Inspection on 10/03/06 for Belper Views

This inspection was carried out on 10th March 2006.

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

Belper Views 29/09/09

Belper Views 22/04/09

Belper Views 19/11/08

Belper Views 30/04/08

Belper Views 02/05/07

Belper Views 12/05/06

Belper Views 23/11/05

Belper Views 19/07/05

Belper Views 02/02/05

Belper Views 10/03/04

Similar services:

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St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Belper Views 50/52 Holbrook Road Belper Derbyshire DE56 1PB Lead Inspector Brian Marks Unannounced Inspection 10th March 2006 09:00 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 Belper Views DS0000019936.V292136.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. Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Belper Views Address 50/52 Holbrook Road Belper Derbyshire DE56 1PB 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) (01773) 829733 Mr Alan Kilkenny Mrs Susan Shirley Matthew Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2005 Brief Description of the Service: The home is a large detached brick building with its own large garden and patio area, set on a hill on the outskirts of Belper. The home offers a good range of community and leisure facilities, although there are no shopping facilities in the immediate area. The home offers accommodation for 25 older people in single rooms, some with en-suite facilities available, and has a good range of communal areas, offering a variety of spaces for residents and their visitors to use. Residents at the home are registered with 1 of 2 local Doctor’s practices and there is a small community hospital in the town. Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place at the home over 4 hours. Additionally, time was spent in preparation for the visit, looking at previous reports and other documents. At the home, apart from examining documents, care files and records; time was spent in a tour of the building and speaking to 2 of the residents. The manager and some of the staff on duty were also spoken to, and they were observed throughout the visit, looking after and dealing with residents and visitors. An important activity of inspection is the careful examination of residents’ individual care records, and 3 were selected for this purpose. The aim of inspection activity during the current inspection year is to assess a service against the ‘key’ National Minimum Standards and these are identified at the beginning of each section of the report. A number of these keys standards were examined at the last 2 inspections so, for a more complete picture of this service, this report should be read in conjunction with the reports dated 19 July and 23 November 2005. What the service does well: What has improved since the last inspection? With the appointment of an activities coordinator and a new cook, key areas of life at the home have shown good levels of improvement, and the atmosphere of the home is more lively and animated. The service users guide has been amended to stay in line with the law and improvements in the home’s environment have continued, to increase resident comfort an enjoyment of the home’s facilities. The manager has applied to register with the CSCI and that process has almost been completed in order to comply with the law. Belper Views DS0000019936.V292136.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. Belper Views DS0000019936.V292136.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 Belper Views DS0000019936.V292136.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): 1 and 3. The home now has a Service Users Guide that meets the requirements of the law. People do not come to live at the home without the care they need from the home, and its staff, being identified. However, this is not comprehensively written down, and mistakes may occur. EVIDENCE: The home had previously provided a Statement of Purpose and Service Users Guide but the manager has reviewed and revised the second of these as required at the last inspection, so that information given to people living at the is correct. The service user files examined contained a range of information that had been prepared at the time of admission and although some work had been put in since the last inspection to improve their standard, there remains work to be done. Areas of particular concern and risk – (risk assessments) – had only been completed for some residents and these had not all been reviewed and evaluated at appropriate intervals to make sure that the information was accurate. Examples noted were general assessments in relation to nutritional Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 9 and moving and handling needs. Whilst these assessments were linked to the daily care plan (see next section), the overall package of documents still lacked clarity and details about how needs were to be met, and about how proper services were to be provided by staff not always included. The possibility of purchasing a complete system of care documentation was discussed with the home’s manager and the possibility of this will be reviewed at the next inspection as a way of improving care standards. Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 10 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, 9 and 10. The care of all residents, including health care, is planned and given in ways that respect individuality and privacy, and the management of medicines has been improved. However, the care plan documents do not efficiently support care activities and resident welfare. EVIDENCE: All residents have their own file containing care records and care plans, and 3 files were looked at in detail during the inspection. Some improvements in the quality of the care plans were noted but the standard remains varied and the requirement made at the last inspection remains. It was agreed by the home’s management that the style of current care plans does not encourage a comprehensive service being designed for each resident and that they do not describe clearly how different needs are to be met. As noted in the previous section the idea of the purchase of professionally produced sets of care documents was discussed with the manager at this visit, and this will be reviewed at the next inspection. The one storage issue around medication made as a requirement at the last inspection has been dealt with and safety improved. Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 11 Although some residents had their own telephones in their rooms, for the others a large numbered telephone was available outside the main lounge. An alternative provision of a cell phone for receiving calls in private was discussed and the provider stated that this would shortly be provided so that residents do not block the office phone and a call line is always available to them. Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 12 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 and 15. Social life at the home and arrangements in the kitchen had been improved by the appointment of an activities coordinator and a new cook respectively. The management of the home has been more alert to resident needs in these 2 key areas of the home’s life. EVIDENCE: As recommended at the last inspection, an activities coordinator has been appointed at the home and has already made an impact on the amount of social and leisure time being spent with the residents. The development is to be commended as a good example of the progress being made at improving the lives of the people at the home. Also since the last inspection a new cook has been appointed and he has put in a lot of work with the home’s proprietor to make the improvements recommended at the last inspection. Storage arrangements in the kitchen have been changed and more space has been made available, with a different approach to purchasing food to make sure that excess stocks are not carried. The cook reported that it was his intention to use increasing amounts of fresh ingredients and the new menus reflect this. Written menus are now placed on each table in the dining room and choices at mealtimes have been improved to meet the range of resident preferences. General standards of record keeping in the kitchen have also been improved. Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home has comprehensive policies and procedures in relation to the protection of vulnerable people, and staff are made aware of their responsibilities in this area. EVIDENCE: The home has a detailed policy and procedure in relation to the protection of vulnerable adults, and this includes the local statutory procedure to be followed. Staff are given instruction at the time they join the home and also through other later training; not all had received this follow-up. There had been no incidents of use of the statutory procedures during the past 12 months but the manager has previous experience of the matter. Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 14 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 The proprietor of the home has continued to make improvements to facilities at the home. EVIDENCE: A brief tour of the building was made to look at the improvements since the last inspection: The storeroom next to entrance hall of the home has been converted to the main laundry, which will improve facilities for both residents and staff. All bedroom doors have been supplied with resident names, to assist with orientation. The improvements to the kitchen noted above. Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 15 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. Good levels of training have been provided to staff so that they work consistently and safely. Whilst recruitment of new staff has been carried out properly in the past, lack of recent experience has exposed serious flaws in the home’s systems and potentially the wrong people for the job may be employed. EVIDENCE: Records on staff files showed that 8 care staff had completed or were completing an NVQ qualification at a minimum of level 2, and the required target of 50 of staff should be achieved within 6 months. Staff were observed with the residents during the inspection and interactions were seen to be warm and professional. From examination of the staff roster, the numbers of staff regularly on duty is satisfactory and meets the previously agreed levels. Standards of cleanliness of the home and activities in the kitchen, the latter noted above, indicate that sufficient domestic and catering staff are employed to meet the needs of the registered numbers of residents. Since the last inspection the recruitment of new staff, the first in some time at the home, has exposed serious weaknesses in the process followed, in particular the steps taken by the home’s management to obtain checks from the Criminal Records Bureau about prospective employees. This has resulted in the potential recruitment of people who are not right for the job, and an immediate requirements notice was left at the home at the end of the Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 16 inspection requiring the home’s management to make urgent applications, in order to make sure that the problem is urgently rectified. Examination of the files of all established staff indicated that the correct checks had been carried out for them. From the examination of staff records and discussion with the manager satisfactory levels of staff training in relation have been carried out in relation to the core health and safety activities, apart from instruction in relation to the control of infections. Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 17 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 and 38. The manager has completed aspects of confirming her status at the home, including registration with CSCI and obtaining a suitable qualification. Systems for measuring the quality of services at the home have yet to be developed by the provider. EVIDENCE: The manager has applied to register with CSCI since the last inspection, and the process for this is almost complete. She has also registered with a training agency for a Registered Manager’s training course and awaits a commencement date; both of these are required by law. The manager continues to have a stabilising influence on the home and to update systems of administration. The owner of the home is a regular visitor to the home and has offered the new manager support in adapting to her role. The owner has not yet produced a written monthly report about his visits to the home, which is required by law, Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 18 and has not introduced any activities which give them any indication of how successfully the home is being operated and which produce a measure of the quality of its services. A comprehensive risk assessment has been carried out and written up that looks at all aspects of the home’s environment. This will help the home’s management to operate safely and to fully comply with Health and Safety legislation. Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 19 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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X 2 X X X X STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 3 Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 20 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 OP3 Regulation 14(1-2) Requirement The registered person must make sure that the needs of all residents are fully assessed at the point of admission, and that those needs are recorded fully and kept under regular review. (Previous timescale of 31/01/06 not met). The registered person must ensure that comprehensive risk assessments of individual service users capabilities and needs are recorded, and kept under regular review. (Previous timescale of 31/01/06 not met). Care plans must clearly show how service users needs are being met, including identified risks. They must be kept updated and regularly reviewed and must show the involvement of service users/relatives. (Previous timescale of 31/03/06 not met). The proposal to provide a cell phone for service users to make private telephone calls must be carried out. This is to provide DS0000019936.V292136.R01.S.doc Timescale for action 30/06/06 2. OP3 14(1-2) 30/06/06 3. OP7 15(2) 30/06/06 4. OP10 16 30/06/06 Belper Views Version 5.1 Page 21 access to a private telephone for service users who could make a call, independent of staff. 5. OP22 23 The need for additional call points in the main lounge must be the subject of a risk assessment, which includes discussion with residents and their representatives. (Previous timescale of 31/01/06 not met). The registered person must ensure that no staff work unsupervised at the home until full checks have been received from the Criminal Records Bureau. All staff must receive appropriate training or instruction in infection control. The manager must register with a Registered Managers (NVQ level 4) course by the due date. The Registered Provider must carry out monthly monitoring visits in accordance with regulation 26 and retain a copy of written reports at the home for inspection. (Previous timescale of 31/12/05 not met). The registered person must develop a system of monitoring activities at the home that will allow for a measure of the quality of services to be established. This should include the development of an annual plan for the home. 30/06/06 6. OP29 19(5) Schedule 2 31/03/06 7. 8. 9. OP30 OP31 OP33 18(1) 10 26 30/09/06 30/04/06 30/04/06 10. OP33 24(1) 30/06/06 Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP16 Good Practice Recommendations The complaints procedure should allow for recording of all concerns and problems, and for records to be stored confidentially. The displayed version should be suitable for people with a visual impairment. All staff should undertake regular update training in adult protection. The Registered Person should consider replacing the medibath with one that service users would find more suitable. There should be safe and accessible facilities for service users to undertake their own laundry if they choose to do this. The manager should monitor the impact on direct care of service users due to staff undertaking domestic and laundry duties, through Regulation 26 monitoring. 2. 3. 4. 5. OP18 OP21 OP26 OP27 Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Belper Views DS0000019936.V292136.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!