Inspection on 30/01/07 for Bellevue Court

This inspection was carried out on 30th January 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

Bellevue Court 30/01/09

Bellevue Court 12/08/08

Bellevue Court 25/09/07

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Bellevue Court Bellevue Court Woodcross Street Woodcross Wolverhampton West Midlands WV14 9RT Lead Inspector Keith Salmon Key Unannounced Inspection 30th January 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 Bellevue Court DS0000039462.V328916.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.V328916.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 6722300 bellevuecourt@schealthcare.co.uk None 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.V328916.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th October 2006 Brief Description of the Service: Bellevue Court provides care for persons with a mental illness or dementia. Located on the borders of Wolverhampton and Dudley the Home benefits from local shops and access to public transport bus stop being in close proximity. Residents with dementia are accommodated on the ground and second floors of the Home, and those with mental illness reside on the first floor. At the time of this Inspection fees for care ranged from a minimum of £418 per week up-to a maximum of £996 per week. Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This ‘Key’ Unannounced Inspection was held on 30 January 2007, commencing at 09.30am, concluding at 1.00pm (a total of 3.5 hours), and was conducted by Mr Keith Salmon. Present throughout the Inspection, on behalf of the Home, was Mrs. Gail Goddard, Registered Manager. The main objective of this Inspection was to review all of the ‘Key’ Standards, as set out on the National Minimum Standards for Care Homes for Older People, and to determine progress made by the Home in meeting ‘Requirements’ arising from the previous Inspection held on 30 October 2006. This Report is based on observations made during a tour of the Home, a review of care related documentation, staff duty rotas and staff files, plus a range of other documents/records reflecting the general operation of the Home. The Inspector also held 1:1 discussions with the Registered Manager, 4 Residents, 2 visitors, and several members of Staff. What the service does well: What has improved since the last inspection? Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 6 Seven of the nine ‘Requirements’, cited at the previous Inspection, and covering the following areas, have been fully met, i.e. The washing machine used by some Residents for carrying out personal laundry has been replaced. Access to the premises is now improved whilst remaining secure. Accidents are now appropriately recorded and reported as necessary. New Staff only commence work at the Home following necessary security checks. Formal supervision of staff is now satisfactory. There is noticeable progress in improving the standard of internal décor and furnishings – e.g. a number of bedrooms have been repainted. In addition, as part of the on-going redecoration programme, some rooms are being developed for more flexible use, e.g. the hairdressing salon is to be utilised for craft activities when the hairdresser is not in attendance and the ground floor lounge is to be divided to create a ‘quiet’ area. 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. Bellevue Court DS0000039462.V328916.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 Bellevue Court DS0000039462.V328916.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): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Processes to ensure appropriate and thorough care needs assessment, prior to any decision to admit a new Resident to the Home, are in place and are effectively applied. EVIDENCE: ‘Case Tracking’ involved the review of 4 Residents’ Care Plans/Files, (i.e. those relating to the four most recently admitted Residents). The sample included Residents with dementia and some designated as having ‘mental illness’. This review demonstrated potential Residents have their care needs assessed by the Registered Manager, or Deputy Manager, prior to taking up residence. Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 9 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): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The model of Care Plan utilised by the Home is of a design, which is easy to read and comprehensive. The care provided by the Home is effective in meeting Residents’ assessed care needs, and is delivered considerately and effectively. The storage, administration, and disposal of medicines are generally in accordance with accepted good practice. However, no evidence was seen of regular revue of medicine regimes. EVIDENCE: As a component part of the ‘Case Tracking’ exercise, Care Plans/Files were reviewed and discussions held with 4 Residents. The Inspector specifically looked to ascertain whether Care Plans:Were easy to follow and understand Were current Provided involvement of SU/Relative/Advocate Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 10 Made reference to Risk Assessment where indicated by the ‘care needs assessment’ process, e.g. pressure area risk assessment, nutrition, continence, self-direction Provided evidence of regular audit by the Manager This review demonstrated care planning processes and documentation are comprehensive and reliably applied with all of the above aspects of care having been covered. A Review was undertaken of the policies/procedures relating to the management/administration of medicines, i.e. records relating to the supply, storage, and disposal of medicines (including records of ambient and medicine refrigerator temperatures), the maintenance of medicine administration records (MAR Sheets), and the maintenance of the Controlled Drugs Register. The Inspector also reviewed the contents of the medicine trolleys, secondary/back-up storage and storage of medical gases. Whilst the management of medicines was found to be generally satisfactory, it is recommended the Home introduce a rolling programme of medicines review, to include a re-assessment of PRN Medicines, i.e. move to regular prescription when PRN medicines are given frequently. Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 11 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): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Leisure opportunities are provided, which are consistent with Residents’ capabilities. The Home facilitates achievement of desired lifestyle through Residents conducting the pattern of their day, where possible, as they wish, including contact with family and friends, and continuation of religious practices. Access to the Home, via the front entrance, for ‘self caring’ Residents and Visitors is now satisfactory. There is a daily choice of attractive and nutritious meals. EVIDENCE: Care plans, weekly activity sheets, and the ‘Therapeutic Activities’ log provided evidence that Residents, particularly those in the ‘Kingfisher Suite’, undertake a range of activities. As most of the Residents in ‘Nightingale’ and ‘Lark’ Units are more dependent activities are tailored to accommodate Residents’ individual levels of dementia. Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 12 The range offers a well established pattern of activities including; escorted walks in the local park (including ball games for those Residents capable of such activity), visiting entertainers, craft sessions, pub meals, exercise to music, drama therapy, formally arranged Summer Holidays, trips to Blackpool, the local cinema, meals at MacDonald’s, and visits to a local café for ‘Coffee and Cakes’ afternoons. Residents confirmed to the Inspector they have choice regarding activities, exercise that choice and enjoy the activities. The Home employs two full-time Staff as Activities Co-ordinators, who plan and lead leisure and social activities. One of the Co-ordinators also drives the Home’s minibus on trips and outings. As mentioned in the previous Report, the available Staff hours are currently deployed over 3 relatively separate Units with Care Staff continuing activities when the ‘Activities’ Staff move on to other parts of the Home. At the previous Inspection the Inspectors raised the possibility that such arrangements may not meet the activity requirements of a potential 68 Residents, spread over three floors, in the most effective manner. It was therefore ‘Recommended’ the provision and deployment of the ‘Activities’ Staff resource be reviewed. The Manager informed the Inspector there were now firm plans by ‘Southern Cross’ to review staffing in this area, with the aim of effecting an increase in designated hours. Also, the deployment of ‘Activities’ Staff was currently the subject of discussion at Staff Meetings, which was confirmed by a member of Staff during a 1:1 discussion with the Inspector. Menus are based on a four-week cycle and provide mainly ‘traditional’ meals with seasonal adjustments. Residents expressed the view they were generally satisfied with the quality of food provided. A ‘Requirement’ of the previous Inspection necessitated the repair or replacement of the washing machine on the first floor, provided to enable selfcaring Residents to undertake laundering of their personal clothing. During the tour of the premises the Inspector observed this machine had been replaced and is in use by Residents ‘risk assessed’ as being able to do their own personal laundry. In addition, a ‘Requirement’ necessitating a review of the control of access to the premises, has been resolved by the Reception Area, which has a clear view of the entrance lobby, being manned during daytime hours. In addition, improvements have been made to the front door bell system to enable Staff to be aware of visitors at other times, and Residents, who are capable of leaving and returning as they please, are now able to do so when they so wish. The Inspector considers both of these ‘Requirements’ to be met. Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 13 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are now fully enabled to pursue the complaints process, and are reliably protected from abuse. Staff recognise they have a role in protecting Residents from abuse and are confident they would be able to carry out that role. Documentation of ‘incidents’ relating to/involving Residents is satisfactorily completed. EVIDENCE: Three ‘Requirements’ were issued at the previous Inspection relating to the recording, assessment, and notification of accidents/incidents. At this Inspection it was observed the Manager has worked effectively in meeting these ‘Requirements’ as follows:A clear and concise Complaints Procedure, which includes reference to the Commission for Social Care Inspection as the regulatory body, together with contact details, is now displayed in the main hallway. Information on how to raise a complaint is now included in the Service User Guide. The Home now maintains a record of complaints, which was observed to be current. An examination of ‘Accidents/Incidents’ Records demonstrated nothing of particular concern for the Inspector. Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 14 Residents, who were able, and Visitors stated they would have no hesitation in raising matters if they had any concerns, and were confident these would be dealt with promptly. Policies relating to protection of Residents from abuse were observed to be in place and readily accessible, including ‘Whistle Blowing’, ‘Abuse Awareness’ and ‘Adult Protection’. Staff training files indicated Staff have now received training in respect of these Policies. Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 15 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 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home provides a safe, generally well-maintained environment offering comfortable bedrooms and communal areas. Décor should be satisfactory when the current redecoration programme is completed. Although the cleanliness in the Home is generally satisfactory there remains a smell of urine in some parts of the Home. Specialist equipment, consistent with meeting the assessed care needs of Service Users, and the demands of tasks carried out by Care Staff, is available. Laundry facilities are now satisfactory. Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 16 EVIDENCE: At the time of the Inspection redecoration/refurbishment of the premises was seen to be on-going, and the Home is making positive strides towards improving this area of care. Repainting and repapering work has been completed in all lounge/dining areas and corridors. A refurbishment plan was reviewed, which included projected completion dates for a range of works covering replacement of carpets for the entrance to the Home and six bedrooms, replacement of thirteen beds and mattresses, twelve sets of bedroom furniture, eleven bedroom armchairs, dining and lounge furniture, and soft furnishings in every bedroom. In addition, as part of the overall programme, the Home proposes to develop some of the communal rooms for more flexible use, e.g. the hairdressing salon is to be utilised for craft activities when the hairdresser is not in attendance and the ground floor lounge is to be divided to create a ‘quiet’ area. The redecoration programme is making a notable contribution to establishing a much more pleasant environment, and when plans for the replacement of carpets in bedrooms and communal areas are complete the overall ambience of the Home should be greatly enhanced to the benefit of Residents, Visitors and Staff. However, during a tour of the premises it was noted the carpet in the top floor lounge has an unpleasant smell, which is clearly due to continence problems experienced by some of the client group located on that floor. Whilst it is accepted that, to some degree, this situation is unavoidable there is now a need to replace this carpet with appropriate floor covering and to build into the on-going redecoration/refurbishment programme a budget enabling relatively frequent replacement. It is suggested the replacement floor covering is aimed at maintaining a ‘homely’ ambience in addition to any hygiene considerations. A ‘Requirement’ will be cited to this effect. In summary, the environment has shown clear improvement since the previous Inspection and on satisfactory completion of planned work, particularly the replacement of carpets, the Home should be a candidate for moving from ‘adequate’ to ‘good’ in respect of this ‘Outcome’ area. Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 17 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, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers and skill-mix listed on the staff rota are sufficient to meet the assessed care needs of current Residents. Recruitment and employment practices are consistent with the safeguarding of Residents. The commitment of the Home to providing training for Care Staff has improved and is now considered to be good. EVIDENCE: Staffing rotas from the current and several preceding weeks were examined. It was found that staffing numbers, and skill-mix, on duty were and are sufficient to enable a service provision, commensurate to the care needs of the Service Users. At the previous Inspection the following ‘Requirement’ was issued “The Registered Manager must ensure new Staff do not commence work at the Home until all checks as specified under the relevant Regulation(s) and Standard have been satisfactorily completed”. Staff Personal Files, including those identified as being unsatisfactory at the previous Inspection, were examined and now demonstrate full compliance with the Standard and Schedule 2 of the Regulations. This’ Requirement’ has been met. Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 18 In addition, Staff files, and discussion with Staff members, provided evidence of an on-going Staff training programme, which provides a thorough, and relevant, orientation/induction programme, followed by comprehensive ‘foundation’ training, e.g. ‘manual handling and lifting’, ‘fire safety’, ‘first aid’, ‘simple infection control’, and ‘dementia awareness’ training. Currently, the Home meets the ‘Standard’ relating to the proportion of Care Staff who have attained NVQ Level 2, or higher, with a figure of 58 . A further 10 are currently undergoing training, with a further 7 to commence in the near future. In addition, 3 Staff are undertaking a course to improve their understanding, and use, of the English Language with a view to commencing NVQ Courses. Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 19 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): 31,33,35,36,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A more focussed attention by the Manager on management systems and practices is presenting signs of improvement though there remains scope for further development. Formal supervision practice is now in accordance with Regulation/Standards. Health and Safety Policies/Procedures/Practices are satisfactory. EVIDENCE: Since the previous Inspection, management systems and practices have shown sufficient improvement for the quality rating to be moved upwards from ‘poor’ to ‘adequate.’ Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 20 Specifically, the action plan, introduced by ‘Southern Cross’ Senior Managers as a support process for the development of the Home’s Manager, is now well established. Twice weekly on-site input from the Operations Manager appears to be effecting positive change with seven out of nine Requirements from the previous Inspection having been fully met; a more active and purposeful use of staff meetings; development of plans in relation to the use of accommodation; satisfactory completion of formal staff supervision; the introduction of a new approach to staff management, training, supervision, and administrative systems generally. In the light of these changes the Inspector considers there are significant signs of improvement in the Management of the Home. Though Residents’ cash is held in a ‘pool’, accounting/documentation systems in place appear to protect Service Users’ finances. All monies are maintained securely in a locked cash box, with access limited to a small number of approved Staff. The basis of accounting for these monies is through a computerised ‘on-line’ system, which was introduced by the new Proprietors. This is backed by entries in the ‘in-house’ handwritten ledger, which is maintained on a daily basis. A review of this system, including the tracking of two Accounts chosen at random by the Inspector, demonstrated the system to be robustly effective. The computer system provided information on individual Service User’s available monies, together with the total sum of monies, which should be in the cash box. These were checked by the Inspector and found to be in order. All monies are checked, on a monthly basis, by the person undertaking the Regulation 26 Visit, with the outcome being fully documented, in addition to regular audits by Auditors from the Parent Company. Although the practice of ‘pooling’ Residents’ personal monies contravenes the detail of Standard 35, the Inspector is satisfied that given the rigorous systems in place, and the diligent way in which they are applied, the overall ‘Outcome’….“Service users’ financial interests are safeguarded” …is met. The Inspector was shown a Staff Supervision plan for 2006/7. Review of a sample of staff files, and discussion with Staff, showed planned supervisions had been fulfilled to date. Therefore, a ‘Requirement’ made at the previous Inspection in respect of this ‘Outcome’ area is considered to be met. All relevant records relating to maintenance of equipment/electrical testing/ water safety/fire safety are maintained in easily accessible form and demonstrated this aspect of the Home’s management to be fully up-to-date. Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 21 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 2 X X X X X X 2 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 2 X 3 X 3 3 X 3 Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 31/03/07 1. OP19 16. (2)(j)(k) 23. (2)(d) The Responsible Individual must ensure that the refurbishment plan for the Home is completed. (Timescale from November 2005 inspection). 2. OP19 16. (2)(j)(k) 23. (2)(d) 3. OP26 16. – (2)(j)(k) 4. OP31 10. - (1) The Responsible Individual must 31/03/07 ensure the on-going redecoration/refurbishment programme, addresses the need for frequent carpet/floor covering replacement where necessary to prevent malodours. The Responsible Individual must 28/02/07 ensure the top floor lounge carpet is replaced with new floor covering whilst maintaining a homely ambience. The Registered Manager must 31/03/07 continue to follow the ‘management improvement’ plan agreed between the Manager and the Provider. Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 23 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 OP9 Good Practice Recommendations That the Home introduce a rolling programme of medicines review to include reassessment of PRN Medicines, i.e. possibly move to regular prescription when PRN medicines given frequently. It is recommended that, as part of the increasing level of dialogue between Staff and Management, the provision, and deployment of the ‘Activities’ Staff resource be reviewed. 2. OP12 Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Bellevue Court DS0000039462.V328916.R01.S.doc Version 5.2 Page 25 - 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. 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