Inspection on 19/07/05 for Belper Views

This inspection was carried out on 19th July 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

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 10/03/06

Belper Views 23/11/05

Belper Views 02/02/05

Belper Views 10/03/04

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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 19 July 2005 9.00am 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 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 C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Belper Views Address 50/52 Holbrook Road Belper Derbyshire DE56 1PB 01773 829733 Telephone number Fax number Email 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 Alan Kilkenny Mrs Margaret Stone (appointed but not registered) PC Care Home only 25 Category(ies) of 25 places - OP Old Age registration, with number of places Belper Views C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None stated 1 February 2005 and 20 April 2005 (Pharmacy inspection) 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 latter 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 Doctors practices and there is a small community hospital in the town. Date of last inspection Belper Views C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 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 a morning. Additionally, time was spent in preparation for the visit, looking at previous reports and other documents. At the home, apart from examining the home’s documents and records, time was spent looking around the building and speaking to residents. The particular emphasis of this visit was to review the recommendations made at the last 2 inspections. The manager and proprietor were also spoken to, and the staff were observed throughout the visit, looking after and dealing with residents and visitors. What the service does well: What has improved since the last inspection? What they could do better: Some key documents – the service user’s guide and complaints procedure – require amendment, as these are required by law. Some aspects of the management of medicines still require attention to ensure complete safety as do other aspects of general Health and Safety at the home. In order to identify hazards, formal risk assessment of all aspects of running the care home need to be carried out by the proprietor and safety of residents achieved by taking any actions indicated by that assessment. Activities arranged at the Belper Views C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 Page 6 home, although improved, remain underdeveloped and most residents are not very active in their daily lives. 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 C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Belper Views C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 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 standard(s) 1 The home did not have a Service Users Guide that met the requirements of the law. EVIDENCE: The home had previously provided a Statement of Purpose and Service Users Guide but the manager had not reviewed and revised the second of these as required at the last inspection. This could result in wrong information being given to residents of the home. Belper Views C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 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 standard(s) 9 and 10 Improvements have been made in the management of medicines but further work needs to be done to ensure complete resident safety. Residents are not able to make telephone calls in private independently of staff. EVIDENCE: A large number of recommendations were made in respect of the management of residents’ medicines at the last visit by the pharmacy inspector and the manager has made good progress in attending to the majority of these, but the system remains unsafe. The arrangements for storage have been improved by the provision of a small refrigerator for items that need a lower storage temperature and the large amount of excess or out of date medicines in the main storage cupboard have been disposed of. The overall temperature of this cupboard has been attended to by shielding the hot water pipes within it. The manager has improved recording practices through the proper use of the Medicines Administration Record (MAR) sheets, although there were still some sheets that were not signed and dated properly which could lead to errors being made. A backup system of all medicines received into the home had not been developed which would assist with monitoring and audit and further improve safety. The medication policies for the home had been partially revised to make sure staff are working more consistently. Belper Views C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 Page 10 Although some residents had their own telephones in their rooms, for the others a large numbered telephone was available outside the main lounge. This was not in a private area being a main thoroughfare for the home and there was no seat provided nearby; anyone using the phone would potentially be obstructing the corridor. The manager stated that the cordless office telephone was available for residents to use but whilst this was usable in resident bedrooms it would not always be available for resident use. Belper Views C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 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 standard(s) 12 Social life at the home had shown some improvements but residents remained largely unmotivated and uninvolved. EVIDENCE: The manager reported that there had been an improvement in the level of activities organised for residents and that those who had expressed an interest in religious matters had enjoyed the irregular visits of a local church group. Examination of the home’s office diary indicated other events but generally the residents remained unmotivated by the social life at the home and only a minority participated fully. Belper Views C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 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 standard(s) 16 The home has a formal complaints procedure in place and on display at the home but more informal problems with resident lives at the homes are not recorded in a systematic way. EVIDENCE: The copy of the complaints procedure on display in the communal area had been updated since the last inspection but there was still no system in place for recording informal concerns and problems raised by residents on a day-today basis. This will allow the proprietor and manager to be fully aware of how the home is operating and of any problems in the daily lives of residents, no matter how small they may appear to be. Belper Views C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 22 and 26 The physical arrangements of the home have continued to improve and fire safety work has been carried out that meets the requirements of the law. Work still needs to be done to make the home completely safe and comfortable for residents to live in. EVIDENCE: The proprietor had continued to improve the home and create a better environment for residents to live in by completing the following since the last inspection: The dining room had been redecorated, specific problem areas in bedrooms had been resolved, the rusty commodes in use had been replaced, the problem with waste disposal had been resolved and poor practices around clothes drying had been stopped. The Fire Officer had visited the home twice since the last inspection and was satisfied that all the problems identified had been properly and safely dealt with. Belper Views C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 Page 14 However, a number of issues remained unattended to since the last inspection that may place the residents at risk or affect their comfort at the home: Toilet frames were still not secured to the floor, additional call points had not been supplied in the main lounge (although the manager stated that staff were always in this room and residents could easily access staff if not), the laundry facilities were across the back yard and not easily available to residents, and the lighting and carpet outside rooms 6,7,and 8 was unsuitable (although these were not planned for occupation and due for review of their arrangements). Belper Views C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these Standards was specifically examined at this inspection. EVIDENCE: Belper Views C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33 and 38 The new manager at the home has made a positive impact at the home and is to be commended for the work completed so far. There are still some aspects of the home’s operation that need to be done to make the home completely safe for residents. EVIDENCE: A new manager has been confirmed in post since the last inspection and from the amount of work she has put since that time has had a stabilising influence on the home. She has not yet applied to register with the CSCI and had not commenced on a Registered Manager’s training course, both of which are required by law. 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 a bout his visits to the home, which is required by law. Belper Views C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 Page 17 From observation on the day of the inspection the home was free from any serious hazards but a number of items were identified and discussed with the manager that needed looking at to make the home completely safe for residents. Belper Views C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 2 x 2 x x x x STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 x 2 x x x x 2 Belper Views C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 Page 19 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 1 Regulation 5(1-2) Requirement The service user guide must include information about complaints and the role of the Commission for Social Care Inspection and also the last inspection report. On handwritten MAR charts the date of birth, date of medication commenced and full name of the service user must be recorded. The person completeing the entry must initial it. (Previous timescale of 15/06/05 not met). A new entry must be written onto the MAR chart if the instructions for a medication are altered. (Previous timescale of 15/06/05 not met). The home must record the receipt of all medication into the home. (Previous timescale of 15/07/05 not met). All medicines that require a lower storage tempeature must be kept in the refrigerator. The manager must ensure that medicines are used from the blister packs in the correct order. Spare medicated dressings must be treated as other prescribed medications. they must be Timescale for action 31.10.05 2. 9 13, 17 31.10.05 3. 9 13, 17 31.10.05 4. 9 13, 17 31.10.05 5. 6. 7. 9 9 9 13 13 13 31.08.05 31.08.05 31.08.05 Belper Views C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 Page 20 8. 10 16 9. 12 16 10. 20 13 11. 12. 22 22 13 23 13. 14. 15. 31 31 33 8, 9 10 26 stored in the main medicines storage area or within a secure cupboard at the current location. The arrangements for service users to make private telephone calls must be reviewed. There must be access to a private telephone for service users who could make a call independent of staff. (Previous timescale of 1/04/05 not met. The Registered person must consult with service users about activities and provide a structured programme of daily activities. Serious thought must be given to providing a motivator/activities co-ordinator for the Home. (Previous timescale of 1/04/05 not met). Rooms 6,7 and 8 must not be occupied until a risk assessment of the dim lighting and trip hazard presented by the carpet in the hall outsidehas been carried out and necessary steps to control hazards taken. All toilet frames must be secured to floor. (Previous timescale of 1/06/05 not met). The need for additional call points in the ,ain lounge must be the subject of a risk assessment, that includes discussion with reeidents and their representatives. The manager must apply to register with the CSCI. 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 14/02/05 not met). C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc 31.10.05 31.10.05 Ongoing 31.10.05 31.08.05 31.08.05 31.12.05 31.08.05 Belper Views Version 1.40 Page 21 16. 38 13 17. 38 23 18. 38 13 The registered person must carry 31.10.05 out a complete environmental risk assessment for the whole of the home and take steps to eliminate or minimise any hazards identified. Specifically the registered person must must risk assess the step leading to the lounge extension and take any action needed to make this safe. (Previous timescale of 1/04/05 not met). The building work in the lounge 31/08/05 must be completed to a good standard. (Previous timescale of 1/04/05 not met). Unnecessary risks to service 31.08.05 users must be eliminated:Window restrictors must be in place and work safely. Disposable razors must be stored safely. (Previous timescale of 1/03/05 not met). 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. 3. 4. Refer to Standard 9 9 15 16 Good Practice Recommendations If a MAR chart is handwritten or altered by a member of staff this should be signed and dated by them, and checked, signed by a second member of staff. The manager should practice stock rotation of medicines to ensure that the older stocks are used up first. A choice of main lunchtime meal should be made available to residents. The complaint procedure must allow for recording of all concerns and problems, and for records to be stored confidentially. The displayed version must be suitable for people with a visual impairment. The Registered Person should consider replacing the medibath with one that service users would find more suitable. Consider some additional signage to the bedroom and store rooms. C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 Page 22 5. 6. 21 22 Belper Views 7. 8. 26 27 There must 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. Belper Views C52-C02 S19936 Belper Views V239948 190705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection South Point 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. 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