Inspection on 23/11/05 for Belper Views

This inspection was carried out on 23rd November 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 19/07/05

Belper Views 02/02/05

Belper Views 10/03/04

Similar services:

Byars Care Home

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 23rd November 2005 11.30 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 Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 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.V267820.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 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 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. Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 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 5 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 5 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 4 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 inspection so, for a more complete picture of this service, this report should be read in conjunction with the report dated 6 July 2005. Any standards not included in these 2 inspections will be looked at during the next visit in 2006. What the service does well: What has improved since the last inspection? What they could do better: The standard of documents used for the planning of care need to be improved substantially and initial assessments and care plans need to be drawn up to Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 Page 6 support the staff to work consistently and safely. Similarly there needs to be documentation on each resident’s care record to demonstrate that activities and care practices are being evaluated and reviewed regularly. Documents and records that support the catering service of the home need to be developed and regularly used to improve monitoring and to demonstrate that the preferences of residents are being respected. 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. Social activities arranged at the home, although improved, remain underdeveloped and most residents are not very active in their daily lives. To meet the requirements of the law the manager must register with the CSCI and an urgent reminder notice to do so was left at the home during this inspection. 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.V267820.R01.S.doc Version 5.0 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.V267820.R01.S.doc Version 5.0 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, 3, and 6 The home did not have a Service Users Guide that met 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 the care that is needed at the time they move in may not be properly provided. 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. The service user files examined contained a range of information that had been prepared at the time of admission but these were either not complete enough to help staff care for the individual person properly or, in one case, not present at all. Areas of particular concern and risk (risk assessments) had only been completed for some residents but these had not been reviewed and evaluated at appropriate intervals to make sure that the information was accurate. Examples noted were general assessments in relation to nutritional and Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 Page 9 moving and handling needs, as well as specific assessments related swallowing problems. Whilst these assessments were linked to the daily care plan (see next section), the overall package of documents lacked clarity and details about how needs were to be met, and about how proper services were to be provided by staff. The home does not provide an intermediate care service so Standard 6 does not apply. Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 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, 8, 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 4 files were looked at in detail during the inspection. The quality of the care plans produced at the home is varied but mostly poor, with the file of a newly admitted resident containing no records at all. It was agreed 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. None of care plans and care activities had been regularly reviewed as the law requires, and this could mean that service users are being placed at risk or that their welfare is not being properly maintained. Continued progress has been made with the recommendations from a previous visit by the pharmacy inspector, and one storage issue remains to make the system fully safe. Generally the arrangements for receipt, storage and Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 Page 11 administration have been improved; in particular the standards of recording on the MAR sheets now ensure much safer practice. Residents reported that they had regular access to medical and nursing services, as they required it and care records supported this. 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 so that residents do not block the office phone and a call line is always available to them. All the residents spoken to stated that the staff treated them in a friendly way and that their privacy was respected at all times. Two of those spoken to spent substantial amounts of time in their rooms and this presented no problems, for example. Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 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, 13, 14 and 15 Social life at the home had shown some improvements but residents remained largely unmotivated and uninvolved, although there are a regular number of visitors to the home. Residents feel in control of their lives at the home and enjoy a satisfactory diet. EVIDENCE: The manager reported that there had continued to be activities organised for residents and an entertainer had been booked to visit the home soon after the inspection. Those who had expressed an interest in religious matters have enjoyed the irregular visits of a local church group. The residents spoken to were happy to be able to run their lives at the home as they pleased, and a number were in their rooms listening to music or watching television during the visit. All residents spoken to had all retained contact with their families and received visitors at the home on a regular basis. One service user was also out of the home at the time of the visit at an appointment with his solicitor that he had arranged himself. According to the residents, their routines were arranged according to their preferences and they all reported that they were free to use all the facilities of the home as they wished to. Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 Page 13 From a visit to the kitchen and discussion with the staff the catering service at the home is organised and the kitchen well equipped and arranged. However, there was complete lack of documentation present that might indicate a planned menu, what had been served to residents and their preferences or needs in relation to any special dietary problems. Examination of the storage areas indicated good stocks of food, which is purchased and delivered at regular intervals through the week. The observations of residents spoken to were positive about the quality, quantity and regularity of meals served at the home. Preferences were catered for and most said that choices were available at the main mealtimes; however 2 said the lunch meals were ‘plain’ and ‘not a lot to write home about’. Staff are available to help at mealtimes for those that need it and special arrangements were made for people with diabetes and those who needed a gluten free diet. Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 Page 14 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): None of these Standards was specifically examined at this inspection. EVIDENCE: Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 Page 15 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 and 26 The home is clean, hygienic and offers good standards of comfort to residents in the bedrooms, garden and communal areas. EVIDENCE: A look around the home indicated that the requirements in respect of the building, made at the last inspection, had been dealt with: Dim lighting in corridors had been improved and loose carpets attended to. All toilet frames had been fixed to the floor. Window restrictors had been made fully safe. However, the following had remained unattended to and may place the residents at risk or affect their comfort at the home: 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 communal areas and bedrooms of the home were clean and tidy and free from odours at the time of this inspection. Residents spoken to had no Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 Page 16 complaints about the laundry service of the home and all residents observed in the home wore clean and well-presented clothing. Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 Page 17 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): None of these Standards was specifically examined at this inspection. EVIDENCE: Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 Page 18 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 35 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. An application for her registration with the CSCI must be urgently made to fully comply with the law. EVIDENCE: A new manager continues to have a stabilising influence on the home and to update systems of administration. She has not yet applied to register with the CSCI as required at the last inspection and an immediate requirement to do so was left at the time of the inspection. She had also not commenced on a Registered Manager’s training course; both of these 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 about his visits to the home, which is required by law. There have been no activities introduced which give the managers of the home Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 Page 19 any indication of how successfully it is being and which produce a measure of the quality of its services. Records of resident finances indicated that these were in order and all activities involved with looking after their money were properly carried out. Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 Page 20 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 2 2 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X 2 X X X 3 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 2 X 2 X 3 X X 2 Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 Page 21 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 OP31 Regulation 8, 9 Requirement The manager must apply to register with the CSCI. (An immediate requirement notice was left at the home at this inspection. Previous timescale of 31/08/05 not met). 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. (Previous timescale of 31/10/05 not met). 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. The registered person must ensure that comprehensive risk assessments of individual service users capabilities and needs are recorded, and kept under regular review. DS0000019936.V267820.R01.S.doc Timescale for action 07/12/05 2. OP1 5(1-2) 31/12/05 3. OP3 14(1-2) 31/01/06 4. OP3 14(1-2) 31/01/06 Belper Views Version 5.0 Page 22 5. OP7 15(2) 6. OP9 13 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. Spare medicated dressings must be treated as other prescribed medications. They must be stored in the main medicines storage area or within a secure cupboard at the current location. (Previous timescale of 31/08/05 not met). 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 31/10/05 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). The meals at the home must be arranged on a planned basis, through the provision of a regular menu and the recording of resident preferences and the meals they have been served with. Residents must be made aware of what is planned on a day-to-day basis. The need for additional call points in the main lounge must DS0000019936.V267820.R01.S.doc 31/03/06 31/01/06 7. OP10 16 31/01/06 8. OP12 16 31/01/06 9. OP15 16(2) 31/01/06 10. OP22 23 31/01/06 Page 23 Belper Views Version 5.0 be the subject of a risk assessment, which includes discussion with residents and their representatives. (Previous timescale of 31/08/05 not met). 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. 11. 12. OP31 OP33 10 26 31/12/05 31/12/05 13. OP38 13 (Previous timescale of 31/08/05 not met). The registered person must carry 31/01/06 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 risk assess the step leading to the lounge extension and take any action needed to make this safe. (Previous timescale of 31/10/05 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. Refer to Standard OP15 OP16 Good Practice Recommendations A choice of main lunchtime meal should be made available to residents. The complaints procedure must allow for recording of all concerns and problems, and for records to be stored DS0000019936.V267820.R01.S.doc Version 5.0 Page 24 Belper Views 3. 4. 5. 6. 7. OP21 OP22 OP26 OP27 OP33 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 storeroom doors. 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. The registered provider must develop a system of assessing the quality of the home’s services. Belper Views DS0000019936.V267820.R01.S.doc Version 5.0 Page 25 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.V267820.R01.S.doc Version 5.0 Page 26 - 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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