Inspection on 02/11/05 for Bellevue Court

This inspection was carried out on 2nd November 2005.

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

Bellevue Court 30/01/09

Bellevue Court 12/08/08

Bellevue Court 25/09/07

Bellevue Court 30/01/07

Bellevue Court 30/10/06

Bellevue Court 10/03/06

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 08/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Bellevue Court (Highfield Care Homes No 2 Limited) Bellevue Court Woodcross Street Woodcross Wolverhampton West Midlands WV14 9RT Lead Inspector Rosalind Dennis Unannounced Inspection 2nd November 2005 11:00 X10029.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 (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 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 and Care Homes for Adults 18 – 65*. 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 (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bellevue Court (Highfield Care Homes No 2 Limited) Bellevue Court Woodcross Street Woodcross Wolverhampton West Midlands WV14 9RT 01902 662166 01902 6722300 Address 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) Southern Cross Care Homes No 2 Limited Care Home 68 Category(ies) of Dementia (38), Mental disorder, excluding registration, with number learning disability or dementia (30) of places Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th December 2004 Brief Description of the Service: Bellevue Court is registered with the Commission For Social care Commission to provide care for adults and older persons with a mental illness and/or dementia. The home has three floors with a lift and stairs providing access between floors. Generally older persons reside on the ground and upper floors and younger adults or individuals with more complex mental health reside on the middle floor. Bellevue Court is located on the borders of Wolverhampton and Dudley, with local shops and a bus stop close by. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and lasted for approximately 6 hours. The inspection included observing activity within the home, looking at residents care records, speaking with staff and two residents. A random selection of bedrooms and communal rooms was also undertaken although the third floor was not observed on this occasion. The manager and staff on duty were welcoming and offered their fullest co-operation throughout the inspection. Due to the nature of some of the residents mental illness the inspector was unable to ascertain their views of the service and care received. However residents seen during the inspection appeared well cared for and staff attentive in meeting their needs. A new manager has recently commenced at Bellevue Court, who along with a stable staff group appears committed to developing and enhancing the service from which residents will benefit. The manager is awaiting formal completion of the registration process with CSCI. What the service does well: What has improved since the last inspection? Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 6 Some improvements have been made to the storage of medication, however two requirements regarding medication practice remain outstanding. 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. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4. Standard 6 is not applicable to this home. The home has an admission procedure that is effective in ensuring that individuals moving into Bellevue Court know that the home will meet their needs. Staff individually and collectively have the skills and knowledge to meet residents needs. EVIDENCE: Observations were made of four care files on the ground floor (dementia care) and four care files on the middle floor (mental health/younger adults). All contained sufficient information that would enable the successful admission of an individual to Bellevue Court. Pre-admission assessments incorporate Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 9 physical, social and mental health assessments and social profiles provide staff with information on individual resident’s preferences and a history before their illness. This encourages staff to give care in a personalised way. Discussions with staff during the inspection indicate that they have a good understanding of the varying needs of the people accommodated. Observations of staff files show that staff have received a range of training specific to meeting the needs of service users. Due to the nature of some of the residents mental illness the inspector was unable to ascertain their views of the service and care received. However observation confirmed that these residents appeared well cared for and staff attentive in meeting resident’s needs. Through observation of staff working with residents, observation of residents care plans, staff training records and discussions with staff and residents, the home demonstrates that it meets the needs of the current residents. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are 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 and 10. For some residents the care planning system is good and provides staff with the information they require to meet residents’ needs. The current care planning and risk assessment process in use on the middle floor is not sufficient as it does not provide staff with enough information to meet the needs of adults with more complex mental health needs. The process for storage and administration of medication is not robust and potentially could place residents at risk. EVIDENCE: Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 11 All files on the ground floor (dementia care) contained an extensive range of care plans and risk assessments relevant for each individual case tracked during the inspection. For example a care plan for a resident requiring PEG feeding included comprehensive information regarding their feed regime. A review by the dietician showed that the home adheres to the regime prescribed, but seeks prompt and appropriate advice when necessary. Another care plan demonstrated that staff recognise potential communication difficulties such as for individuals whose first language is not English. All risk assessments that were observed clearly identified resident’s needs and the interventions required to reduce risks such as the management of mood changes and aggressive behaviour. Documentation had been reviewed at least monthly and when changes occurred with resident’s healthcare needs. The manager has commenced auditing care documentation to ensure that staff adhere to policy and an example of a completed audit was seen on this unit. Observations of four care files on the middle floor identified some deficits with the recording of information. Although files had care plans and risk assessments in place these appeared to be orientated towards general care needs rather than mental health needs. For example risk assessments were in place regarding pressure sore risk, moving and handling and nutrition. Care plans had been drawn up identifying alcohol abuse, smoking and resident safety but these “risk areas” had not been expanded in the form of a risk assessment. Thus there was little guidance available for staff on how to manage these potential risks. Daily records on this floor were well-maintained and provided confirmation that needs were met. However “clients progress/weekly reports” which, according to staff are for key workers to complete had not been recorded on a consistent basis. Some entries had been recorded on a weekly basis and other entries on a monthly basis; in one file the last recorded entry was 18th September 2005. A separate file is maintained when residents exhibit challenging behaviour and staff document interventions that are required to diffuse situations. Residents are informed that closer observations are being made of their behaviour and staff spoke positively regarding this system as it generally initiates a prompt improvement in behaviour. It is acknowledged that the home has recently changed all care documentation and observation of files showed that staff have had to rewrite and transfer information into new care files. Discussion with the manager indicated that the documentation in use on the middle floor has already been considered not to be fully appropriate for this particular client group. Further consideration is required to ensure that appropriate risk management strategies are in place. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 12 Previous inspections in 2004 identified deficits with medication practices and storage. Observations made at this inspection confirmed that requirements were still outstanding. Examination of stock cupboards showed that medication was organised according each resident. However some residents had a number of boxes of the same drug dating back several months, indicating stock rotation within the cupboard was not occurring and that for these residents medication had been repeatedly ordered. A number of medication administration records (MAR) charts examined had gaps where a signature to confirm administration or an abbreviation for nonadministration should have been. Two trained staff spoken with could not provide confirmation whether the drugs had been given. The temperature within the treatment room was recorded by the inspector at 28 degrees centigrade and observations of records showed that it is generally around 27-28 degrees, thus still exceeding the maximum level. Records show that the temperature of the drugs fridge has frequently been recorded at below the required minimum level of 2 degrees centigrade. Documentary evidence supplied by the manager confirms that the fitting of a ventilation unit within the treatment room has been identified for action. The manager confirms that she is planning to commence auditing MAR charts; this should be commenced as a matter of priority. The CSCI pharmacist inspector is to visit the home to conduct a more in depth inspection of medication practices and procedures. Staff were observed treating residents with dignity and respect, two residents residing on the middle floor confirmed that staff were approachable and respectful. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home provides social and recreational activities that provide variation and interest for people living at the home. EVIDENCE: Observations of records maintained by the homes activity co-ordinator shows that a good range of activities are provided both in-house and in the wider community. A “weekly timetable” on each floor gives some structure to the planned activities although discussion with the activity co-ordinator and one resident confirm that plans change depending on resident needs and choice. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 14 Pictorial guides regarding activities are available for those with communication difficulties. In-house activities include snooker, quizzes that are usually led by a resident and reminiscence therapies. The home has access to its own transport and group trips occur on a regular basis with residents being free to choose whether they attend. Recent outings have included a canal trip, visit to Penkridge market, shopping and cinema visits. It was observed that some “recreational activity” records had not been completed by care staff on a regular basis. Three residents on the younger persons unit were satisfied with the level of activities provided by the home, one resident was very keen to discuss her achievements at a local college. Younger adults have not had a holiday this year and although residents did not highlight this as a problem, the registered person will need to ensure that a holiday is incorporated into next year’s plans. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed on this occasion. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Bellevue Court provides residents with a comfortable place to live. Although some redecoration and refurbishment has commenced, continued investment is required to improve and enhance the environment. EVIDENCE: Since the last inspection some improvements to the home’s décor and furnishings have taken place, however observation of a number of individual bedrooms and bathrooms, shows that further investment is required. One resident showed her recently redecorated bedroom, which was decorated to a Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 17 high standard. The resident was very pleased with the décor and confirmed that she had chosen it. In other bedrooms the décor was satisfactory but in some, particularly on the ground floor it was noticed that wallpaper borders were peeling off and paintwork chipped. A recent Regulation 26 monitoring visit by the operations manager has identified the need for a refurbishment plan and the manager confirmed that this is in hand. Residents on the ground floor were observed moving freely around the unit, closely supervised by staff. Bedroom doors are not routinely locked on this floor unless a resident requests this to be done. Pictorial signage was seen on toilet and bathroom doors in order to make these facilities more prominent to individuals with dementia. The flooring in one walk in shower on the ground floor was quite stained and one bathroom requires refurbishment. The home has limited areas for storage and the hairdressing room is currently being used as a storage area. Minutes from a recent Health and safety meeting demonstrate that the home has already identified a lack of storage space and is looking at ways to address this. Observations made during the inspection confirmed that systems are in place to control the spread of infection and the home has met the requirements to fit sluice disinfectors. The laundry facilities appear adequate to meet the laundering requirements of residents and dissolvable bags are available in order to limit staff contact with soiled linen. It was noted that there appeared to be limited ventilation within the laundry room, staff have previously recorded the temperature within this room and the records show that it had been recorded at 31 degrees centigrade in the summer months. It is advised that a record is kept to ensure the temperature does not exceed 30 degrees and is maintained at a reasonably comfortable level. The fire officer visited in April 2005 and was satisfied with fire safety provision within the home at that time. Discussion with the manager highlighted several incidents where individuals that had previously been residents at the home had managed to gain access to the home. The registered person is required to review the security to the home. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the 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 and 30. Training specific to the needs of people that access the service is provided, resulting in a knowledgeable workforce that have the appropriate skills to meet the needs of residents. EVIDENCE: Observations of training records show that staff have attended a variety of different study days and courses to ensure they are sufficiently skilled to meet the needs of the current residents. During 2005 study sessions have included; mental health-an introduction, mental health issues, drugs in mental health and nutritional support for people with dementia. Other training includes fire safety, abuse awareness and food hygiene with dates for moving and handling training planned. Group discussion with staff confirmed attendance at study sessions and that training opportunities within the home were generally good. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 19 The manager confirmed that twelve staff have attained NVQ Level 2 or equivalent and a further 15 staff are currently studying for this qualification. Since commencing in post the manager has reviewed the Registered Mental Nurse (RMN) input on the middle floor and an RMN is now available on each shift day and at night. This is good practice and appropriate to meet the mental health needs of these residents. Other staffing arrangements within the home remain unchanged and are as follows: Ground floor-2 carers am, 2 carers pm and 2 at night with Registered Nurse (RN) cover on all shifts. Middle floor-3 carers am, 3 carers pm and 2 at night with RMN cover on all shifts. Top floor- 4 carers am, 3 carers pm and 2 at night with RN cover on all shifts. Three staff members that work on the ground floor felt that the levels are generally satisfactory although identified that short notice absences can cause occasional difficulty. Observations made during the inspection suggest that levels appeared appropriate for the current needs of residents. Feedback from staff that work in other parts of the home will be obtained at the next inspection. Two residents on the middle floor that were spoken with were satisfied with the level of staff. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 38 There are clear lines of accountability within the management structure and the management approach creates an open and positive atmosphere from which residents and staff benefit. A safe working environment and a staff group that is appropriately skilled ensures that the health, safety and welfare of residents is promoted. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 21 EVIDENCE: Residents and staff that were spoken with were generally positive regarding the changes with the ownership of the home and the new management structure. Since the appointment of the new manager a local consultant psychiatrist has written to the home to comment on recent improvements that have occurred for which residents will benefit. The manager is awaiting formal completion of the registration process with CSCI; previous experience as a registered manager and supporting qualifications confirm that the manager has the necessary skills to be the registered manager of Bellevue Court. Discussions during the inspection demonstrate the manager’s commitment to improving services within the home. All records pertaining to the maintenance and servicing of equipment were observed to be up to date and well organised and observations during the inspection confirmed a safe environment. For example wardrobes were secured to the wall and all bed rails that were observed in use were fitted correctly. The manager confirmed that the maintenance person is responsible for fitting bed rails. Two members of care staff confirmed they do not fit bed rails but will inform the maintenance person if an individual is risk assessed as needing them. Completed bed rail risk assessments showed that staff are aware that if pressure overlays are used than additional height bed rails must be fitted. Although observations suggest that the maintenance person and staff are aware of current guidance regarding the fitting of bed rails, the manager was strongly advised to seek clarification that training has definitely been provided, that the maintenance programme incorporates bed rails and who takes responsibility for fitting bed rails in the maintenance person’s absence. The manager has recently set up a Health and Safety Committee within the home, which enables designated members of staff to discuss and feedback on any health and safety issues. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 22 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 X 2 X 3 3 4 3 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X ENVIRONMENT Standard No Score 19 2 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 X 32 3 33 X 34 X 35 X 36 X 37 X 38 3 Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard Regulation 14,15 Timescale for action Identified risks and hazards must 01/02/06 be adequately assessed and include the strategies needed to minimise the risk. Any necessary restrictions on freedom and choice are discussed with the resident and recorded. To address the gaps in the 01/01/06 recording on the medication administration charts. (Previous timescale of 20/9/04 not met) To review the ventilation in the 01/01/06 clinical room so that the temperature does not exceed 25 degrees. (Previous timescale of 20/9/04 not met.) The temperature of the drugs 01/01/06 fridge must be maintained at between 2 and 8°C and a daily minimum and maximum temperature recorded. All stock must be rotated so that 01/02/06 the oldest is used first The Manager must regularly 01/02/06 audit the medication to ensure the integrity of the MAR charts is maintained The registered person must 01/07/06 DS0000039462.V264520.R01.S.doc Version 5.0 Page 24 Requirement 2 OP9 13(2) 3 OP9 13(2) 4 OP9 13(2) 5 6 OP9 OP9 13(2) 13(2) 7 OP19 23 (2)(d) Bellevue Court (Highfield Care Homes No 2 Limited) 16 (2)(j) 8 OP19 13(4)(c) ensure that the refurbishment plan for the home is completed. The registered person must ensure that systems are in place to maintain a safe and secure entrance to the home 01/02/06 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 Refer to Standard OP12OP7 Good Practice Recommendations The registered person is advised to provide clarification to staff on the expected frequency of completing the recreational activity reports and outline staff responsibilities for completing the weekly/progress reports. It is advised that the temperature of the laundry room be monitored daily to establish whether the temperature within this room is at a reasonably comfortable level for staff. The registered person is strongly advised to clarify that training in fitting of bed rails has been provided for staff, that bed rails are included in the maintenance programme and determines who takes responsibility for the fitting of bed rails in the absence of the maintenance person. 2 OP19 3 OP38 Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V264520.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE 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. 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