Inspection on 13/09/07 for Belvedere

This inspection was carried out on 13th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Belvedere 25/11/09

Belvedere 03/06/09

Belvedere 03/09/08

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Belvedere Wellington Street Accrington Lancashire BB5 2NN Lead Inspector Mrs Lynn Mitton Unannounced Inspection 10:00 13 September 2007 th 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 Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 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. Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belvedere Address Wellington Street Accrington Lancashire BB5 2NN 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) 01254 238248 01254 872161 Unlimitedcare Limited Care Home 38 Category(ies) of Dementia (11), Old age, not falling within any registration, with number other category (27) of places Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only: Code PC, to service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category: Code OP (maximum number of places: 27). Dementia: Code DE (maximum number of places: 11) The maximum number of service users who can be accommodated is: 38. Date of last inspection New service – 1st inspection Brief Description of the Service: Belvedere is registered with the Commission to provide accommodation and personal care for up to 38 older people. A maximum of 11 of the 38 people can be placed there who have dementia. The registered person for Belvedere is Francesca Windsor, who runs the home on a day-to-day basis. The home is situated close to Accrington town centre and all amenities and transport links are nearby. Belvedere used to be a local authority home for older people and was built for this purpose. There is a small car park and enclosed private garden to the rear. There are 38 single bedrooms, all of which are en-suite. Accommodation is over three floors. A passenger lift is available. There is a large and smaller lounge and a dining room on the ground floor and other small lounges on the other floors. There are suitable and accessible toilet and bathing facilities. There is a call alarm system. The home is staffed 24 hrs per day. Fees for the cost of a weeks care at Belvedere ranges from £360.00 - £530.00. T here was information available to potential residents and their families advising them of the home and giving them details about the type of service they could expect. Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted on 13th September 2007. This was the first inspection since Belvedere was first registered with the Commission in April 2007. The registered person completed a Annual Quality Assurance Assessment. The inspector spoke to people in receipt of a service, visitors to the home and to the care staff on duty at the time of the inspection. Throughout the report there are references to the “case tracking process”, this is a method whereby the inspector focuses on a small representative group of people using the service. Records regarding these people were inspected. Three people were case tracked, their files examined in detail and three care staff member’s files were also case tracked. Information about the service was received on the Commissions resident’s questionnaire, and relative’s questionnaire. Comments and findings of these surveys are referred to throughout this report. The inspection was conducted with the registered person. During the inspection a number of records, policies and procedures were also viewed. There were 13 people placed at Belvedere at the time of the inspection. What the service does well: When asked; “what do you feel the service does well?” one residents relative wrote; “They do seem to treat each resident individually and listen to them. The feel of Belvedere is very like a home environment rather than and institution”. One visitor to Belvedere told the inspector; “this place is marvellous and I am very happy with the level of care my relative gets. The food is excellent and the staff can’t do enough, its absolutely magic”. Assessment documentation was sufficient to ensure the needs of residents could be met upon admission. Contracts were in place advising people about the terms and conditions of their stay at Belvedere. Personal support was offered in accordance with resident’s wishes, and in a way that promoted privacy dignity and independence. People using the service had opportunities to maintain family links, and they valued this. Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 Page 6 People using the service were able to exercise choice and control in their day to day living. The general layout and décor of the home provided comfortable and clean surroundings, and was warm, tidy, clean, and free from offensive odours. Some training had been undertaken to ensure that care staff had the skills to care for people using the service. The attitude of the staff and management was to run the home around the needs and choices of the residents. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 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 Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP1, OP2, OP3 & OP6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessment documentation was sufficient to ensure the needs of residents could be met upon admission. Contracts were in place advising people about the terms and conditions of their stay at Belvedere. EVIDENCE: One visitor to Belvedere told the inspector; “My relative had a full assessment before she moved into Belvedere. Francesca visited her at her previous placement and I visited Belvedere twice before she moved in. My relative has settled in very well and the staff have been great”. The inspector was shown a “Residents Guide”. This document had most of the information needed so that potential new users of the service were well informed. The inspector and registered person discussed the need for the residents guide to be in formats suitable for all potential residents, for example in large print. The inspector advised that the residents guide should also include the contact details of the Commission, not include any references to Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 Page 9 nursing, and the terms and conditions of staying at Belvedere including the amount and method of payment of fees. Three peoples files were examined during the case tracking process. They had all been issued with a contract; this document explained the terms and conditions of their stay at Belvedere, was dated and had been signed by the person using the service. Assessment documentation was seen to have been completed for people prior to their admission. Assessment documentation contained good information to develop a plan of care and meet the person’s needs. Intermediate Care is not offered at Belvedere. Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP7, OP8 & OP10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s care and health needs were appropriately recorded, and should ensure that care staff knew how people’s needs were to be met. Personal support was offered in accordance with resident’s wishes, and promoted privacy, dignity and independence. EVIDENCE: Three plans of care were examined and overall these contained good detail, and had been reviewed. However, 2 care plans did not show that residents or their next of kin had been involved, none had a photograph, and one care plan was lacking in detailed information. The inspector advised that care plans should give staff the information they need to look after each person. Information about people’s health needs, were also in place. The inspector and registered person discussed one persons weight records. Daily records contained relevant information. Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 Page 11 Following discussion with the registered person it was agreed that the Commissions pharmacist would visit Belvedere in order to look at the medication standard. People using the service told the inspector that they felt they were spoken to and treat with dignity and respect and gave examples of this. The inspector observed this was the case, and staff spoken to could also give examples of how they put these values into practice. Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP12, OP13, OP14 & OP15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were able to exercise choice and control in their day-to-day living. A programme of planned activities promoted their enjoyment, as well as mental and physical stimulation. Meals were varied and provided a social occasion on a daily basis. EVIDENCE: The inspector observed people exercising choice and control over day-to-day elements of their lives, for example, spending time in their room, and getting up at different times. Care staff were seen to respect these choices and opinions. The care plans seen gave a good account of personal preferences with regard to food, hobbies, personal grooming and routines. The inspector was advised that activities took place in the home such as bingo, hand care, dominoes, “memory lane” reminiscent prompts, and music. The inspector advised that when such activities took place a record should be made on people’s daily Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 Page 13 records. Members of the clergy who visited Belvedere regularly met people’s religious needs. Resident’s bedrooms were seen furnished with personal belongings. A number of visitors came to the home on the day of the inspection. The visitors’ book was being completed. One visitor told the inspector; “ I am always made welcome here, its home from home, very clean and I’m always offered a drink”. There was a record made of main meals served. The inspector advised that this should include puddings rather than the list of available options. The menu was not on display for resident’s information. Residents with special needs, for example diabetic and soft diets were catered for. The inspector enjoyed lunch with the residents on the day of the inspection and it was seen to be a social occasion. Nutritional assessments were seen on care plans case tracked. One person was observed being supported during their meal. Alternative choice was available. One person told the inspector; “ the food is great here and there’s always plenty of it”. Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP16, OP18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Policies and procedures enabled people using the service and their families to voice any concerns. Staff had not received training about protecting vulnerable people. EVIDENCE: There was a complaints policy and procedure in place, and this was on display in communal areas for users of the service and their visitors to see. There had been one complaint to the home. Visitors to Belvedere spoken to by the inspector said they were satisfied they would be listened to if they had any concerns or complaints. Staff had not undertaken Protection of Vulnerable Adults training. The inspector advised that this must be planned and implemented as soon as possible. A Protection of Vulnerable Adults policy and procedure was in place. Staff spoken to during the inspection could identify different types of abuse and knew what to do it they had any concerns. Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP19 & OP26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The layout and décor of the home provided comfortable and clean surroundings, and was warm, tidy, clean, and free from offensive odours. EVIDENCE: The inspector conducted a tour of the building visiting communal areas and bedrooms. The home was clean and homely, and had been redecorated, re furnished and re-carpeted for registration. All bedrooms were en-suite. Security cameras were operational by the front door and exterior of the building. Suitable laundry facilities, of industrial standard were in place. Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP27, OP28, OP29 & OP30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number of staff on duty reflected the needs of the residents. Recruitment and selection procedures are robust and protect residents from harm. Some training had been undertaken to ensure care staff had the skills to care for residents. EVIDENCE: The staffing rota was seen; this demonstrated that there were sufficient staff members on duty to care for the needs of people presently living at Belvedere. The inspector was advised that the registered person was continuing to recruit more staff as the number of residents increase. There were at least 3 care staff on duty from 8 am until 2pm and 2 care staff from 2pm until 9pm. At the time of the inspection one member of staff was allocated to the 3 residents who were living in the dementia unit, but were spending much of their waking day in the homes main unit. At night one wake and watch person worked exclusively with these people. In the main unit, there was 1 wake and watch and one sleep-in staff. There was a cook employed 35 hours per week. The inspector advised that the registered person must include herself included on the rota, as she was overseeing the day-to-day running of the home. The inspector also advised that the rota must be robust and accurate, for example, completed in ink, and would benefit from being made clearer, for example, senior carers, night staff and cooks identified. Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 Page 17 Three staff files were case tracked these demonstrated that staff were not always being recruited in a way that safeguarded people using the service. The inspector advised that photo’s must be on staff files, good practice would be to make a record of interview, and 2 written references must be obtained for all members of staff. Training records showed that eight care staff had obtained NVQ2, and five had also completed NVQ 3. The inspector advised that Common Induction Standards training must be in place for new care staff. The training matrix demonstrated that outstanding training included; POVA and prevention of abuse, and fire safety training. Training in progress for staff included - moving and handling, food hygiene, administration of medication, dementia and health and safety. No records of 1:1 supervisions were seen, the inspector advised that a system of providing all staff with regular supervision must be established. Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): OP31, OP33, OP35 & OP38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management and staff run the home around the needs and choices of the residents. Residents and regular visitors to the home were consulted about the day-to-day running of the home. EVIDENCE: The registered person purchased and registered Belvedere in April 2007 and works hands on at the home most days. The registered person advised the inspector that she was undertaking NVQ 4 registered managers’ award training. The inspector and registered person discussed the post of registered manager as the previous manager had retired in May 2007. The inspector advised that this situation should be formally resolved as a matter of urgency. Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 Page 19 The inspector was advised that a Quality Assurance and quality monitoring systems had not yet been implemented as the home had been open less than 6 months. A business plan had been developed for registration purposes. The inspector advised that regular house meetings are also a good way of finding out people’s views and that minutes should be recorded. The inspector was advised that the registered person was not appointee for anyone; and that all other residents’ finances were dealt with by the residents themselves, their next of kin or families. Staff had not completed fire safety training. Records regarding the prevention of fire, and routine maintenance records of the gas and electrical supplies and appliances such as the stair lift were seen and found to be in good order. Health and safety staff training was ongoing and some was outstanding, for example, 1st Aid, and fire safety training. Door wedges were in evidence on the inspector’s arrival at Belvedere. The inspector advised that these must not be used and suitable alternatives for ease of access in communal areas must be found. Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 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 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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 OP1 Regulation 5 (1) Requirement The residents guide must be in formats suitable for all potential residents, include the contact details of the Commission, not include any references to nursing, and include the terms and conditions of staying at Belvedere including the amount and method of payment of fees. Care plans should contain all relevant information so that staff know each persons needs and how to meet them. All staff must undertake protection of vulnerable adults training. All staff recruited must have all documentation as required by this legislation. Staff must complete training that will ensure they have the required skills to ensure safe working practices. Timescale for action 29/02/08 2 OP7 15 29/02/08 3 4 5 OP18 OP29 OP38 13(6) Schedule 2 13 19/12/07 19/12/07 29/02/08 Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 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 2 3 Refer to Standard OP12 OP15 Good Practice Recommendations Recreational and leisure activities should be on offer and this recorded in people’s daily records. A menu should be in place of all meals served and this information should be available to people using the service. The staff rota should clearly demonstrate who is on duty, who is in charge of each shift and include the registered person whilst she is managing the home on a day-to-day basis. Induction training and other staff training as identified in this report should be completed as soon as possible. The registered person should resolve the outstanding issue of a registered manager in post. OP27 4 5 OP30 OP31 Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Belvedere DS0000069343.V345017.R01.S.doc Version 5.2 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. 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