of around 8 hours. All ‘key’ standards were assessed during the daythat is those areas of service delivery that are considered essential to the running of a care home. During the inspection we spoke with people living at the home, staff and the manager, Gail Goddard who was on duty for the duration of the inspection. Time was also spent observing the interactions between staff and people living at the home, as many of the people living at Bellevue Court are unable to express their views of the service they receive. We also looked at care records and other documentation and observed a selection of bedrooms and communal areas. For the purpose of this inspection Gail Goddard had responded to a request by the Commission to complete an annual quality assessment document (AQAA)this is an opportunity for providers to share with us areas that they believe they are doing well, yet Bellevue Court’s AQAA provided us with little information to demonstrate how it provides good outcomes to people, or the improvements it has made in the last year and how it is still planning to improve. As a result of the findings of this inspection the quality rating for this service has changed and is now 1 star. This means the people who use this service experience adequate outcomes. What the service does well: The home has the benefit of a stable staff group who work hard on a day-today basis to meet the needs of the people living at Bellevue Court. Staff support people to be independent, providing additional support to people as and when they need it. Observations made during the inspection found staff to be kind in their approach to people and eager to ensure that people were comfortable and their needs met. Bellevue Court has a good assessment and admission procedure, which ensures that people are only admitted to the home if the service is confident that it can meet their needs. Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 Page 6 People living at the service are able to enjoy a range of activities, based on their capabilities and preference and staff assist people to exercise choice as far as possible and according to their differing capabilities. People living at Bellevue Court have access to a complaints procedure, which is accessible to them and their representatives if they need to make a complaint. What has improved since the last inspection? What they could do better: At the last inspection it was viewed that improvements had occurred within the service and its management, however this inspection identifies areas requiring improvement. These include:The home needs to improve the way it stores medication so that people are not placed at risk of receiving ineffective medication. There have been considerable delays in the completion of a refurbishment programme, started in 2005. This inspection identifies that parts of the home need attention including communal areas, corridors, bathrooms and toilets. Of particular concern was the patio area immediately outside Kingfisher unit, where we saw that some of the paving slabs were cracked, loose and uneven and there was nothing to make people aware of these hazards. We spoke with a person who alleged they had been injured during a fall on the patio and it appeared from looking at the person’s care records and speaking with them that there had been a delay in seeking medical attention, this resulted in us making a referral to the safeguarding adults team for investigation under their procedures. We also required the home to take immediate action to ensure that the patio area was safe. Staff are provided with an induction which currently does not meet ‘Skills for Care’ standards. There are some gaps in the training programme, although there are plans to deal with this. The home needs to ensure staff have access to formal supervision at least six times a year. Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 Page 7 The home’s process of obtaining feedback from people, including staff would benefit from being open and transparent, so that people are informed of action taken by the home in response to any feedback Some issues identified as needing attention at this inspection fall outside the manager’s immediate role, such as funding and implementing the refurbishment programme but it is considered other issues needing improvement should have been identified and acted on through the manager’s own monitoring of systems and processes. 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. Bellevue Court DS0000039462.V370319.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 Bellevue Court DS0000039462.V370319.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Bellevue Court has a good assessment and admission procedure, which ensures that people are only admitted to the home if the service is confident that it can meet their needs EVIDENCE: People continue to have their needs fully assessed by a representative of Bellevue Court prior to and on admission to the home. Copies of these assessments were present on the care files seen, which also show that the home seeks information on individual likes, dislikes and preferences and recognises cultural and spiritual needs. One person recently admitted to Bellevue Court spoke of his satisfaction with his admission, describing how he was made to feel welcome and has been happy with all aspects of the service since his admission. Observation of this Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 Page 10 person’s care file showed that regular meetings have taken place involving the person, relevant professionals involved in their care and representatives of the home so as to determine whether the service is meeting their needs. Each unit has a specific Service User guide, providing people with clear information on the facilities and services provided, and includes information on the fees charged. It is documented that the guide can be made available in different formats, such as audio tape, if needed. Bellevue Court DS0000039462.V370319.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): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments are generally well written and provide staff with information to meet people’s needs. People who are able to comment on the service are pleased with the care they receive. EVIDENCE: We observed staff interactions with people with dementia and this shows that staff interact well and have the necessary skills to care for people with dementia. People appeared content and well-cared for, the staff group were responding to people appropriately and with kindness. Two people who live on the top floor of the home (Nightingale unit) spoke about how they are able to make choices in their day-to-day lives. Observations of these people’s care plans identify their preferences and provide information for staff on how to meet their needs. Staff gave a good account of how they try and enable people, who find it difficult to communicate their needs, to make choices, giving examples of how they support people to Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 Page 12 choose the clothes they prefer to wear. Most of the care plans we saw for people living on Nightingale and Lark units were clear and comprehensive, although the frequency of how often care plans had been evaluated was variable and this was brought to the attention of the manager. We looked at the care records for two people living on the middle floor of the home (Kingfisher unit) and we found that the home has improved the way it plans people’s care, showing a greater emphasis on meeting individual mental health needs through a more person-centred approach to care. A staff member spoke about the importance of involving people in the drawing up and review of their care plans and a discussion with a person living on this unit confirmed their involvement and awareness of their care plan. A range of risk assessments on individual files provides additional information on any recognised or potential risks to the individual and looks at managing the risk in a positive way. Staff working on each of the units, gave good accounts of the varying needs of people living at the home and how they meet those needs. Examination of a selection of medication administration record sheets found these to be completed accurately, with all medication signed and accounted for. We looked at one of the home’s medication storage rooms, this showed that the temperature of the room has been too high and we found the home needs to change the way it takes the temperature of the medication fridge. We found that medication currently in use to reduce people’s blood sugar levels was stored incorrectly and we informed staff of the importance of storing this correctly. Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the service are able to enjoy a range of activities, based on their capabilities and preference and staff assist people to exercise choice as far as possible and according to their differing capabilities. The meals at the home are good, offering variety and catering for different nutritional needs. EVIDENCE: Information on activities and events is advertised on notice boards throughout the home. We observed people on Nightingale unit being supported by staff to participate in board games. Staff showed us where they keep records of activities people take part in, which shows that people are provided with different activities, including visits from people outside of the home, such as singing entertainers. It was suggested to staff that written records could be further enhanced by recording any notable response from the person to indicate enjoyment or dislike of an activity, which can be beneficial when people are less able to communicate their views. Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 Page 14 Staff on both Nightingale and Lark unit spoke about difficulties in providing activities when there are less staff on duty or when people’s needs are high, these comments were fedback to the manager and there is a need for the provision of activities on these units to be kept under review. A person living on Kingfisher unit spoke about the different activities he participates in and confirmed that regular meetings are held which includes discussions on what people like to do. Two people commented on their disappointment that the home does not have access to its own transport at present, these people and the staff looking after them commented on how this has created some restrictions on accessing external events and activities, particularly at short notice if the weather is good. The manager is aware of people’s views about the home not having it’s own transport, but is reportedly working to company directives. Little information was provided within the home’s AQAA to describe how it provides good outcomes to people in this outcome group, however information obtained during the inspection shows that it continues to do so, with the manager recognising that the home could do better with activities with a focus on rehabilitation. People confirmed that they are offered a choice of meals and all people who were able to provide us with feedback described the meals as good. Records were seen on Nightingale unit, which show that staff monitor and keep records of people’s dietary and fluid intake. Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 Page 15 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): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at Bellevue Court have access to a complaints procedure, which is accessible to them and their representatives if they need to make a complaint. People living at Bellevue Court are not fully protected from the risk of harm and the instigation of safeguarding procedures is not consistent. EVIDENCE: Bellevue Court has a clear complaints procedure, copies of which are readily available in different locations around the home. The manager reported to us the home had received three complaints from an unknown source in the last twelve months and that senior management had investigated these. The manager confirmed that since the last inspection the home’s own trainer has taken on the role of providing training on Safeguarding Vulnerable Adults, the manager recognises that the home would benefit from providing specific training relating to local area policy. The manager informed us that training in newly introduced mental health legislation has not yet been provided to all staff, which is disappointing as at the last inspection it was reported that this training was to be ‘cascaded’ to staff. A recent alleged incident was referred appropriately by the manager to the local safeguarding adults team and the home is currently looking at why staff Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 Page 16 had not made accurate records at the time of that alleged incident. During observation of the accident book at this inspection, it was found that an alleged incident had not triggered staff to inform the manager or initiate a referral to the local team-this indicates that staff do not seem aware of when incidents need external input. During the inspection we became concerned that a person alleged they had been injured during a fall on the patio and it appeared from looking at the person’s care records and speaking with them that there had been a delay in seeking medical attention, this resulted in us making a referral to the safeguarding adults team for investigation under their procedures. We also required the home to take immediate action to ensure that the patio area was safe. Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are pleased with their individual bedrooms but parts of the home need attention so that people are provided with a good standard of communal accommodation and living environment. The home needs to take urgent action to ensure people are provided with safe outside spaces. EVIDENCE: We looked at a selection of bedrooms on each of the three floors and this shows that the décor within people’s bedrooms is satisfactory. We found the lounge and dining area on the ground floor to be well-decorated, creating a homely atmosphere, although carpets in the corridors on this floor were showing signs of wear and tear. Since the last inspection the décor in the lounge, dining area and corridors on the top floor has become quite shabby and there was a noticeable odour. There are some murals and paintings on Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 Page 18 some of the walls on the top floor, but overall there is little in the way of providing sensory stimulation for people with dementia within the whole home. Furniture in the top floor lounge looked old, staff reported to us that chairs needed attention and we observed one person seated in a chair, which was not working properly and we informed the manager of this. One person living on Kingfisher unit showed us how he is able to keep his bedroom ‘private’ through the use of a key to lock and unlock his bedroom door and described how he takes responsibility for keeping his room clean, this person spoke of how pleased he is with his room. The manager and staff spoke of plans to change the layout of Kingfisher unit, so as to afford more privacy to people wanting to relax in communal areas. However it is disappointing that no progress has been made since the last inspection to put these plans into practice or to provide a supervised kitchenette area on this unit. The manager spoke of the slow progress of the refurbishment programme, started initially in 2005; it is now a requirement to make environmental improvements to the whole home so as to enhance the living environment. The home recently had an infection control audit undertaken by a local infection control specialist and the manager confirmed the home is acting on those areas where improvements need to be made. Information provided by the manager shows that 66 of staff have received training on the prevention of infection and management of infection control. Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is on balance good. This judgement has been made using available evidence including a visit to this service. Observations of staff working demonstrate that staff have the necessary skills to support the people currently living at the home. Although there are some gaps in the training programme there are plans to deal with this. The recruitment procedure is robust and protects people from the employment of inappropriate staff. EVIDENCE: Staff working on Kingfisher unit, confirmed that since the last inspection training sessions on specific mental illnesses have been provided and that plans for this training are on-going. Discussions with staff who care for people with dementia confirmed good training opportunities, including support for studying for NVQ in care and more specific training in meeting the needs of people with dementia. Observation of staff files and the home’s training matrix shows some gaps with training in safe working practices, although notices around the home indicate that staff training is to be provided very soon, which should rectify these deficits. Staff files that were observed contained all the required pre-employment checks confirming that the home operates a robust recruitment procedure. Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 Page 20 The file for a new member of staff showed they had received an induction, however the induction documentation intended for staff to complete is notably outdated and does not meet current ‘Skills for Care’ standards, we received confirmation from senior management at the end of the inspection that this will be introduced without delay. We spoke with staff who provided differing opinions on whether they thought staffing levels were enough and comments were fedback to the manager, who provided confirmation that staffing levels change depending on the needs of people living at the home. Staffing levels on the day of inspection appeared sufficient for the numbers and dependency of people living at Bellevue. Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager, Gail Goddard has the skills and knowledge to lead the staff team and manage the home, however a more focussed attention on management systems and processes is needed to ensure people are consistently provided with positive quality outcomes. EVIDENCE: The manager, Gail Goddard, has considerable experience of managing care services and has the supportive management qualifications for the role. At the last inspection it was viewed that improvements had occurred within the service and its management, however this inspection identifies areas requiring improvement. Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 Page 22 For the purpose of this inspection Gail Goddard had responded to a request by the Commission to complete an annual quality assessment document (AQAA)this is an opportunity for providers to share with us areas that they believe they are doing well, yet Bellevue Court’s AQAA provided us with little information to demonstrate how it provides good outcomes to people, or the improvements it has made in the last year and how it is still planning to improve. Information obtained by us during the inspection shows that there have been improvements, such as with how people access their finances and implementing training about mental illness, but there are areas which need improving, including the environment, record-keeping and effective systems to monitor staff adherence to policies and procedures. We received mixed views from staff regarding how the home is currently functioning, some staff viewed there to be a lack of clarity about the boundaries of senior staff roles. At the last inspection staff spoke of how the supervisory approach used by the home was beneficial, at this inspection some staff viewed the supervision process as ineffective and a check of one staff members file found their supervision sessions to be infrequent and not to the expected six sessions per year. The manager confirmed that members of the senior management team regularly visit the home and we observed a written record for such a visit conducted recently. There are currently changes within the organisation structure and we saw notices to provide reassurances and information to people. Since the last inspection the home has changed the way people access their finances, which now affords people greater privacy and helps to ensure their dignity is not compromised. We also observed the ways in which transactions are recorded which shows a robust process for the safekeeping of money. Staff confirmed that meetings happen on a regular basis for people residing on the middle floor, and we observed copies of questionnaires which had been completed during April of this year which shows that people are given opportunity to comment on different aspects of the home and the services provided. The questionnaires are available in large print format with pictorial symbols, designed to assist people who may have communication difficulties. At the last inspection we discussed with senior management about publishing the results of surveys so as to keep people informed of results and any action taken, this has not yet been implemented for the surveys completed in April. We saw copies of meetings held for people’s significant others and were informed by the manager that these happen on a three monthly basis. Staff confirmed they have regular meetings and we saw minutes for a recent meeting. The manager informed us that staff are also given opportunity to complete questionnaires, although the manager informed us that the results of Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 Page 23 last years staff survey have not been made known to her-the process would be enhanced by operating an open and transparent quality assurance process. Information was provided within the AQAA to confirm that servicing and maintenance of equipment is undertaken and policies and procedures are regularly reviewed. When we looked at the records to show that weekly checks on the fire alarm are undertaken we found that checks had not been undertaken for the week preceding the inspection, the manager informed us that the person who does the checks was not available that week, however it would be expected that the home would have another member of staff who would be competent to take on the role. The manager reported that a visit by the local fire officer is imminent. Observation of a selection of bedrooms showed these have systems in place to ensure people’s safety such as wardrobes secured to the wall and the use of window restrictors to reduce the risk of windows been opened too wide. As previously mentioned we found that a person alleged they had fallen on the patio, when we observed the patio we found that a number of paving slabs were loose, cracked and the patio uneven and we sent a letter to the provider informing them of our concerns. We also informed a senior representative of the company on the day of the inspection who agreed that action would be taken to make people aware of the hazard until work is commenced to make the patio safe. Bellevue Court DS0000039462.V370319.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13 (2) Requirement Medication must be stored and given in accordance with manufacturers’ instructions. This is to ensure that people are not placed at risk of harm from receiving medication which has lost its potency and is therefore ineffective. Timescale for action 19/09/08 2 OP18 13 (6) 19/09/08 Arrangements must be made to ensure that all staff have a clear understanding of adult protection and whistleblowing procedures and are aware of their role and the procedure to follow in recognising and reporting allegations of abuse. This is to ensure that people living at the home are protected from harm or abuse. All parts of the home, including bathrooms, toilets and communal areas must be kept in a good state of repair. This is to ensure that people are provided with a clean, homely and safe place to live. . Action must be taken to ensure DS0000039462.V370319.R01.S.doc 3 OP19 23(2) 19/12/08 4 OP19 13(4)(a,c) 19/08/08 Page 26 Bellevue Court Version 5.2 5 OP36 18(2)(a) the patio area is safe for people to access. (Urgent action required) The registered person must ensure staff receive formal supervision at least six times a year and that records are kept. This will ensure that staff are competent to do their job and that this competency is maintained through a process of monitoring and reflecting on practice. 19/10/08 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 OP33 Good Practice Recommendations It is recommended that the home looks at ways to increase access to the results of ‘satisfaction’ survey’s-this is to keep people living at the home and/or their significant others informed of action taken by the home in response to any feedback 12/08/08-not yet implemented for surveys completed earlier this year. Bellevue Court DS0000039462.V370319.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. 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