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Inspection on 30/01/09 for Bellevue Court

Also see our care home review for Bellevue Court for more information

This inspection was carried out on 30th January 2009.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

CARE HOMES FOR OLDER PEOPLE Bellevue Court Woodcross Street Woodcross Wolverhampton West Midlands WV14 9RT Lead Inspector Karen Powell Key Unannounced Inspection 30th January 2009 10:15 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.V374036.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.V374036.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bellevue Court Address 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 Ltd 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) Manager post vacant Care Home 68 Category(ies) of Dementia (38), Mental disorder, excluding registration, with number learning disability or dementia (30) of places Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th August 2008 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 £454.00 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.V374036.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of the service was unannounced and took place on 30th January 2009 by one inspector over a period of approximately eight hours. A range of evidence was used to make judgements about this service to include discussions with people using the service the manager and senior management of Southern Cross and some of the staff. We also examined a number of records to include care records of people living at the home, staff training, staff recruitment and health and safety records. Two people who live in the home were ‘case tracked this involves establishing individuals experience of living in the care home by meeting them, discussing their care with staff, looking at care files and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. One individuals records who no longer lives at the home were examined as this person had been referred into the safeguarding of adults process. We followed up issues as a result of that meeting. This is the second key inspection to the service; the last inspection took place on 12th August 2008. Prior to the key inspection in August an Annual Quality Assurance Assessment (AQAA) document was posted to Bellevue Court for completion. The AQAA is a self-assessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for them to share with us areas that they believe they are doing well. By law they must complete this and return it to us within a given timescale. The registered manager at the time completed this. The purpose of the inspection was to assess all 22 ‘Key’ National Minimum Standards for Care Homes for older people and any further standards necessary. We also looked at compliance with the requirements made at the August 2008 inspection visit. Information to produce this report was gathered from the findings on the day and also by review of information received by CSCI prior to the inspection date. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. What the service does well: Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 6 The manager is a respected individual who in the short time he has been in post has begun to improve the outcomes for people living and working at the home. The staff are cheerful and helpful and encourage people to enjoy themselves as well as making sure they are safe and looked after. More than 50 of care staff are trained to NVQ 2 or above. This exceeds national minimum standards. Visitors are made welcome into the home. There is a clear and accessible complaints procedure, which is used in addressing any concerns or complaints raised by people. What has improved since the last inspection? Care plans are in the process of being reviewed to tailor make them to the needs of people using the service. Training in a variety of topics has been rolled out, equipping the staff with the knowledge and skills they require to do their jobs well. In response to the question what has improved since the last inspection? staff told us the following; • • Change of the home manager who comes to the floor every day to support staff Care has improved with better care plans, risk assessments and menus for people living at the home More training sessions to educate staff Head office are more motivated to refurbish the home to make it more modern • • What they could do better: Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 7 The home should respond promptly when there is a change in an individuals needs, which may require input from other healthcare professionals involved in the persons care and well being. Individuals privacy and dignity must not be compromised by re arranging room arrangements without careful thought and planning and involving the person concerned. The programme for the redecoration/refurbishment of the identified areas within the home is urgently required, including planning for the future developments within the home to ensure that people have a suitable environment in which to live. Urgent attention is required to the ground floor patio area adjacent to Nightingale unit to reduce the risk of accidents to people living, working and visiting the home. 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.V374036.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.V374036.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): 3 Quality in this outcome area is good. People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an admissions procedure in place, which is documented in the statement of purpose and service user guide. This information is currently Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 10 under review but is usually given to people who may be considering moving into Bellevue Court. People wishing to move into the home or their representatives are encouraged to view the home before making a decision about moving in. We looked at the records of the latest person admitted to the home. They were unable to discuss the process with us. The admission took place in an emergency and was dealt with via the local care management team, from which the home obtained an overview assessment. A care plan was devised in a timely way from the overview assessment, the homes own observations, and discussions with family. Bellevue Court DS0000039462.V374036.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 & 10 Quality in this outcome area is adequate. Care plans and risk assessments are generally well written and provide staff with information to meet people’s needs. The handling of medication is in line with current good practice. Individuals privacy and dignity is generally maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked in detail at two peoples care records who live at the home. Each contained a plan of care, which included details of how their needs should be met. They demonstrated that their representatives had been involved in their Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 12 plan of care. Staff we spoke to had a good understanding of the support that these people required. We looked at the care plan of someone who has since moved on from the care home. Concerns about how the home had managed the persons care had been referred into the adult protection process. When we examined the care records it was seen that the individual had been assessed as having behaviours that challenged the service. When this behaviour became an issue at the home it was noted from the care records that there had been a two day delay before the home informed the individuals GP and social worker. Through discussion with the operations manager she felt that staff lacked training in the area of dealing with challenging behaviour and since the incident all staff have completed training in this area. The home acted very quickly to address this training issue. The manager informed us that he is carrying out care plan audits to identify any shortfalls within care plans. He stated that this has been working well and generally raising the standards of care plans. We spoke to the nurse in charge of the medication round during the visit. She competently discussed the procedure with us. Medication administration records and storage for one person we case tracked on Nightingale unit was found to be satisfactory. We discussed the disposal of medications procedure and the safe handling of controlled drugs, which was found to be in line with good practice. All records relating to the safe handling of medications was found to be satisfactory. It was considered that the requirement relating to safe storage made at the last inspection had been met. Peoples preferred terms of address was seen stated on their care plan. Observations made on the day of the inspection saw staff treating people living at the home with respect and sensitivity. CSCI had been informed of concerns about an incident where one person living at the home had been moved to share with another resident, this person not being consulted about someone else sharing with them. It was acknowledged by the deputy manager that this did take place at the request of the person wishing to move into the room. We saw the care records of this individual, which stated they had requested the move into the room. However the care records of the other person clearly documented their dissatisfaction at being requested to turn off her main light and radio. This situation compromised the privacy and dignity of that individual. Also the home should not occupy a designated single room as a double room. The matter has since been resolved and both people have their own rooms. Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 13 Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 14 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. Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a designated activities worker who arranges in house and external activities. On the day of the inspection a disco had been arranged for people living on Kingfisher unit. Everyone who was participating appeared to Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 15 be enjoying the activity. Refreshments were available for everyone. The disco was being provided by a relative of a person who lives at the home. We saw pictures of activities that had taken place at the home, in particular Christmas entertainment. Forthcoming activities are advertised on the homes notice boards. A four week rolling programme of activities is in place. We were told any additional activities are publicised as a separate announcement as they are arranged. One person we saw attends a day centre, which was documented in their care plan. Another told us of a computer course which had been arranged for them by the home. We saw individual folders of people who live at the home and activities they had taken part in. An activity sheet is completed which states the type of activity undertaken, pictures of the person and comments by staff as to their response to the activity. This helps staff to plan future activities, particularly with the group of people the home cares for. Overwhelming feedback from staff and those people who were able to contribute to the inspection process was that they would welcome the homes mini bus back. It has been out of action for sometime and appears that it cannot be repaired. People told us we miss the mini bus so much, we would like the mini bus back, we went out on so many trips. It was convenient for us. Now we have to rely on taxis and ring and ride which is not as good and as frequent. One staff member told us it limits who we can take out in taxis because of access and mobility. The operations manager shared with us that it is planned to recruit further hours into activities posts, sharing the hours across the three floors of the home. We spoke to relatives who were visiting the home who told us they could visit their loved one as they wish and are welcomed by staff. One person we case tracked told us of their participation and enjoyment of attending the local day centre. They told us they could choose what they want to do with their day. We saw one person returning from a shopping trip, they were happy to share with us where they had been and what they had brought. The home fully supports people who are able to visit the community to do so. We spoke to the cook in detail. She demonstrated a clear understanding of the dietary needs of the people we case tracked, as seen in their care records. The lunchtime meal was observed on Nightingale unit, which was relaxed with staff assisting people where required. Tables were nicely laid and the meal looked well presented and was enjoyed by all. Soft music was playing in the background. This was an identified area on the managers improvement plan, which had been put into practice and was working well. The cook and senior mangers shared with us that the home is soon to implement new menus, which will give more choice to people living at the home. Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 16 Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. There is a clear complaints procedure, which is accessible and ensures the views of people living at Bellevue Court and their relatives are listened to. Staff receive training so that they have an understanding in adult protection to ensure people they support are protected from abuse, ensuring their well being. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a clear and accessible complaints procedure, which is publicised in the homes reception area. Relatives spoken to were clear on who they could speak to if they had any concerns. Staff spoken to could tell us that they were aware there was a policy on dealing with complaints and where it could be located. There have been three complaints made since the last inspection, which the home has dealt with satisfactorily through the homes complaints procedure. CSCI received concerns regarding care practice, which were investigated as Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 18 part of this inspection and are reported in the health and personal care outcome group and staffing outcome group of this report. The home has worked co-operatively with the safeguarding adults team in the two referrals made since the last inspection and issues have been satisfactorily concluded. Staff have attended adult protection training as a result of one adult protection outcome and it is evident that the home have learnt from investigations to improve practice. It is considered that the requirement made to ensure staff have a clear understanding of adult protection procedures and whistle blowing procedures has been achieved. Staff spoken to were clear about what action to take if they suspected any incidents of poor practice. Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. The environment of the home in parts is in need of redecoration and refurbishment to provide people with a homely and more comfortable place to live. The home is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection there has been little progress in refurbishing and redecorating the areas, which we identified as needing improvement at the last Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 20 inspection. These included the ground floor carpets showing signs of wear and tear, the dining room floor covering on the middle floor being taped down in three areas where tears had posed a trip hazard and decoration of the top floor corridors. The external patio adjacent to Nightingale unit is uneven and requires re laying as it currently uneven and people access this readily to smoke. The parker bath used regularly and liked by people living at the home has not been in use for sometime as it is broken. There are other bathing facilities on the top floor but we were told by staff that people prefer the use of the parker bath. The home has produced a refurbishment plan, which highlights further improvements to be made. There is little décor that is sensory stimulating for people living throughout the home who have dementia. One member of staff on the top floor of the home and who has completed dementia training had some worthwhile and valuable ideas that the home would benefit from her expertise and knowledge in developing at Bellevue Court. This was fed back to the senior management team at the inspection. The operations manager is new in post and along with the project manager and manager of the care home acknowledge that the home is in need of the refurbishment work to be completed and stated the programme would be rolled out over the next six months. The cook reported that a new cooker has been ordered and further areas of development are due to be implemented. This includes a tiled sandwich preparation area; fly screens and new pots and pans. We looked at the bedrooms of those people we case tracked and these were found to be personalised with the exception of the recent admission. The home told us they are working with the individuals family to bring in personal possessions. It was noted that in care plans where people had a special interest for example, listening to music, these facilities were available in individuals bedrooms. It was reported by staff that the manager carries out regular room audits to ensure individuals personal space is also looked after to a good standard. A dedicated housekeeping team look after the environment with regards to cleaning. During the home tour it was noted that the home was clean and tidy throughout. Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 17, 28, 29 & 30 Quality in this outcome area is good. The arrangement for staffing, their support and development ensures that the needs of people living at Bellevue Court are met. People have confidence in the staff at the home because checks are done to make sure that they are suitable to care for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions with staff on all floors confirmed that training opportunities have improved since the last inspection. Staff told us that they have undertaken a variety of courses since the last inspection which include; dealing with challenging behaviour, dementia, safe use of bed guards, moving and handling, health and safety, pressure care, fire safety, food hygiene, and customer care. A training matrix is in place, which identifies training completed, refresher training updates required and when training is due. Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 22 More than 50 of care staff are trained to NVQ 2 or above. This exceeds national minimum standards. It was reported by one staff member that more staff are undertaking this training. Staffing levels are maintained on each floor to support the needs of people living at the home. Staff spoken to generally felt there are enough staff on to meet the needs of the people living at the home. Some staff expressed that they felt they do not have enough time do activities with people because they are expected to get all the care duties done by lunch time. Activity hours are currently being reviewed to increase hours available by designated activity staff on each floor as previously mentioned. Those individuals who were able to contribute to discussions about staff said they thought the staff group were good and looked after them well. One person who spoke to us during the inspection was unhappy about a particular incident that had happened during the day. This was handled well by the manager and the person involved was later seen settled and relaxed. Visitors spoken to commented that staff were good and looked after their relatives with care and compassion. Recruitment files examined showed the home had followed a robust recruitment procedure. All pre employment checks had been undertaken before the individuals had commenced work. We spoke to one new recruit who was happy to share with us their experience of starting work at the home. They showed us their induction training records, which are linked to the skills for care council. This means that staff receive training supported by the homes manager and experienced staff members to ensure they have the necessary skills to start working with the people living at the home. Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 23 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, 36 & 38 Quality in this outcome area is good. The management team is committed to improving the quality of the service providing better outcomes for people living and working at Bellevue Court. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mr Sarabadu has been in post for approximately four months. He has the required qualifications and skills to manage the home. A number of audit checks have been introduced to improve the service, which were discussed with Mr Sarabadu in detail. The senior managers have developed their own Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 24 improvement plan and it was encouraging to see that even though Mr Sarabadu is relatively new in post achievements have been made. An example of these include a more robust handover procedure, weekly head of department meetings, accident report audits, care plan audits arranging regular staff meetings. The improvement plan gives target dates for completion and who is responsible in carrying out the task. Throughout the inspection Mr Sarabadu and the staff team were observed to be kind, caring and patient with the people using the service. It was evident that good relationships have been developed and maintained with people living at the home. Customer satisfaction surveys have been sent out to people using the service and their representatives to elicit their views about Bellevue Court but these have not been received back yet. A relatives meeting has been arranged for next week. The home intends to arrange meetings for those people living at the home who wish to attend. Staff spoken to confirmed they feel supported to do their jobs and receive regular supervision by their supervisor. Random staff supervision records sampled showed evidence of supervision meetings being carried out. It was considered that the requirement made at the last inspection to ensure staff receive formal supervision at the required frequency has been met. People living at the home are protected by the home carrying out checks required by regulation at the required frequency. Records were not examined on this occasion but were confirmed as being completed on the AQAA completed in August 2008 for our inspection undertaken in August 2008. Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 25 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 2 9 3 10 2 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 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x x 3 x 3 Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 OP19 Good Practice Recommendations Action must be taken to ensure the patio area on the ground floor exit to the rear garden adjacent to Nightingale unit is safe for people to access. 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. 2. OP19 Bellevue Court DS0000039462.V374036.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. Extracts may not be used or reproduced without the express permission of CSCI Bellevue Court DS0000039462.V374036.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!