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Inspection on 25/11/05 for Bellevue Residential Care Home

Also see our care home review for Bellevue Residential Care Home for more information

This inspection was carried out on 25th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

What the care home does well

Bellevue has a very settled and stable staff group and provides a consistent level of care to the service users living there. The service users are treated respectfully and with sensitivity.

What has improved since the last inspection?

The manager had not addressed the agenda for action since the previous inspection in part due to the vacant hours in the home requiring greater input from her on shifts. However, some areas where documentation was not available at the previous inspection were addressed, such as the protection of vulnerable adults policy.

What the care home could do better:

The numbers of staff employed by the home do not support cover of vacant hours, as experienced by the home at the time of the inspection. The manager must consider an action plan which addresses such circumstances and include alternatives, such as agency staff, to ensure safe numbers are maintained at all times. The overall progress of the home in attaining the standards must be improved to perform at a basic minimum standard.

CARE HOMES FOR OLDER PEOPLE Bellevue Residential Care Home 51 Church Road Clacton on Sea Essex CO15 6BQ Lead Inspector Sara Naylor-Wild Unannounced Inspection 25th November 2005 11:00 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 Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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 Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bellevue Residential Care Home Address 51 Church Road Clacton on Sea Essex CO15 6BQ 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) 01255 473976 Anglia Care Homes Ltd Mrs Sandhya Sahadew Care Home 10 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Mental Disorder, excluding learning disability or dementia - over 65 years of age (10) Bellevue Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 10 persons) Persons of either sex, aged 65 years and over, who require care by reason of mental disorder (not to exceed 10 persons) One person, whose name was made known to the Commission in February 2003, under the age of 65 years, who requires care by reason of mental disorder The total number of service users accommodated in the home must not exceed ten persons 14th April 2005 Date of last inspection Brief Description of the Service: Bellevue is a detached house situated in a quiet residential area within walking distance of the seafront and local facilities. Accommodation is on two floors; a passenger lift provides access to facilities on the first floor. The home provides a garden area to the back of the premises. Parking is available to the front of the premises. Bellvue provides long term residential services for 9 older people with either dementia or mental disorder and one person under 65 years of age with mental disorder. Bellevue Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on 25th November 2005. The manager Mrs Sahadew was present throughout the visit. The inspection process included: discussions with the manager, two staff, two service users, examination of documents and premises observations. What the service does well: 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. Bellevue Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 6 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 Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not revisited at this inspection. EVIDENCE: Bellevue Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not revisited at this inspection. EVIDENCE: Bellevue Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12. Opportunities for participation in activities had been developed. EVIDENCE: The activities on offer in the home had been given a higher profile, and included some additional elements such as quizzes, reminiscence, etc. The manger was advised to ensure that the continuing development of the opportunities on offer reflected service users’ wishes and abilities. Observation of the interaction between staff and service users continues to provide a positive picture of the close working relationship they have developed with staff, demonstrating a good knowledge and understanding of the individuals. Bellevue Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 10 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. The home has a satisfactory protection of vulnerable adults policy. EVIDENCE: The policy and procedures relating to the protection of vulnerable adults from abuse did not contain the correct steps in relation to local guidance. This had since been updated and now provided a clear pathway in respect of recognising and responding to abuse. Bellevue Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19. Premises remain unchanged from previous visits. EVIDENCE: The premises are generally presented as a homely family environment. The décor is regularly updated and carpets had been replaced in some areas. Overall the home does suffer from some of the peculiarities in its layout, i.e. changes in floor levels, thin corridors. However, the proprietors have sought to reduce the impact of these wherever possible and they do not appear to limit the service users in utilising the facilities. Bellevue Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30. The numbers of staff making up the staff group are restrictive to covering vacant hours. The staff working at the home have a mix of skills and experience and are supported in their work through the training on offer. EVIDENCE: Prior to the inspection the Commission was notified of an occasion when staffing numbers fell to unsafe levels as a result of staff sickness. At this time the manager was contacted and gave indications of how the vacant hours would be covered and maintained. During the inspection further discussion was held in relation to the covering of long term sickness. The numbers of staff available on the rota total 8, which does not provide sufficient flexibility to cover the rota at short notice. The manger was advised of the need to develop alternative measures such as agency or bank staff. There are 5 staff of a staff group of 8 currently trained to NVQ level 2. Staff spoken to had attended training in a variety of topics including medication, moving and handling, whole person care needs, infection control, fire prevention and first aid. The manager had undertaken training to become a Dementia trainer. Some staff files appeared to indicate that some mandatory training required updating. The manager was advised to develop a training register. Bellevue Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 38. The quality assurance process has been initiated. Documents relating to health and safety were present. EVIDENCE: The manager was able to provide evidence of the initiation of the next round of a quality assurance process with questionnaires being distributed to visitors. The previous outcomes to questionnaires had been collated, but no action plan set out to respond to them. The manager was advised to fulfil the process on this occasion. Records relating to the health and safety requirements of the home were in place and satisfactory. Bellevue Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 14 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 2 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X 3 Bellevue Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 15 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 OP1 Regulation 5 Requirement The registered person must develop the Service Users Guide to include details as laid down in Regulation 5 of the Care Homes Regulations, and NMS 1. This standard was not assessed at this visit and is therefore carried over to the next inspection. The registered person must develop the care plans in the home to include specific detail regarding how the service users’ needs are being met, and to ensure that they meet mental health good practice guidance. This standard was not assessed at this inspection and is therefore carried over to the next visit. The registered person must ensure that service users’ wishes in respect of daily living and activities are respected. This standard was not assessed at this inspection and is therefore carried over to the next visit. Timescale for action 31/03/06 2 OP7 15 31/03/06 3 OP12OP14 12 31/03/06 Bellevue Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 16 5 OP29 19, Schedule 2 6 OP4OP27O P30 18 7 OP36 18 (2) 8 OP37 17 The registered person must ensure that the home is proactive in respect of recruitment, adheres to the written policy and that records required by Regulation are obtained prior to appointment. This standard was not assessed at this inspection and is therefore carried over to the next visit. The registered person must ensure that there is a staff training and development programme, which meets National Training Organisation requirements, and responds to the identified needs of service users. This standard was not assessed at this inspection and is therefore carried over to the next visit. The registered person must ensure that staff receive regular supervision, which follows current good practice guidelines. This standard was not assessed at this inspection and is therefore carried over to the next visit. The registered person must ensure that the home’s records required by Care Homes Regulations 2001 are updated and maintained. This standard was not assessed at this inspection and is therefore carried over to the next visit. 31/03/06 31/03/06 31/03/06 31/03/06 Bellevue Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 17 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 OP3 Good Practice Recommendations The registered person should develop the pre admission assessment to ensure that it contains sufficient detail to determine the suitability of admission and commence a care planning process. This standard was not assessed at this inspection and is therefore carried over to the next visit. The registered person should keep the issues regarding changes in floor height under review, and take further remedial action if required. The registered person should attain an Occupational Therapists assessment of the premises. This standard was not assessed at this inspection and is therefore carried over to the next visit. The registered person should ensure that a plan of works are developed in response to the risk assessments undertaken in respect of radiator surface temperatures. This standard was not assessed at this inspection and is therefore carried over to the next visit. The registered manager should obtain NVQ level 4 in management by 2005. This standard was not assessed at this inspection and is therefore carried over to the next visit. The registered manager should ensure that the outcomes of quality assurance feedback is collated and an action plan devised in response. 2 3 OP19 OP22 4 OP25 5 OP31 6 OP33 Bellevue Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bellevue Residential Care Home DS0000059848.V263090.R01.S.doc Version 5.0 Page 19 - 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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