Inspection on 15/09/05 for Bellsgrove

This inspection was carried out on 15th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Bellsgrove 14/01/09

Bellsgrove 16/07/08

Bellsgrove 02/08/07

Bellsgrove 20/02/07

Bellsgrove 22/06/06

Bellsgrove 05/01/06

Bellsgrove 10/12/04

Bellsgrove 15/10/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Bellsgrove Bellsgrove 250 Cobham Road Fetcham Surrey KT22 9JF Lead Inspector Sandra Holland Unannounced Inspection 15th September 2005 10:00 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 Bellsgrove DS0000013568.V252832.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. Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bellsgrove Address Bellsgrove 250 Cobham Road Fetcham Surrey KT22 9JF 01372 379596 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) Mr Somasundaram Logathas Mrs Shyamala Logathas Mr James Iswurdut Sobun Care Home 14 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (5), Learning disability (1), Mental Disorder, of places excluding learning disability or dementia - over 65 years of age (5), Old age, not falling within any other category (14), Sensory impairment (1) Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Categories DE, LD and SI apply to a named service user only. 5 service users may fall within categories DE(E) or MD(E). For up to 5 additional places for day care within categories OP, DE(E) or MD(E). 10th December 2004 Date of last inspection Brief Description of the Service: Bellsgrove is a family run care home registered to accommodate up to fourteen older people. Up to five residents who may have dementia and up to five residents who may have mental disorder can be accommodated. The home is also registered to provide day care for up to five people. The home is a large detached property situated in the village of Fetcham, with a range of local shops nearby. The accommodation is set over two floors, with a passenger lift serving both floors. There are fourteen single bedrooms, a spacious lounge/dining room and a large conservatory. An enclosed garden is provided to the rear of the property and limited car parking is available to the front. Bellsgrove DS0000013568.V252832.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 the first to be carried out in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. The inspection took place over six and a half hours and was carried out by Mrs. Sandra Holland, Lead Inspector for the service. Mr. Somasundaram Logathas and Mrs. Shyamala Logathas, Registered Providers were present representing the service. A full tour of the premises was carried out and a number of records and documents were examined, including staff files, individual plans and medication administration records (MAR). Twelve residents, three visitors and two members of staff were spoken with. The inspector wishes to thank the residents and staff for their hospitality, time and assistance. The people living at Bellsgrove prefer to be known as residents and that is the term that will be used throughout the report. What the service does well: What has improved since the last inspection? What they could do better: The contracts between the home and residents need to be reviewed and revised. Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 6 Pre-admission assessments need to be drawn up to include all the areas required by the National Minimum Standards. Residents’ plans of care need to be reviewed when changes in residents’ needs are noted. Risk assessments of areas of risk to residents must be identified, kept under review and updated when a change in need is noted. Staff administering medication must be appropriately trained and medication must be stored appropriately. The programme of activities that is drawn up must be in consultation with residents, meet residents’ specific needs and residents must be assisted to engage in local, social and community activities. Staff must be trained in the Protection Of Vulnerable Adults. An Occupational Therapist or other specialist professional must assess the home to ensure that it meets residents’ needs. Covers must be fitted to all radiators to safeguard from burning. The bedroom that has an unpleasant odour must be treated to remove the odour and the call bell panel must be replaced. Staffing in the home must be reviewed to ensure that staff do not work excessive hours. Staff who agree to work extra hours should be asked to sign a Working Time Directive disclaimer, to show that they are doing this voluntarily. Recruitment procedures must be improved to ensure the safety of the residents. Staff must receive mandatory training and other training appropriate to the work they carry out in the home. The home must be managed more effectively and the providers must supervise the manager. Staff must be appropriately supervised. The standard of record keeping in the home must be improved. Hazards to the health and safety of residents must be identified and removed or minimised. Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 7 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. Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 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 Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. Contracts detailing the conditions of residence are issued promptly to residents. These contain most, but not all the required information. Informal pre-admission assessments are carried out. EVIDENCE: The provider stated that a contract or statement of the terms and conditions of residence at the home is drawn up and supplied to the resident on admission. Contracts seen had been signed by the resident or their representative and by the home’s representative. These were dated within a day or two of admission. The contracts seen detailed the services to be provided and notice periods but did not indicate the room to be occupied. One contract had been updated by the addition of an extra page, with the room number handwritten on, but the main body of the contract referred to the home not having a lift, which had been installed at the time of signing. Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 10 The provider stated that prospective residents are assessed before admission to the home, either in their own home or wherever they are residing. The relatives of a recently admitted resident confirmed that he was visited in hospital, prior to admission by a representative of the home. The provider advised that the home does not have a formal pre-admission assessment form, but follow printed guidelines. These were seen and referred to obtaining information about the prospective resident from their general practitioner (G.P.), before a home visit is carried out. No guidance was provided regarding the prospective resident giving their consent to this. The guidelines also referred to obtaining information about the prospective resident from a community nurse, if involved. The guidelines stated that further information should be sought from the next of kin, regarding the social history and financial position of the prospective resident. From the records seen, it is clear that the information regarding prospective residents is not gathered in one document and the pre-admission assessment does not include all the areas to be assessed, as stated in the National Minimum Standards for Care Homes for Older People. As no written preadmission assessment is retained, it is not clear who has undertaken any assessment or when. Requirements have been made. Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9. Individual plans of care are drawn up for each resident. Residents’ healthcare needs are met. EVIDENCE: The provider advised that a plan covering the aspects of care required by each resident is drawn up. These were seen to include personal care, mobility, mental health condition, continence support required and whether assistance is required with food or feeding. From the record held, it was clear that the care plans have been reviewed on a regular basis. It was noted that changes to the care plan have not been made when a change in a resident’s needs has been indicated. For example the care plan for one resident recorded deterioration in their mental condition, but stated, “Continue with care plan”. It is a requirement that each resident is involved in the planning of their care and should sign the care plan to show their involvement. If this is impracticable, the resident’s representative should be involved and should sign on their behalf. An explanation of why this has occurred should be recorded in the care plan. The care plans seen on inspection did not record the involvement of the resident or their representative. Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 12 Assessments of risks to the health and welfare of residents are identified, assessed and recorded. Risk assessments seen included residents’ mobility, hazards and risks within the home, such as the stairs or the lift and risks such as wandering away from the premises. From the records seen, it was clear that some risk assessments have not been updated for a long period, some were very basic and provided little information as to control measures and some did not reflect significant changes in a resident’s condition. One resident had fallen and broken a hip, but the only risk assessment contained in the care plan was dated prior to the injury and had not been reviewed or revised. For other residents with a specific, identified risk regarding their mobility, no risk assessment had been carried out. A recommendation was made at the last inspection that the home’s risk assessments were more detailed as the home was admitting more dependent residents. This has not been carried out. Residents’ healthcare needs appear to be well met. Individual care plans referred to a number of healthcare professionals being involved in the support of residents, including a chiropodist, G.P. and optician. A chart to list the visits made by healthcare professionals was seen in care plans, but these had not been kept up to date. The last entry for the visit of the chiropodist to one resident was dated two years previously, although the provider stated that the chiropodist had attended the resident recently. The provider stated that medication is supplied to the home by a local pharmacy in individual, “blister packs”, to be administered by staff in the home. He also stated that a number of staff are undertaking distance training in the safe handling of medicines through a local college. The workbook for only one member of staff was available to see. One member of staff stated that they administer medication, but have not had training for this. It is a requirement that only staff that have been appropriately trained administer medication. Although most medication in the home is stored appropriately, a liquid medication was seen stored in an unlocked kitchen cupboard. The kitchen is sometimes locked, but the keys were left in the lock, during the course of the inspection. In a downstairs bathroom, two containers of ointment were stored openly on the window ledge. Both of the ointments were out of date, one being dated 2004 and one dated 2002. The provider was aware that all medications should be kept in a locked provision and immediately moved them. An immediate requirement regarding the safe handling and administration of medication was made. Other requirements have also been made. Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 13 Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15. A plan of activities is drawn up, but those planned were not seen in action. The meal served looked well balanced and appetising. EVIDENCE: The provider stated that an activities co-ordinator is employed at the home for two days each week, usually Monday and Thursday and a weekly activity plan was seen displayed. It was noted however, that the planned activities were not carried out on the day of inspection, which was Thursday. The provider stated that the activities co-ordinator was not working on the day of inspection because she had worked the previous day and had taken residents to a garden centre, although no reference to this was seen in the daily notes recording residents’ care and support. It was noted that at the beginning of the inspection at 10.00 a.m., all residents were seated in the lounge, dining room or conservatory. During the tour of the home, no residents were observed spending time in their bedrooms. Some residents were observed reading the papers, playing cards or doing a jigsaw, but other residents were not being occupied or stimulated. As a number of the residents may have dementia or mental health problems, the range of activities on offer and being carried out, must take the specific needs of these Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 15 residents into account. The hours worked by the activities co-ordinator and other staff should be reviewed to ensure that enough staff are provided to carry out the activities planned. It was clear that visitors to the home are made welcome and the visitors spoken to confirmed this, and that refreshments are always offered. One resident told of keeping in touch with family abroad and receiving regular phone calls on the home’s telephone. He advised that he did not wish to have a telephone in his room, as apart from the regular family call, he did not make other calls. Residents were seen enjoying their midday meal, which was well balanced and looked and smelt appetising. The residents were seated at two dining tables, one in the dining area of the lounge and another in the conservatory. The tables were attractively set with colourful tablecloths and tablemats. Residents spoken to said that they enjoy the meals served, the portions were good and that a choice was available. Two residents were seen to have chosen a different meal to the majority of residents on the day of inspection. A requirement has been made. Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 16 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. Some aspects of the home’s management do not fully ensure the protection of residents. EVIDENCE: The home keeps a copy of the Surrey Multi-Agency Procedure for the Protection Of Vulnerable Adults, which the provider stated would be followed in the event of any allegation of abuse or suspected abuse. The provider also stated that he undertook training provided by Surrey approximately five years ago. No record was available to show that any other staff had undertaken training in the protection of vulnerable adults and one staff member had difficulty understanding what this was, when questioned. Another member of staff had stated that they had undertaken this training in the past with a different employer. Both members of staff stated that they would report any concerns they had to the manager or the provider. One member of staff was aware of how to report concerns to authorities outside the home, but one was not. The provider stated that the home does not manage the financial affairs of any residents. In order to minimise financial involvement, the provider stated that the home does not hold money for safekeeping for residents. Any extra costs for hairdressing or chiropody for example, are paid for by the home and reimbursed by the resident or their representative. Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 17 The provider stated that two members of staff, who are related to him, work part-time at the home as they also have full-time jobs and a further member of staff is also related. Two other members of staff were seen to work a high number of hours. This imbalance in the staffing structure may prevent an open reporting of concerns. A requirement has been made. Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 18 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, 20, 21, 22, 23, 25 and 26. The overall decoration and furnishings in this home provide a comfortable environment for residents. Some improvements are required to make residents’ private space more attractive and to make the home safer. EVIDENCE: The home is decorated and furnished in a homely and domestic style, with attractive public rooms. The gardens are well presented with colourful, seasonal flowers and plants. The outside areas of the home were neatly presented, with access to the rear garden provided by steps or a ramp, both with fitted handrails. Communal space is provided in a large lounge / dining room and a conservatory, both of which have dining tables and a selection of armchairs. All bedrooms are for single occupancy and some have en-suite toilets and basins, whilst the remainder have fitted wash hand basins. The majority of bedroom furniture is provided by the home, but the provider advised that residents are welcome to bring in items of their own and some items were Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 19 seen. A number of shortfalls in the required standard of bedrooms and ensuite facilities were noted: • One bedroom was noted have an unpleasant odour and the operation panel for the call system was missing. • In another bedroom with an en-suite toilet and basin, the toilet seat cover was broken and placed to one side. The provider stated that this has happened on a number of occasions, but did not state why it had not been replaced. • The curtains in a bedroom were hanging away from some of the hooks. (The provider reattached them). • A toilet brush in an en-suite toilet was very worn and not clean. • A bedroom carpet was marked with cigarette burns, which the provider stated were caused approximately two years ago, by the previous occupant. • Two bedroom ceilings and an en-suite toilet wall were badly stained (by a water leak, the provider stated). • In a number of bedrooms, packets of pads to aid incontinence were stored visibly on top of wardrobes or shelves, which may cause embarrassment to the occupiers. Toilets and bathrooms are provided in sufficient numbers to meet the needs of the residents and are positioned near to their bedrooms and communal rooms. Two of the bathrooms have easy access baths, one with a hoist attached and another a specialist, moveable bath. Handrails are provided along the corridor walls to assist residents, but a specialist assessment of the home by an occupational therapist or other specialist, which was recommended at the last inspection, has not been carried out. Requirements have been made. Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 20 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, 29 and 30. Staffing at the home requires review to ensure that it meets the needs of residents. The recruitment practices at the home potentially place residents at risk. EVIDENCE: The provider stated that services at the home are provide by a very small team of staff, including the manager and two registered providers. Three members of staff are related to the providers. All staff share roles within the home, including personal care, cooking, laundry tasks and assisting with activities. The provider stated that a cleaner is contracted to clean the home for one day each week, on variable days, as available. This person was not listed on the staff rota and the provider stated that this person does not have a Criminal Record Bureau (CRB) clearance. The provider also stated that no documentation relating to the cleaner was available, as it had all been sent for end of year accounting. From the rota and speaking to staff, it was clear that some staff have been working a very large number of hours in the home. One member of staff had worked for seven days each week for the past three weeks and another provides sleeping-in, on-call cover, every night of the week, on-going. The sleeping in member of staff also works shifts during the day at the home. It is required that staffing is reviewed to ensure the safety of residents and to protect the health of these members of staff. Working for a large number of Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 21 hours on a regular basis may affect the performance of staff, to the detriment of the residents. The provider stated that staff have not been asked to sign Working Time Directive (WTD) disclaimers, which state that staff are working excess hours voluntarily. The provider was advised to arrange this, to safeguard against allegations that staff have been made to work these hours. It was noted that the rota did not accurately reflect the staffing arrangements in place at the time of inspection. The manager was listed on the rota as being on duty, but the provider stated that the manager had changed his day off, although the rota had not been amended to show this. The rota must be a true and accurate record of the staff on duty at any time. Erasing fluid had also been used to make changes to the rota, which should not be used. Any alterations to the rota should be drawn through with a single line and the new shift marked beside it. From the staff files seen, the recruitment practices at the home must be greatly improved as they are of a very poor standard. For two members of staff, no recruitment documentation was held on file whatsoever and the provider stated that he could not remember their surnames. For another member of staff, who has been permitted to take residents out of the home alone, no CRB or references had been obtained. The provider stated that this member of staff had taken residents out to the garden centre, the day before the inspection, even though the car insurance details held on file for this person had expired. The provider stated that for one other member of staff, he had not obtained a second reference as the staff member was related to him. A requirement was made at the last inspection that persons must not be employed unless all the required records and documents have been obtained and this continues to be unmet. A further requirement that staff should be appropriately trained also remains unmet. A recommendation that a staff training plan be drawn up has not been carried out. A number of members of staff have undertaken training for National Vocational Qualifications (NVQ), including one provider achieving NVQ level 4, Registered Manager’s Award and one provider and another staff member, both achieving NVQ Level 2 in Care. Mandatory training required to ensure the safety of residents, has not been carried out to the required frequency. The provider stated that first aid and fire prevention training courses had been cancelled by the by the training provider, although no record was available to confirm this. The provider was advised of the possibility of further action being taken if requirements continue to be unmet. Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 22 An immediate requirement was made. Other requirements have also been made. Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 36, 37 and 38. The home needs much stronger and effective management to safeguard the residents. EVIDENCE: The registered manager was not present on the day of inspection, although as noted previously, he was scheduled on the rota to be on duty. The registered providers were both present in the home, with one provider appearing to take a management role and the other provider taking a personal care and cooking role. The provider apparently managing the home at the time of inspection supplied most of the information required. In discussion, he appeared unaware of the seriousness of the shortfalls in the home’s standard of record keeping and staffing issues and of the impact from a resident’s point of view, of the shortfalls noted in the bedrooms. Although the home is being run as a family Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 24 style unit, which is of benefit to residents, the same level of informality is unacceptable in relation to the checks to be made, records to be maintained and standards to be achieved, all of which should be in place to protect residents. A requirement was previously made that staff were to be appropriately and formally supervised, but no supervision records were available for inspection. An appraisal record for the manager, was seen. A number of records in the home were inspected. The home maintains two visitors books, one for “official” visitors, which the inspector signed and one for all other visitors. The inspector who carried out the last CSCI inspection in December 2004 made the last entry in the official visitors book. A visit by the Environmental Health Officer in March 2005 was not recorded. The last entry in the other visitor’s book was made in December 2004, although there were three visitors in the home during the inspection. When this was discussed with the provider he stated that it is kept in the drawer and not enforced. It is a requirement that a record is kept of all visitors to the home, including the names of visitors. The accident record book in the home was seen and the first entry was made in June 2004. Four accidents were recorded in the book, but none of these had been notified to CSCI under the requirements of Regulation 37. The accident book is of a style that is designed to protect the confidentiality of individuals recorded in it, but it had not been used as intended, as the tear out pages had not been removed. A number of shortfalls in the required standards of health and safety were also noted: • The call system panel was not present in one bedroom. • A bedside lamp in a residents bedroom was positioned on the floor, was fitted with an electric bulb that was too large and the bulb fitting was loose. • One radiator in a downstairs bathroom, and a towel rail in an upstairs bathroom were not covered to protect residents from burning themselves. • Substances that are hazardous to health were stored in an unlocked provision. The shortfalls in the required standards and the number of requirements and recommendations would indicate the need for more effective and planned, management of the home. It is of concern that although the registered manager holds responsibility for many of these areas, it is clear that the registered providers have not adequately supervised the manager or monitored his actions. The providers Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 25 have a responsibility under Regulation 26 of The Care Homes Regulations 2001 (As Amended), to ensure that they monitor the home at least once a month. An immediate requirement was made and other requirements have been made. Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 26 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 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 2 3 3 3 2 3 2 2 2 STAFFING Standard No Score 27 1 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x x x x 1 1 2 Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 27 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 OP2 Regulation 5(1)(b&c) & 17 (2) Requirement Timescale for action 14/10/05 2 OP3 14 (1) (a-c) The registered person must produce a written guide to the care home which shall include: (b) the terms and conditions in respect of accommodation to be provided for residents, including as to the amount and method of payment and (c) a standard form of contract for the provision of services and facilities by the provider to residents. Additionally a record must be maintained of the care home’s charges to residents, including any extra payments payable for additional services not covered by those charges, and the amounts paid by or in respect of each resident, as required by Schedule 4.8. The registered person must not 14/10/05 provide accommodation to a resident at the care home unless, so far as it is practicable to do so: (a) The needs of the resident have been assessed by a suitably qualified or suitably trained person (b) the registered person has obtained a copy of the assessment and (c) there DS0000013568.V252832.R01.S.doc Version 5.0 Bellsgrove Page 28 3 OP7 15(2)(ad)&13 (4)(c) 4 OP9 13 (2) 5 OP12 16 (2) (m & n) 6 OP18 and OP30 18 (1) (c) 7 OP22 12 (1) (a) has been appropriate consultation regarding the assessment with the resident or a representative of the resident. The registered person must: (a) make the resident’s plan available to the resident (b) keep the resident’s plan under review (c) where appropriate and, unless it is impractical to carry out such consultation, after consultation with the resident or a representative of a resident, revise the resident’s plan and (d) notify the resident of any such revision. The registered person must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person must, having regard to the size of the care home and the number and needs of residents, consult with residents about their social interests, and make arrangements to enable them to engage in local, social and community activities and to visit. Additionally residents must be consulted about the programme of activities arranged by or on behalf of the care home and provide facilities for recreation. The registered person must ensure that the persons employed at the care home receive training appropriate to the work they are to perform. The registered person must ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of residents. Specifically, an occupational therapist or other suitably DS0000013568.V252832.R01.S.doc 14/10/05 15/09/05 14/10/05 12/12/05 12/12/05 Bellsgrove Version 5.0 Page 29 8 OP24 23 (1) (b-d) 9 OP25 and OP 38 13 (4)( c) 10 11 OP26 OP27 16 (2) (k) 18 (1) (a) 12 OP29 19(1) (a&b) Sched. 2 13 OP31 26(1)(3)( 4)&(5)(b& c) qualified person, must assess the home to ensure it meets the needs of the residents. The registered person must having regard to the numbers and needs of the residents ensure that: (b) the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally (c) equipment provided at the care home for use by residents or persons who work at the care home is maintained in good working order and (d) all parts of the care home are kept clean and reasonably decorated. The registered person must ensure that unnecessary risks to the health or safety of residents are identified and so far as possible eliminated. The registered person must keep the home free from offensive odours. The registered person must ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of residents. UNMET FROM 31/03/05 The registered person must not employ a person to work at the care home unless: (a) the person is fit to work at the care home and (b) he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2. UNMET FROM 31/12/04 Where the registered provider is a partnership, the care home shall be visited in accordance DS0000013568.V252832.R01.S.doc 18/11/05 14/10/05 14/10/05 14/10/05 15/09/05 14/10/05 Bellsgrove Version 5.0 Page 30 14 OP36 18 (2) (a) 15 16 OP37 OP38 17 (2) Schedule 4 13 (4) (a) with this regulation by one of the partners. Visits must take place at least once a month and be unannounced. The person carrying out the visit must: (a) interview with their consent and in private, such of the residents and their representatives and persons working at the care home as appears necessary to form an opinion of the standard of care provided in the care home (b) inspect the premises of the care home, its record of events and record of any complaints and (c) prepare a written report on the conduct of the care home. The registered person must supply a copy of the report required to be made under paragraph (4) (c), to the registered manager and in the case of a partnership, to each of the partners. The registered person must 14/10/05 ensure that persons working at the care home are appropriately supervised. UNMET FROM 28/02/05 The registered person must 14/10/05 maintain in the care home the records specified in Schedule 4. The registered person must 14/10/05 ensure that all parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 31 No. Refer to Standard Good Practice Recommendations Bellsgrove DS0000013568.V252832.R01.S.doc Version 5.0 Page 32 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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