Inspection on 30/12/05 for Belmont Grange Care Home

This inspection was carried out on 30th December 2005.

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

Belmont Grange Care Home 18/07/07

Belmont Grange Care Home 11/08/06

Belmont Grange Care Home 28/06/05

Belmont Grange Care Home 12/01/05

Belmont Grange Care Home 05/08/04

Belmont Grange Care Home 11/02/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Belmont Grange Care Home Broomside Lane Belmont Durham DH1 2QW Lead Inspector Mrs Sue Lowther Unannounced Inspection 30th December 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Belmont Grange Care Home DS0000000695.V275875.R01.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. Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Belmont Grange Care Home Address Broomside Lane Belmont Durham DH1 2QW 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) 0191 3849853 0191 3869513 Four Seasons Health Care (England) Limited Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability (2), Terminally ill (8) of places Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Physical Disability. Up to 2 persons with a physical disability may be accommodated commensurate with the home’s statement of purpose. 28th June 2005 Date of last inspection Brief Description of the Service: Belmont Grange is a care home registered to provide care (including 24 hour nursing care) for persons aged 65 years or older. It is situated in the centre of Belmont and is within easy reach of the shops and local amenities. The main building is listed with a modern built extension added. It consists of a two-storey building. There are 25 single bedrooms and 4 double rooms, 1 of which is en suite. Individual bedrooms may not be furnished with all of the items outlined in the National Minimum Standards for Care Homes for Older People. This would be based on the choice of the service user and on an assessment of need. There is a passenger lift available. The home and was purchased by the current owners Four Seasons Healthcare (England) Limited in 2000. The home is surrounded by well-maintained gardens and has ample car parking space available for visitors. Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over a period of 5 hours on the 30th December 2005. The home did not know the inspection was going to take place. The plan for the inspection was to check whether the home had implemented the requirements and recommendations made at the previous inspection; to talk with the residents about living in the home; to meet with care staff; and to look at records. What the service does well: What has improved since the last inspection? Each service user has now been supplied with a statement of terms and conditions. Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 6 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. Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 4 Service users receive appropriate information about the home and their needs are assessed prior to admission. EVIDENCE: The administrator and company representative confirmed that all service users have been issued with a terms and conditions document, which they have signed to confirm that they understand the service that they are entitled to receive. All service users are assessed prior to going to live in the home into the home. In addition to care manager assessments prospective service users are visited either in hospital or their own home by one of the nurses who will assess the person and confirm that Belmont Grange can meet their needs. The file of one service user recently admitted to the home was examined and was found to contain comprehensive information. The home does not provide intermediate care and therefore assessment of Standard 6 is not required. Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Residents cannot be assured that all of their care needs can be met. The storage of some medication was unsafe. EVIDENCE: All of the residents who live at Belmont Grange Care Home had a care plan. Four of the care plans were inspected. They were not written in enough detail to ensure that staff could fully understand service users’ needs. It was sometimes difficult to decipher what care service users were receiving. In addition some of the plans did not reflect the needs identified in the admission assessment. In some instances the needs of the clients had altered and had been referred to in the daily progress sheets however the actual plan of care detailing instructions to staff had not been updated when the service users needs had changed. Staff confirmed that the needs of these people were being met even though there was a lack of clear plans. As highlighted in the previous inspection report, this approach is dependant on informal communication systems. Residents are at risk of not having their needs met if these informal systems break down. Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 10 An audit was undertaken of medications. The recording of administration was found to be satisfactory. However medication administration recording sheets should contain a running total of medication received to enable an audit to be easily undertaken. Some medications, which were no longer required, had been removed from the dosette packs and were stored in medicine pots. The nurse in charge advised the inspector that she was waiting for a second nurse to sign for these so that they could be disposed of. This is unacceptable practice. The residents spoken to felt that the staff “were wonderful” and “always cheerful”. The inspector observed, through the actions and responses of staff, that staff respect service users’ privacy and dignity. Service users spoken to expressed their general satisfaction with the manner and attitude of the people employed at Belmont Grange. Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14&15 The range and choice of activities available within the home were extremely limited due to there being no dedicated activities organiser. EVIDENCE: The home still does not have an activities coordinator in post. However the company representative advised the inspector the post has now been advertised. Relatives and service users confirmed that they are looking forward to having this structured facility as staff do not have the time to organise activities. Service users confirmed that they could have as many visitors as they like and at any time they chose. Several visitors spoken to during the inspection said that staff were approachable and that they were always made to feel welcome. The lunchtime meal was being served during the inspection. It looked nice and service users said they enjoyed it. Staff were available to assist service users who needed help. Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 12 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): 16,17&18 Service users can be confident that their concerns and complaints are dealt with appropriately and that safeguards are in place to protect them from abuse. EVIDENCE: The company representative confirmed that all complaints are taken very seriously and that the company has a robust policy and procedure for dealing with complaints about the service. All complaints investigated by the home are documented with the outcome and actions taken recorded. Staff training has taken place in the protection of vulnerable adults in abuse. Staff recruitment procedures were adequate and staff were employed and deployed following appropriate CRB and POVA checks. Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 13 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): 23 & 24 The home is safe and well maintained however some furniture and carpets are showing signs of wear and tear. EVIDENCE: The inspector looked around the building and saw that some service users in this unit had brought small items of furniture into the home to personalise their rooms and make them look homely. However in some of the rooms the furniture was broken and carpets were showing signs of wear and tear. An audit of all rooms must be undertaken and items replaced where wear and tear is identified. Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 14 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&30 Staffing levels are maintained to ensure that the care needs of service users are met. Service users are protected by the recruitment procedure and policy at the home. EVIDENCE: The duty rota evidenced that sufficient staff are on duty and deployed appropriately in order to meet the personal care needs of the service users. Excluding ancillary staff, current staffing levels for Belmont Grange are: a qualified nurse on duty throughout the day and night; plus, between 8am – 8pm 4 care assistants, and between 8pm – 8am 2 care assistants. The home had staff files in place, which provided evidence that the appointment of a new staff member is made through proper recruitment processes. This includes the vetting of staff through the use of references, POVA first checks and Criminal Record Bureau (CRB) checks. Four Seasons Health Care have a training department who are now coordinating staff training in NVQ. Staff require an update of their training with regard to moving and handling and fire safety. Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 15 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&38 There is no registered manager in post to provide clear, consistent leadership throughout the home. EVIDENCE: The home is without a Registered Manager and this has been the case for several months. There have been no service user, staff or relatives meetings during this time. The administrator is responsible for the record keeping with regard to service user finances. She was able to identify the amount that each resident had in his or her account. There has been no regular staff supervision since the previous manager left. This must be addressed as a matter of urgency. The handyman employed by the home was on sick leave at the time of the inspection, however a handy man from another home within the same company is visiting Belmont Grange on a regular basis to carry out routine and urgent maintenance. Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 16 Servicing records were examined and found to be up to date and in order. There is evidence of regular servicing of fire equipment, gas and electrical appliances being carried out. A record is maintained of regular water temperature tests in the home. There has been no staff training since the last inspection. As stated previously, all staff must receive an update of their training with regard to fire safety and moving and handling practice. Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 17 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 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 X X X X 2 2 X X STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 1 X 1 Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 18 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 OP7OP8 Regulation 15(1)&(2) Requirement All care plans must be reviewed to ensure that the plan is up to date with the care that service users are receiving. (Previous requirement – timescale of 30/09/05 not met) The Registered person must ensure that staff comply with company policy regarding the disposal of medication. An audit of all bedrooms is required. Furniture & carpets, which are showing signs of wear& tear, must be replaced. The company must seek to appoint a suitable person to manage the care home. A formal system for staff supervision must be implemented for all staff. To protect vulnerable service user health welfare and safety the Registered Person must ensure that all staff are trained in fire safety and moving and handling procedures. Timescale for action 28/02/06 2 OP9 13 & 17 30/12/05 3 OP23OP24 13,16&23 31/03/06 4 5 6 OP31 OP36 OP30OP38 8&9 18(2) 12(1), 13(4) & 23(4) 31/03/06 28/02/06 28/02/06 Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 19 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 OP12 OP33 Good Practice Recommendations The company representative advised that a budget is now available to employ an activities coordinator. This post should be filled to enhance the daily life of service users. Service user, relatives and staff meetings must be resumed. Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Belmont Grange Care Home DS0000000695.V275875.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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