Inspection on 30/10/06 for Bellevue Court

This inspection was carried out on 30th October 2006.

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 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 (Highfield Care Homes No 2 Limited) Bellevue Court Woodcross Street Woodcross Wolverhampton West Midlands WV14 9RT Lead Inspector Keith Salmon Key Unannounced Inspection 30th October 2006 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 (Highfield Care Homes No 2 Limited) DS0000039462.V297375.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 (Highfield Care Homes No 2 Limited) DS0000039462.V297375.R01.S.doc Version 5.2 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) None Southern Cross Care Homes No 2 Limited 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 (Highfield Care Homes No 2 Limited) DS0000039462.V297375.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th March 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 (Highfield Care Homes No 2 Limited) DS0000039462.V297375.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 October 2006, commencing at 9.30am, concluding at 3.30pm (a total of 6 hours), and was conducted by Mr Keith Salmon and Mrs Debbie Sharman. Present on behalf of the Home, throughout the Inspection, was Ms. Sandra Brown (RGN), who was in charge for the day, as the Registered Manager (Mrs. Gail Goddard) was attending a training course. Due to the necessity to obtain information from the Manager, Mr Salmon completed the Inspection through a follow-up visit on 1 November 2006 to hold a 1:1 discussion with Mrs. Goddard. 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 the single ‘Requirement’ arising from the previous Inspection held on 10 March, 2006. This Report is a product of 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 Inspectors also held 1:1 discussions with the Registered Manager, 4 Residents, three visitors, and several members of Staff. What the service does well: Arrangements within the Mental Health Unit which enable a small number of Residents to maximise there potential for independence, i.e. being supported in how they choose to ‘live their lives’, is innovative and well thought through – particularly in respect of ‘risk assessment’. Given that a high proportion of Residents are not capable of expressing a view on the quality of care provided it is of importance that the views of Relatives/representatives are heard. Relatives who had discussions with the Inspectors during this Inspection made positive comments including: “The staff on the top floor are always kind and helpful often in difficult situations” “I feel my Mum is well cared for in Bellevue. She seems to be happy and is not agitated or upset when I visit. The level of care she receives is very good and I am always kept informed of any problems with her health etc. All the staff seem very caring towards her and I am very happy with her treatment at Bellevue.” Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V297375.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 (Highfield Care Homes No 2 Limited) DS0000039462.V297375.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 (Highfield Care Homes No 2 Limited) DS0000039462.V297375.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 8 Residents’ Care Plans/Files, (i.e. those relating to the four most recently admitted Residents, plus 4 selected at random). The sampled 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 (Highfield Care Homes No 2 Limited) DS0000039462.V297375.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 the 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 Current Provided involvement of SU/Relative/Advocate Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V297375.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. 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 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 given frequently. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V297375.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 adequate. 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 unsatisfactory. 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. Activities are more individually tailored for Residents in Nightingale and Lark Units as most are more dependent due to having severe dementia related illness. The range offers a well followed 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, Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V297375.R01.S.doc Version 5.2 Page 12 trips to Blackpool, to the local cinema, meals at MacDonald’s, and visits to a local café for ‘Coffee and Cakes’ afternoons. Residents confirmed to the Inspectors they have choice regarding activities, exercise that choice and enjoy all activities. At the time of the Inspection Residents on Kingfisher Unit were taking part in an indoor ball game, which one Resident informed the Inspector they did quite regularly and which they enjoyed. T The Home employs two Staff, on a full-time basis, 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. However, it emerged from discussions with Staff that the hours currently dedicated to activities’ planning and coordination may be insufficient given the size of the Home, with up-to 60 Residents, plus the way in which the Activities’ Staff work-time is managed, (i.e. over 3 relatively separate Units with Care Staff continuing activities when the ‘Activities’ Staff move on to other parts of the Home). It is ‘Recommended’ as part of the increasing level of dialogue between Staff and Management, the provision and deployment of the ‘Activities’ Staff resource be reviewed. 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. It was noted the washing machine on the first floor, provided to enable selfcaring Residents to undertake laundering of their personal clothing, is out of order. This provision is an important adjunct to facilitating independence for Residents. Therefore, it will be a ‘Requirement’ of this Inspection that the washing machine is either repaired or replaced as a matter of urgency. Access to the Home is via the main front door, which is locked by a magnetic catch. The Staff gain access to the building through submission of the current pass code onto the keypad located beside the door. People wishing to enter the building, who do not have the code, are required to alert Staff by way of a bell push beside the keypad. Whilst the Inspectors recognise the Home is endeavouring to provide a secure environment this arrangement presents two issues which give cause for concern. Firstly, there is no way of knowing if the bell is working as no sound can be heard. Secondly, the Inspectors experienced a delay of several minutes before gaining access – Staff explained they were unable to leave the tasks they were undertaking, e.g. administering medicines and providing 1:1 personal care for Residents. Whilst this is completely understandable, the possibility of Visitors and, more importantly, Residents, who are capable of leaving and returning as they please, being left waiting outside for several minutes in inclement weather, or in the dark, is not acceptable. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V297375.R01.S.doc Version 5.2 Page 13 Therefore, it is ‘Requirement’ of this Inspection that the arrangements for controlling access to the premises are reviewed, and proposals to resolve this issue be submitted to CSCI for agreement. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V297375.R01.S.doc Version 5.2 Page 14 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 poor. This judgement has been made using available evidence including a visit to this service. Residents may not be fully enabled to pursue the complaints process or reliably protected from abuse. Staff recognise they have a role in protecting Residents from abuse. However, a number of Staff are not confident they would be able to carry out that role due to lack of training in this area. Documentation of ‘incidents’ relating to/involving Residents is not satisfactorily completed. EVIDENCE: The Inspector was informed documentation such as the Service User Guide, and Complaints Policy/Procedure, are in the process of being up-dated to accommodate the change of ownership. Reliable application of ‘protection’ related issues is currently lacking in that two ‘incidents’ involving three Residents, which were recorded in the ‘Accident Book’ during October, were not recorded in the Residents’ Care Plans, and there is no evidence that CSCI was notified, as required by Regulation 37. Furthermore, there is no evidence indicating whether the incidents were considered as potential adult protection issues. Three ‘Requirements’ will be issued at this Inspection to ensure the recording, assessment, and notification of such incidents. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V297375.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 generally safe, well-maintained environment offering comfortable bedrooms and communal areas. Décor should be satisfactory when the current redecoration programme is completed. Furnishings are in good order and present a ‘domestic’ ambience. Specialist equipment, consistent with meeting the assessed care needs of Service Users, and the demands of tasks carried out by Care Staff, are available and found to be appropriately serviced and maintained. The cleanliness in the Home is generally good. Laundry facilities and infection control systems/practices are satisfactory. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V297375.R01.S.doc Version 5.2 Page 16 EVIDENCE: At the time of the Inspection the redecoration/refurbishment of the premises was seen to be on-going. Repainting of the ground floor walls has been completed, with work to repaint walls on the second floor well in advance. Work is expected to commence on the first floor during November. All carpets are relatively new, and well maintained through application of a cleaning regime based on one thorough clean per week, plus ‘spot’ cleaning as necessary. A refurbishment plan was reviewed which included a projected completion date (end of December 2006) for a range of work including; 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 replacement of soft furnishings in every bedroom. The care of Residents has been facilitated in recent times by the purchase of replacement equipment, e.g. hoists. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V297375.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 poor. This judgement has been made using available evidence including a visit to this service. Staff numbers on duty, and skill-mix, were sufficient to meet the assessed care needs of current Residents. Whilst Staff training, in recent times, has not been in accordance with Regulation/Standards, there are indications that more attention to this area is being focussed by the Manager, and is presenting signs of improvement. The Home’s recruitment processes are not fully in accordance with Standards/Regulations and may put Residents at risk. EVIDENCE: OP27 An examination of the current staffing rota, plus those from the immediately preceding weeks, demonstrated staffing numbers, and skill-mix, are sufficient to enable a service provision, which meets the care needs of the Service Users. OP28 Twenty-four, from a total of forty-one, Care Staff have achieved NVQ Level 2, i.e. 58.5 . Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V297375.R01.S.doc Version 5.2 Page 18 OP29 A review of staff personal files showed a shortfall with regard to recruitment/ appointment practices i.e. there was no evidence of risk assessment, and/or management plan, in relation to Staff who had commenced in post pending receipt of satisfactory CRB check More positively, there is evidence to show the majority of Staff have received POVA training, and there is good information on the conduct and outcome of employment interviews. A general observation is that systems, practices, and documentation relating to staff employment, training, and supervision, have lapsed seriously over the past twelve months. However, there has been a recent re-organisation of the management/administration of staff training, including the introduction of a matrix of training needs analysis for each staff member. This addresses induction and foundation training, i.e. manual handling, food hygiene, first aid, fire safety, adult protection, care planning, medicines administration, infection control, NVQ Levels 2/3, challenging behaviour prevention/management, all of which is linked to a month-by-month plan indicating the availability of training opportunities. It is expected that effective application of the training plan should see improvement in these areas (some of which is already evident) and which, in turn, could possibly see the ‘Judgement’ for this area move from ‘Adequate’ to ‘Good’. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V297375.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 poor. This judgement has been made using available evidence including a visit to this service. Although Relatives appear to be generally satisfied with the service, adjudged from comments received, management systems are arguably not sufficiently developed to ensure necessary advances, as required by the Provider’s Improvement Plan. The recently introduced action plan for management improvement (as provided to CSCI) was set against timescales, all of which have not been fully met. As with Staff Training, in recent times supervision has not been in accordance with Regulation/Standards. However, there are indications that more focussed attention by the Manager is presenting signs of improvement in that, overall, there are indications the new arrangements are beginning to take effect, and the next Inspection could show the improvement necessary to move the Judgement, on this group of outcomes, above the current ‘poor’ rating. Health and Safety Policies/Procedures/Practices are satisfactory. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V297375.R01.S.doc Version 5.2 Page 20 EVIDENCE: OP31 The evidence collected by the Inspectors shows the Home has undergone a period during which the general quality of management performance has been poor. The accuracy of this conclusion is supported by the action of the Proprietors in introducing a ‘management improvement plan’. More positively, there is evidence the introduction of a new approach to staff management, training, supervision, and administrative systems generally, is leading to improvement in the management of those areas. OP33 Staff spoke positively of the Manager saying she is making improvements. There is evidence that Relatives’ views have been sought via a satisfaction survey undertaken in June 2006. Although only 6 replies were received a brief perusal by one Inspector showed general satisfaction with the quality of service provided, especially with the approach of Staff. Two respondents stated they would like to be more involved in decision-making. OP35 Accounting/documentation systems in place appear to protect Service Users’ finances, even though Residents’ cash is held in a ‘pool’ which is kept securely in a locked cash box, enabling easy access to funds whenever Service Users request them. Access is 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 belonging to Residents, 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 all monies, which should be in the cash box. These were checked by the Inspector and found to be in order. These monies are checked on a monthly basis by the person undertaking the Regulation 26 Visits, with the outcome being fully documented - there is also regular audits by the Auditors from the Parent Company. Although the practice of ‘pooling’ Residents’ personal monies contravenes the detail of Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V297375.R01.S.doc Version 5.2 Page 21 Standard 35 the Inspector is satisfied, that due to 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. OP36 The Inspectors were shown a Staff Supervision plan for 2006. However, according to staff records sampled, most planned supervisions had not been fulfilled. Furthermore, those that were completed, presented insufficient detail, e.g. giving little indication of individual staff member’s strengths, weaknesses, areas for improvement, or progress achieved. A ‘Requirement’ will be made in respect of this ‘Outcome’ area. OP38 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 (Highfield Care Homes No 2 Limited) DS0000039462.V297375.R01.S.doc Version 5.2 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 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 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V297375.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP14 Regulation 16. – (2)(f) Requirement The Responsible Individual must ensure that the washing machine located on the first floor is either repaired or replaced as a matter of urgency. The Responsible Individual must ensure arrangements, for controlling access to the premises, are reviewed, and proposals to resolve the matter submitted to CSCI for agreement. The Registered Manager must ensure that entries in the ‘Accident Book’ relating to ‘incidents’ involving Residents must be documented in the relevant Resident’s Care Plans, e.g. risk assessment, daily report, assessment of need for referral to the Adult protection Team. The Registered Manager must ensure that when ‘incidents’ involving Residents are assessed as requiring referral to the Adult Protection Team, they are fully documented, and brought to the DS0000039462.V297375.R01.S.doc Timescale for action 30/11/06 2. OP14 12. – (1)(a) (2) (4)(a) 30/11/06 3. OP18 13. – (6) 30/11/06 4. OP18 13. – (6) 30/11/06 Bellevue Court (Highfield Care Homes No 2 Limited) Version 5.2 Page 24 5. OP19 23. (2)(d)16 (2)(j) attention of the that Body as soon as possible. The Responsible Individual must ensure that the refurbishment plan for the Home is completed. (Timescale from November 2005 inspection). The Registered Manager must ensure that ‘incidents’ involving Residents must be reported to CSCI, as required by Regulation 37. 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. The Registered Manager must continue to follow the ‘management improvement’ plan agreed between the Manager and the Provider. The Registered Manager must ensure that the supervision of staff is carried out in accordance with the Standard and Regulation. 31/12/06 6. OP18 13. – (6) 30/11/06 7. OP29 19. – (1) 30/11/06 8. OP31 10. – (1) 31/01/07 9. OP36 18. – (2) 30/11/06 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 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. DS0000039462.V297375.R01.S.doc Version 5.2 Page 25 Bellevue Court (Highfield Care Homes No 2 Limited) 2. OP12 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 is reviewed. 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. (In process of being achieved). 3. OP38 Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V297375.R01.S.doc Version 5.2 Page 26 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 (Highfield Care Homes No 2 Limited) DS0000039462.V297375.R01.S.doc Version 5.2 Page 27 - 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!