Inspection on 22/06/06 for Bellsgrove

This inspection was carried out on 22nd June 2006.

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

The inspector 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 05/01/06

Bellsgrove 15/09/05

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 10:05 22nd June 2006 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.V290364.R02.S.doc Version 5.1 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.V290364.R02.S.doc Version 5.1 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.V290364.R02.S.doc Version 5.1 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). 5th January 2006 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. The fees at this service range from £460.00 to £560.00. Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the first “key” inspection to be carried out in the Commission for Social Care Inspection (CSCI) year, April 2006 to June 2007, and was carried out under the CSCI’s Inspecting for Better Lives programme. As the inspection was unannounced, no-one at the home was aware that it was to take place. Mrs Sandra Holland, Lead Inspector and Mr Deavanand Ramdas, Regulation Inspector carried out the inspection over six hours. Mr Somasundaram Logathas and Mrs Shyamala Logathas, Registered Providers were present representing the service. All areas of the home were seen and a number of documents and records were examined, including care plans and assessments of risks, medication administration record (MAR) charts, the complaints procedure and staff files. Eight residents, one visitor and two members of staff were spoken with. The inspectors wish to thank the residents, staff and providers 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. For clarity, the registered providers and the registered manager will be referred to as the providers and manager throughout the report. At the last inspection on 5th January 2006, a number of immediate and other requirements made at previous inspections, were found not to have been met. As a result, on 12th January 2006, a formal Notice was served to the providers and manager of the service, under the requirements of Regulation 43 of The Care Homes Regulations 2001 (As Amended). The notice was served under the enforcement processes of CSCI and required the providers and manager to ensure full compliance with the requirements made, as failure to comply with the regulations specified, is an offence. A follow-up visit to the service was made on 19th April 2006 to assess compliance with the Regulation 43 Notice. As the level of compliance was not complete, the providers and manager were advised under caution that this would be referred to a Regulation Manager and that further action may be taken. A meeting was requested by CSCI and was held with the providers, manager, Mr Raj Gokhool, Regulation Manager and Mrs Sandra Holland, to discuss the level of compliance with the Regulation 43 Notice. The partial compliance was recognised by CSCI and the providers and manager agreed to provide an Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 6 improvement plan within two weeks of the meeting. They also gave their commitment to meeting all outstanding areas of the requirements within six weeks from the meeting, which was agreed by CSCI. It was advised at the meeting that a “key” inspection would be carried out soon after the expiry date of the agreed timescale. The providers and manager also gave their commitment to the effective on-going management of the service. The requirements of the Regulation 43 Notice have been met, with the exception of the pre-admission assessment requirement. This could not be assessed as no residents had been admitted to the home since the last inspection. What the service does well: What has improved since the last inspection? It was not possible to assess whether pre-admission assessments had been carried out, as no residents had been admitted since the last visit in April. The arrangements for the administration of medication have improved and appear to be managed appropriately. Residents have been consulted about their social interests and the home’s programme of activities. The complaints procedure has been made available to residents. Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 7 The recruitment practices in the home have been improved and the appropriate records and documents have been obtained. Staff are being appropriately supervised What they could do better: Resident’s care plans must be kept up to date and must record all the resident’s current needs. Assessments must be carried out of any known risks to residents, or risks which become known. It is recommended that in the complaints record which is maintained, an entry is regularly made to indicate that the record has been checked. An updated copy of the local authority policy on the safeguarding of adults should be obtained and kept in the home. All parts of the home must be safe for residents to use. The sharp edges of the two ground-floor bathroom floor tiles, must be made safe. Liquid soap and paper towels must be supplied and used in the home to reduce the risks of infection. Enough staff must be provided to carry out all the tasks in the home, to include the cooking, the cleaning and the laundry. Photos of all members of staff must be kept in the home as part of the proof of their identity. Staff must receive training to enable them to carry out their role. The home must be more effectively managed to fully safeguard the residents. The result of the quality survey must be supplied to CSCI and made available in the home, for residents or their representatives. The records required to be kept in the home, must be maintained and be an accurate record. All visitors to the home must be asked to sign the visitors book and the staff rota must accurately record who is on duty at all times. The fire alarm and the temperature of the hot water supply must be regularly tested to ensure the safety of the residents. Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 8 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.V290364.R02.S.doc Version 5.1 Page 9 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.V290364.R02.S.doc Version 5.1 Page 10 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): 3 and 6. It was not possible to assess Standard 3 and Standard 6 is not applicable. EVIDENCE: The provider stated that no residents had been admitted to the home since the last inspection and that intermediate care is not provided at the home. Standard 3 regarding the pre-admission assessment of resident’s needs will be followed up at the next inspection and the requirement in respect of this will be carried forward. Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 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, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are held but need to contain more information to guide staff to the current needs of residents. Assessments of risks must include all known, and any new risks. Residents healthcare needs are well met and resident are treated with respect and dignity. Medication appears to be appropriately managed. EVIDENCE: A care plan is maintained for each resident which should be used to guide staff to the care and support needs of residents. Although a record sheet is marked to show these have been reviewed on a monthly basis, it was evident that these had not been kept up to date and did not reflect resident’s current needs. A number of significant changes of needs were noted for one resident, but these had not been amended in the care plan. No reference was made to the urinary catheter that was fitted for a short period, to it’s removal, or to the use of a special mattress to prevent pressure sores. The resident’s mobility needs had also deteriorated, but these were not reflected in the monthly reviews, or in the daily notes which are maintained. Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 12 From the care plans, it was clear that residents have been referred to healthcare professionals when required and that their healthcare needs have been met. However this has not been recorded fully in the resident’s care plan. Entries in the daily notes confirmed that one resident had been visited by a doctor and a district nurse within the last two months. A record sheet included in the same resident’s care plan to list visits by healthcare professionals had not been regularly completed, the last entry being in 2003. Assessments have been carried out of some risks to residents, but not all. It was noted that in a number of residents’ bedrooms, a floor pad is used to alert night staff that residents are out of bed and may need assistance. During the tour of the premises, the provider stated that a risk assessment had been carried out for the use of these, but assessments were not present in the care plans for the relevant residents. The risk assessment regarding the mobility of the resident referred to above, had not been amended to reflect the deterioration that had taken place. For this resident, risk assessment sheet recorded a low risk for mobility, even though it was noted elsewhere in the care plan, that the resident needed to be assisted by two staff and to use a wheelchair. The administration of medication appeared to be appropriately managed. Medication was stored in a locked provision, stock levels matched the records held and there were no gaps observed in the recording of medication administered. Where medication had been supplied in the middle of the monthly ordering cycle, a pharmacist label had been applied to the MAR chart, which ensures accurate administration instructions. Staff were observed to treat residents with respect and to speak in a friendly, informal manner. Residents were offered choices, encouraged to be independent and were provided with personal assistance in a discreet and tactful way. It was pleasing that one resident made a spontaneous and appreciative comment, that the cultural background of the staff at the home, was one that respected and valued older people. The cultural background of the staff group is of Asian origin whilst the cultural background of the resident group is of British origin. Both the staff and resident groups are of mixed gender. A requirement has been made regarding Standard 7. Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 13 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, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activities are carried out but need to take the specific abilities of residents into account. The hours worked by the activities co-ordinator and the activities programme need to be reviewed. Meals served looked appetising and were enjoyed by residents. EVIDENCE: Staff advised that the activities programme which was displayed is used as a guide, but that activities are carried out according to the wishes of residents. An activities co-ordinator is employed at the home for two hours each day, for two days each week. These working hours and the home’s activities programme must be reviewed to ensure that enough staffing time is available to carry out a varied, active and planned programme of activities. This is necessary to ensure that all residents, and particularly those residents with dementia or mental health difficulties, are offered a range of meaningful activities. The activities co-ordinator was due to be on duty at the home on the day of inspection, but did not arrive. The provider later made contact with her and Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 14 she explained that she had not been able to attend due to a family crisis. Most of the residents were sitting in the lounge or dining area, some watching television or reading newspapers, but many others were not occupied. The provider stated that a record is held of the activities carried out, but this was not up to date, the last entry being dated 2005. The provider advised that the activities co-ordinator maintains a record of the activities carried out in her diary, which was not available in her absence. It is recommended that this record is retained in the home, to indicate how the social and recreational needs of residents are being met. The programme of activities which was on display included soft ball games, drawing & painting, physical exercise and music appreciation. One service user who was spoken with said she chooses not to join in with activities because she has poor eyesight. It was clear that residents are supported to be involved in the local community. The home is very close to local shops and facilities and one resident spoke of going independently for a walk to the shops. Another resident was going out to lunch with a local social club on the day of inspection. The provider advised that a local vicar makes monthly visits to the home. A visitor to the home advised that she was always made welcome. It was noted that a visitor’s book is kept in the entrance hall, but not all visitors are asked to sign it on arrival (including the inspectors). The provider stated that the home does not have a formal policy regarding visitors, but there are no restrictions on visitors to residents. Residents were seen to be offered choices, of meals, refreshments and activities. Staff gave residents time to make their responses and these were respected. The lunchtime meal was served in the dining area of the lounge and the table was laid with a colourful cloth and place mats. The meal looked and smelt appetising, was attractively presented and soft drinks were available. A resident commented that “the meals are delicious”. Although the menu appeared to be reasonably well-balanced, the record of the meals served indicated a short cycle of the main meal selection and some items recorded had been served every other week. As the cooking is undertaken by the home’s staff and not a trained chef, it is recommended that the menu is reviewed with the involvement of a dietician, to ensure that it fully meets the nutritional needs of residents. A requirement regarding Standards 12 and 13 has been made at Standard 37 which refers to record keeping. Recommendations have been made regarding Standards 12 and 15. Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 15 Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 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): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A complaints procedure is available, but a complaints record needs to be maintained. A safeguarding adults procedure is held in the home but needs to be updated. EVIDENCE: The home’s complaints procedure was displayed on the wall in the lounge. The provider stated that no complaints had been received for two years and that no record book is maintained. It is recommended that a record is maintained, which is regularly reviewed. A regular dated and signed entry should be made to indicate whether any, or no, complaints had been made as this provides an open system of monitoring the complaints procedure in the home. Residents and a visitor stated that if they had a complaint, they would advise the providers, who are very approachable and accessible, as they are in day to day involvement with the home. A copy of the local authority procedure for the safeguarding of adults is kept in the home, but this was not the most recent version. It is recommended that an updated copy of the procedure is obtained to ensure that all those working in the home are aware of the correct procedures to follow, in the event of the abuse of, or suspicion of abuse, of a resident. Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 17 From the staff training records, it was seen that some staff have undertaken training in adult abuse awareness. For one member of staff, the record showed that safeguarding adult training had been undertaken in the past, but not for a number of years. The provider stated that the home is not involved in the management of residents’ finances and that no monies are held for safekeeping for residents. A safe is available for the short-term safekeeping of valuables if required. Recommendations have been made regarding Standards 16 and 18. Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 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, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The maintenance of the premises and hygiene in the home must be given a higher priority. Residents have made their rooms individual with their own belongings. EVIDENCE: All areas of the home were seen and most were clean and tidy, although some bedrooms required vacuuming and an en-suite toilet needed cleaning. A number of minor shortfalls in the standard of the premises were noted. One bedroom had a poor odour, even though the window was open. An automatic air freshener on the window sill was empty. The headboard in this bedroom was broken and the provider stated that a carpenter was due to repair it. The vanity units in two bedrooms were very worn, but these are to be replaced, the provider stated. Two of the en-suite toilets required attention, Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 19 one requiring the flooring to be fixed to the wall and one requiring repairs to the boxing around pipe-work. The provider stated that he plans to arrange a carpenter to make these repairs. More seriously, it was noted that the edges of the ceramic floor tiles in the two downstairs bathrooms were exposed in the doorway and were sharp. These are a hazard to residents’ safety and must be covered. A requirement has been made regarding this under Standard 38 which refers to health and safety. Radiators have now been covered to safeguard residents as required by the Regulation 43 Notice referred to in the report summary. It was pleasing to observe that a number of residents had brought their own belongings into the home, to personalise their bedrooms. These included furniture, pictures, photos and ornaments. The rear garden was well maintained and attractive, with pots of seasonal plants and flowers. Garden furniture and sun umbrellas were available for residents’ use. A large, airy conservatory which overlooks the garden, provides an additional seating area and this was fitted with blinds to maintain a comfortable temperature. Hygiene in the home needs to be given a higher priority. Paper towels and liquid soap were available in one toilet in the home, but in a number of other toilets and bathrooms, these were not present. These are required to be supplied and used in the home, to prevent the spread of infection. Containers for an alcohol hand cleaning liquid are present in a number of areas of the home, but these were empty. A requirement has been made regarding Standard 26. Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 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, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing in the home needs to be reviewed and staff need to receive training appropriate to their role. The recommended ratio of staff have achieved a National Vocational Qualification and recruitment practices have improved. EVIDENCE: From speaking to the provider and looking at the rota, it was clear that a very small team of care staff are employed to assist the providers to meet the residents’ needs. These staff carry out all roles in the home, including cooking, laundry and housekeeping tasks. Staff also carry out activities with residents when the activities co-ordinator is not working, the providers stated. Two care staff are allocated to work on each early and late shift, At night, one member of care staff is awake on duty and another member of staff sleeps in the home in case they are required. The provider stated that the sleeping in member of staff usually works an additional two hours in the morning to assist with serving breakfast, or this is covered by one of the providers, but this was not recorded on the staff rota. The rota does not record which staff are allocated to do the cooking, laundry or housekeeping tasks or the working hours of the activities co-ordinator. Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 21 Given the number of residents and their dependency levels, two staff to cover all the roles involved is not adequate to effectively meet all of the residents’ needs. This was indicated by the rooms requiring cleaning and the lack of meaningful social activity taking place. A requirement was made at the last three inspections that the registered persons must ensure that at all times suitably qualified, competent and experienced staff are working at the home in such numbers as are appropriate for the health and welfare of residents. Timescales of 31st March 2005, 14th October 2005 and 3rd February 2006 were given and these have not been met. Staff stated that they have achieved National Vocational Qualification’s (NVQ’s). From the records seen it was noted that three staff have achieved NVQ Level 2 in care and the deputy manager has achieved NVQ Level 3 and the Registered Manager’s Award (RMA). The standard of recruitment documentation and practices has improved. It was noted from the staff files that photographs are not held of each member of staff. It is required that these are obtained to ensure and confirm the identity of staff. The original Criminal Record Bureau (CRB) disclosures have been retained in the home, but this does not accord with data protection law. The original documents should be securely destroyed, with a record retained of the CRB disclosure number and the date of issue. A record is maintained of the training undertaken by staff including recent courses in fire safety and the safe handling of medicines. It was noted that some of the records were very out of date and training courses need to be undertaken again. The deputy manager was doing the cooking on the day of inspection, but his food hygiene training certificate had expired, as it was dated 1997, his first aid certificate had expired and was dated 2000, and the date of the last record for safeguarding adults training was also 2000. Requirements have been made regarding Standards 27, 29 and 30. Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 22 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, 33, 35, 36, 37 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home continues to need more robust management to fully safeguard the residents living there. Improvements need to be made to the standards of record keeping and health and safety practices. EVIDENCE: The home is managed by a registered manager who was seen on the rota to work five days each week. One of the providers stated that he covers the management role on the manager’s days off and has undertaken the NVQ Registered Manager’s Award to enable him to carry out this role. A resident and a visitor both stated that as the providers were in day to day involvement with the home, any issues or queries could be discussed with them. The providers were seen to interact in an informal and approachable manner. Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 23 The provider stated that a survey of the quality of the service has been carried out, but the results were not available and would be forwarded to CSCI. It was agreed that this and a small number of other required documents would be forwarded to CSCI within two weeks from the inspection. Residents are supported with their financial affairs by their families, friends or representatives, the provider stated. Any day to day expenses incurred by residents, such as hairdressing or chiropody are paid for by the home and are invoiced to residents or their representatives. This is good practice as it provides protection to residents from financial abuse. From the records seen, supervision of some staff has now been carried out. This must continue and the recommended frequency is for staff to receive formal supervision six times each year. Some aspects of record keeping need to be improved. All visitors to the home must be asked to sign the visitors book, the staff rota must accurately reflect the staff present in the home and the hours worked, and a record of the activities carried out must be retained in the home. A number of records relating to health and safety were seen, including fire safety records, records of fridge and freezer temperatures and of hot food served, temperatures of the hot water supply. It is of concern that the last entries for the testing of the fire alarm and the temperature of the hot water supply were made in April 2006. The provider stated that it is his responsibility to carry these out and he could give no explanation as to why he had not carried these out for the last two months. It was observed on the tour of the premises, that a number of doors which are designed to close automatically when the fire alarm sounds, had been wedged open. This must not happen as it prevents the doors closing and in the event of a fire, would not stop the spread of fire or smoke. These shortfalls in health and safety checks and practices, potentially place residents at risk and two immediate requirements have been made. Certificates confirming the safety of the electrical fittings in the home and that portable appliances had been tested for safety were held. The provider stated that a gas safety certificate was not held but would be obtained and a copy would be forwarded to CSCI. A copy of the Health and Safety at Work poster and a valid certificate of Employer’s Liability insurance were displayed in the home, as is required. Two immediate and other requirements have been made regarding Standards 31, 33, 37 and 38. Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 24 Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x N/A x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 x x x x 3 x 2 STAFFING Standard No Score 27 1 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 3 2 1 Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 26 YES Are there any outstanding requirements from the last inspection? 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 OP3 Regulation 14 (1) (ac) Requirement The registered person must not 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 has been appropriate consultation regarding the assessment with the resident or a representative of the resident. Timescale for action 22/09/06 2 OP7 15(2)(ad)&13(4)( c) 3 OP7 13 (4) (c) The registered person must: (a) 22/09/06 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. Unnecessary risks to the health 22/06/06 or safety of residents must be identified and so far as possible DS0000013568.V290364.R02.S.doc Version 5.1 Page 27 Bellsgrove eliminated. Specifically, an assessment of the risks associated with the use of floor alarm pads and adjustable beds, must be carried out. 4 OP12 16 (2) (n) The programme of activities must be planned to take account of the residents’ abilities and a record of the activities carried out must be retained in the home. The working hours of the activities co-ordinator must be reviewed to ensure they are sufficient to provide a full range of meaningful activities. The registered person must ensure that all parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety. Specifically, the sharp edges of the floor tiles in the downstairs bathrooms must be made safe. 22/09/06 5 OP38 13 (4) (a) 22/06/06 6 OP26 13 7 OP27 18 (1) (a) Suitable arrangements must be 21/07/06 made to prevent the spread of infection. Specifically, liquid soap and paper towels must be provided and used in all appropriate places in the home. The registered person must 22/09/06 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. Specifically, the working hours of the activities co-ordinator must be reviewed to ensure they are sufficient to meet the social and recreational needs of residents. The number of staff in total and their working hours must be reviewed or specific housekeeping and DS0000013568.V290364.R02.S.doc Version 5.1 Page 28 Bellsgrove domestic staff must be employed to ensure that all task in the home are effectively carried out. UNMET FROM 31/03/05, 14/10/05 and 03/02/06. 8 9 10 OP29 OP30 OP31 19 Sch. 2 18 10 (1) A recent photograph of each 21/07/06 staff member must be retained in the home. Staff must receive training 22/09/06 appropriate to the role they are to perform. The registered provider and the 22/06/06 registered manager must, having regard to the size of the care home, the statement of purpose, and the number and needs of the service users, carry on or manage the care home (as the case may be) with sufficient care, competence and skill. Timescale unmet from 03/02/06. 11 OP33 24 (1-3) The registered person must maintain a system for reviewing at appropriate intervals, the quality of care provided at the care home, must supply to CSCI a report of any review conducted and make a copy of the report available to service users. The system of review must provide for consultation with service users and their representatives. Timescale unmet from 03/03/06. 12 OP37 17(2) Sched 4 The registered person must maintain in the care home the records specified in Schedule 4. Timescale unmet from 03/02/06. 21/07/06 21/07/06 Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 29 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 2 Refer to Standard OP15 OP16 Good Practice Recommendations It is strongly recommended that the menu and dietary needs of residents are reviewed with the involvement of a dietician. It is good practice to maintain a complaints record, which should be regularly reviewed and a signed and dated entry made, in the event that no complaints have been recorded. It is recommended that an updated copy of the local authority procedure on safeguarding adults is obtained and kept in the home. 3 OP18 Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 30 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. Extracts may not be used or reproduced without the express permission of CSCI Bellsgrove DS0000013568.V290364.R02.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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