Inspection on 03/06/09 for Belvedere

This inspection was carried out on 3rd June 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC 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 03/09/08

Belvedere 13/09/07

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 12/10/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Belvedere Wellington Street Accrington Lancashire BB5 2NN Lead Inspector Mr Jeff Pearson Key Unannounced Inspection 3rd June 2009 09:30 DS0000069343.V375790.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Belvedere DS0000069343.V375790.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 (38), Old age, not falling within any registration, with number other category (38) of places Belvedere DS0000069343.V375790.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 with nursing - Code N 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 Dementia - Code DE The maximum number of service users who can be accommodated is: 38 Date of last inspection 3rd September 2008 Brief Description of the Service: Belvedere is registered to provide accommodation, nursing and personal care for up to 38 older people. A maximum of 11 of the 38 people may also have dementia. The home is situated close to Accrington town centre and all amenities and transport links are nearby. Belvedere is a purpose built home for older people. There is a small car park to the front of the home and enclosed private garden to the rear. The home offers 38 single bedrooms, all of which have en-suite toilets. Accommodation is provided over three floors, a passenger lift is available. On the ground floor there is a large lounge, smaller lounge and a dining room. There are further lounges and a dining room on other floors. There are accessible toilets and bathing facilities. The home had available a Statement of Purpose and Service User Guide providing information about the support, care and services available. Previous inspection reports were available on request, from the homes office. This information should help people make an informed choice about moving into Belvedere. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 5 At the time of the inspection visit the range of fees was between £366.00 and £545.00 per week. Hairdressing, newspapers and private chiropody were not included in the fees. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means people using this service experience poor quality outcomes. A key unannounced inspection, which included a visit to the service, was conducted at Belvedere on the 3rd June 2009. The visit took over 9 hours and was carried out by three inspectors, one being a specialist pharmacist inspector focusing on medication management practices. The people living at the home and their relatives were invited to complete surveys, to tell the Commission what they think about the care service provided at Belvedere. Some were received at the Commission and some results have been included within this report. Before the site visit, the owner was required to complete and returned to the Commission an Annual Quality Assurance Assessment (AQAA). This was to enable the service to show how they were performing and provided details about arrangements, practices and procedures at the home. The files/records of three people were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of people living in the own home. We spoke with people living at the home; the deputy manager, owner, staff and visitors. Various documents, including policies, procedures and records were looked at. Most parts of the home were viewed. We did not receive any completed surveys from staff. What the service does well: We received the following positive comments from people living at Belvedere and there relatives - “Its fine we have got used to it” -“No problems” - “I like the people here” - “Staff are good morale boosters” - “They are very caring people, nothing is too much trouble for them”- “Staff appear motivated , concerned and caring, always ready to listen and act if necessary” A report about the care given to each person using the service was written during each shift. This ensured that all staff had some up to date information about the condition of each person to ensure continuity of their care. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 7 Visiting arrangements were good; relatives were being made welcome at the home. One relative said, “We can call in anytime” The home was pleasantly decorated for the comfort of the residents; the lounges had good quality furnishings. The home offers 38 single bedrooms, all of which have en-suite toilets. Residents discussion meetings were being held, which gave people some opportunity to be involved in day to day matters. What has improved since the last inspection? What they could do better: The inspection visit showed the management of the home needed much improvement; to make sure the home is run in the best interest of the residents. To help make sure people are considered properly, there should be a better way of finding out about their needs and abilities before they move into the home and sharing the information with staff. The resident’s individual care plans still needed to include full details of all their needs and how they are to be met, they should always be available and up to date, to ensure staff know exactly what to do for each person. To make sure that people receive the healthcare they need, the district nurse must be contacted when a person using the service requires treatment from them. To make sure people are properly and safely supported with their medication, medication practices, instructions, records and storage needed a number of improvements. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 8 Catering arrangements need to be improved; to make sure healthy diets and choices are promoted. Better arrangements were needed to ensure individual social care needs are responded to, for peoples well being and stimulation. To make sure people are properly and safely supported, staffing levels should ensure there are at all times sufficient numbers of suitably trained and competent staff. To make sure peoples healthcare needs are not neglected, a suitably trained nurse must be on duty at all times to respond to the needs of people in receipt of nursing care. Better arrangements needed to be made to make sure the home is kept clean, for the comfort and well being of the residents. To promote the well being and safety of people using the service, visitors and staff, improvements were needed to identify and reduce potential risks and hazards in the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 9 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.V375790.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The admission process did not ensure peoples’ needs; abilities and preferences were known and planned for, before they moved into the home. EVIDENCE: We made recommendations within our last inspection report about improving the way needs and abilities are assessed and recorded. The AQAA (Annual Quality Assurance Assessment) showed improvements had been made in obtaining more information about prospective residents, however, we found there had been limited improvement with assessment practices since the last inspection. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 11 A pre – admission assessment policy was seen, which outlined the action to be taken to gather information about prospective residents. This included visiting the person and making some notes about their needs, likes and dislikes. We found that peoples’ needs were being considered with records kept, before they moved into the home. However, the records of assessments seen were very brief and lacking in sufficient detail, to provide meaningful information about peoples’ individual needs, abilities and preferences and how they were to be met. For example, one assessment stated “mobility is quite low”, another in respect of memory retention only stated, “has problems”. The assessments seen did not include details about peoples’ spiritual and social needs, or relationships. This lack of information meant it was not clear, that individual needs had been carefully considered and planned for and staff may not understand the particular needs of the person. We spoke with two people who indicated they did not have much choice about moving into the home and that it was not where they wanted to be. One person felt their needs were not being properly met at the home. At the time of this inspection visit, Belvedere did not provide intermediate care. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Health and personal care practices and procedures were not effective in ensuring people’s individual needs are appropriately and safely met. EVIDENCE: This inspection visit raised concerns that people’s healthcare needs may have been neglected and not effectively provided for by a lack of nursing care provision. (See Staffing and Management and Administration) Most residents spoken with were satisfied with care and attention they received at Belvedere, one said “It’s alright I have got used to it”. Three completing surveys indicated they always received the care and support they needed, two said they usually did, one said they sometimes did. Four relatives Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 13 indicated they felt peoples’ needs were usually met and four that they were always met. We made recommendations within our last inspection report, about making sure all care plans have enough detail and clear instructions for staff, on meeting the residents’ personal, health, behavioural and social care needs. The AQAA (Annual Quality Assurance Assessment) stated, “We have an extensive Care Plan, which meets every potential area of a resident’s needs…” However, we looked at the care plans of three people who use the service. These plans did not accurately identify the health and social care needs of each person or give clear directions for staff to follow to ensure their individual needs were met in the way they preferred. One person was identified as having challenging behaviour but a care plan explaining what might trigger such behaviour or what staff should do prevent and deal with this problem was not in place. The care plan for another person stated that catheter care should be given daily without any information about what this entailed. It was clear from these records that the catheter had been in place for some time. However, there was no evidence to suggest that the district nurse had been contacted and made aware of this issue. We asked the staff on duty and they were unclear about whose responsibility it was to contact the district nurse. Failure to contact the district nurse about essential care for a person using the service could seriously affect their health and well being. The daily report for one person stated that assistance had been given with exercises. However, there was no information in the care plan about these exercises or how often these should be done. During a discussion with this person after lunch we were told that the physiotherapist had said help with standing up should be given every two hours. This person said, “The staff help when they have time but they don’t have time and I haven’t stood up at all today.” Not having clear written instructions for staff to follow about exercises and not providing the assistance necessary could seriously affect the health and well being of a person using the service. Appropriate risk assessments including ones for falls, nutrition and the development of pressure sores were in place. However, there was very little guidance for staff to follow about how these risks were to be managed. We looked at the wound care records for one person. There were records of dressing changes and some information about the condition of the wounds. There was also a record of a recent visit from the specialist tissue viability nurse who had advised the nursing staff on the correct treatment of the wounds. However, a detailed care plan for each wound giving precise instructions about the treatment and the dressings to be used was not in place. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 14 We looked at the care records of two people admitted recently for respite care. Although an assessment of their needs and risk assessments had been completed care plans to address these needs were not available. Moreover, both of these people were assessed as being at risk of developing pressure sores. Following the inspection visit, the home owner contacted us to advise that care plans had been completed the night before we visited; which meant they had been at the home for two weeks without care plans. Having detailed care plans in place with clear directions to follow ensures staff know exactly what they need to do in order to meet the individual needs people using the service. A report about the care given to each person using the service was written during each shift. This ensured that all staff had some up to date information about the condition of each person to ensure continuity of their care. Care plans were reviewed monthly but in some instances only the month in which the review had taken place was recorded instead of the actual date. However, care plans were not always updated when the needs of the person changed for example following a visit from the doctor; this meant they were not being used as a working document to provide accurate up to date instructions. The AQAA (Annual Quality Assurance Assessment) stated, “Our administration of medication is of good standard”, however, as part of the inspection a pharmacist inspector looked at how medicines were being handled. We found medicines stock and records to be well organised but our checks of the records and current stock showed that some medicines were not being given to people correctly. We found some examples of stocks not ‘adding up’ which meant that some medicines had been missed even though the records were signed as given. It was of concern that in one case we were told the records did not ‘add up’ because staff had found more tablets in the person’s pocket and given those instead of those still in the packet. This increases the risk of mistakes and consideration was not given to why the tablets had not been taken. We also saw that one person had been given a dose of ‘two’ strong painkillers on four occasions rather than the ‘one’ that was prescribed. Similarly, we found a bottle of eye drops prescribed for another person still sealed up. Staff said the person refused to have them, but there was no evidence this had been discussed with the resident nor that GP advice had been sought. It was of concern that there was not always clear written guidance about the use of medicines prescribed ‘when required’ or about the use of prescribed external preparations (creams). This can lead to confusion for example, a record of a doctor’s visit for one person said they had been prescribed a cream for their ‘upper arm’ but when asked staff thought it was for their legs. Similarly, staff were unsure whether someone was having a supplement drink shown as ‘GP to review’ on a list of medicines sent following a recent stay in hospital. It is important to ensure medicines are given as prescribed to protect people’s health and well-being. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 15 One record showed that tablets had been ‘spoilt’, staff explained that one tablet had been put into a drink and second into ice-cream but had not been taken. Staff said they sometimes needed to put tablets in a drink or food for a second person. It was of concern that checks had not been made to ensure the medicines could be safely administered in food or drink. Additionally, advice needs to be sought from the prescriber to ensure decisions are properly made in the persons best interests, if medicines are being mixed with food so that the person doesn’t know they’re taking them We looked at the administration of medication and found that care staff frequently administer medicines to people receiving nursing care. Carers administering medication had completed certificated medicines training but there was no record to show that this task had been delegated by the nursein-charge. This is important as the registered nurse is accountable to ensure that the carers are competent to carry out this task. We saw a lack of flexibility in the times that medicines are administered, with medicines normally only being administered between 8 o’ clock in the morning and 9 o’ clock at night. This increases the risk that where doses of the same medicine are repeated throughout the day they will be given too closely together, or that doses will be missed. We looked at the arrangements in place for supporting the safe self-administration of medication and were concerned to find no reference to self-administration within one person’s care plan. And, written risk assessments were not completed. It is important that safe selfadministration is assessed and kept under review so that any problems can be identified and managed, to help keep people safe. Similarly, Staff explained that one person had recently been on holiday away from the home. They had spoken to carers who would administer medicines during the holiday but details of the arrangements made were not recorded and records of any medicines leaving the home were not made. It is important that when holidays are planned, all options are considered (risk assessed) to ensure medicines are supplied in the best and safest way for each visit. We looked at medicines storage and found that the home had failed to correctly store controlled drugs in a proper (legal) controlled drugs cupboard. This was identified and required in December 2007 but has not been addressed. Additionally, to support the safe handling of Controlled Drugs, entries need to be made and witnessed in a Controlled Drugs register each time a Controlled Drug is administered, but this had not happened the last time a Controlled Drug was administered. It is important that Controlled Drugs are safely locked away and that all handling is witnessed to reduce the risk of mishandling or miss-use. We looked at the arrangements for the safe disposal of unwanted medicines. Staff explained hat some medicines were returned to the pharmacy. This needs to be addressed because by law all unwanted medicines from a nursing home need to be sent for safe disposal with an authorized waste contractor. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 16 Thorough recorded in-house audits (checks) were not made. This is recommended to help ensure medicines are well-managed and that should any shortfalls arise they will be promptly addressed. The residents spoken with did not express any concerns about how they were treated. The home had signed up to a “Dignity in Care” campaign, with some staff attending seminars and sharing information with the staff team. Observations of care practices during the inspection showed peoples’ privacy needs were being respected. People were being supported to maintain their appearance and personal care was carried out in the privacy of the person’s own room, or the bathroom. Members of staff were observed attending to people in a polite and friendly manner. Comments made about staff were, “The staff are wonderful”, “Staff are usually fine” and “They are alright”. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Arrangements for social and recreational interests were not always effective in responded to people’s individual needs, preferred lifestyles and choices. EVIDENCE: Most residents spoken with indicated they were generally happy living at the home, a chart was displayed of the weekly activities on offer, including - art, skittles, quiz, memories, bingo and DVDs. One person sad they had enjoyed the recent barbeque. We made recommendations within our last inspection report, on promoting interesting and stimulating lifestyles for the residents, by arranging and offering suitable activities, with particular consideration being given to the needs of people with dementia. The AQAA (Annual Quality Assurance Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 18 Assessment) indicated people were now being taken out more often and activities had been increased and the gardening project developed. However, none of the residents completing surveys said suitable activities were always arranged at the home, three indicated they sometimes were, four said usually. People spoken with said, “There is nothing for me going on here” and “We don’t have activities every day, but some people don’t want to do anything”. Staff spoken with said they generally had time for activities, but one person wrote, “I as a resident would like staff if at all possible to have more time to talk”. We did not find any evidence to indicate any progress had been made in providing more suitable activities for the well being of people with dementia. As previously indicated, relationships and social care still needed to be better reflected in the care planning process, one plan stated, “ensure daily activities”, this was not specific enough to make sure individual needs and wishes are effectively responded to in a person centred way. The homes’ visiting arrangements were included in the homes’ guide; the residents spoken mentioned the contact they were having with families and friends. Visitors spoken with indicated they were always made welcome at the home one said, “We can call in anytime, if we have any questions they always sort us out”. Following the inspection visit, we again looked at the information in the AQAA and noted that on occasion, residents had been given cards signed by staff, on behalf of their family members. It was not clear that the relatives had been in agreement with this which would be the appropriate action to take. Routines in the home seemed flexible, people spoken with said they could get up and go to bed whenever they wished. However, it was apparent from observation and discussion, people needing support with mobility and personal care, may be helped at times influenced by staff availability. For example, we spoke with one person who said they would rather get up between 8:30 and 9:00 am, but they were not assisted and brought into the dining room for breakfast until 11:30, lunch would then be offered at 12:30. Also, hot drinks were not being provided in the lounge, as this was considered to be too much of a risk for some people, as there were not enough staff to fully support those residents deemed to be at risk, therefore hot drinks were only served in the dining room which limited choice. (See staffing) Within our last inspection report we recommended the catering arrangements should continue to reviewed and developed, to ensure an effective response to group and individual preferences, healthy eating and independence. The AQAA did not show the catering arrangements had been reviewed or improved in the last 12 months. The AQAA did state that meals are home made, however, we found some frozen pies and burgers were being served and no progress had been made in obtaining more fresh vegetables which had been the owners intention. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 19 There was a mixed response from the residents spoken with about the meals provided at Belvedere, they said - “The food is good”- “It’s alright”- “We get too many sausages”. Three people indicated in surveys that they usually liked the meals provided, one said they sometimes did, three said that they always did. One relative comment was; the home should provide “more choice at meal times”. Two choices were routinely being offered at teatime, but a set meal was still provided at lunchtime. We were told by the cook, they were having a ‘fry up for lunch’ and that tea hadn’t been decided, but they would dig something out. Records showed, there had been some repetition, for example, sausage had been served for lunch on Monday and was again being served on Wednesday. The home had a flexible approach to menu planning, “We make it up as we go every day”, explained the cook, which meant limited scope for forward planning and preparation. Peoples’ food likes and dislikes were known with records kept of likes dislikes and preferences. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People in receipt of nursing care may have had their health care needs neglected, due to a lack of suitably qualified medical staff. EVIDENCE: Four residents completing surveys indicated they knew how go about making a complaint, three said they did not. Two relatives indicated in surveys they were aware of the homes complaints procedures with four stating they were not aware. Some residents spoken with expressed an awareness of how to raise concerns; one person commented that they would tell the owner who “would sort things out” There was a complaints procedure on display in the home in the form of a ‘flow chart’, this was more of an organisational procedure for managers and staff to follow, it was not written in a user friendly language and did not explain how people should to go about making a complaint and did not include the contact details of other agencies, such as Social Services or the Commission. The homes guide did however include a satisfactory complaints procedure; it was Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 21 therefore advised a copy of this version be displayed for residents, relatives and visitors. Records and discussion showed arrangements had been made for staff to received Protection Of Vulnerable adults training, staff spoken with expressed an awareness of the action to be taken in relation to allegations and incidents of abuse. As mentioned previously in this report, we found one plan looked at did not include instructions for staff for effectively managing challenging behaviour, which may put other people at risk from abuse, one person spoken with expressed some concerns about the behaviour of another resident. During the course of the inspection, we were made aware of management practices which gave us cause for concern, in that, we considered some people may have had health care needs neglected due to the absence of suitably trained and qualified staff (see staffing). It was therefore necessary for us to make a safeguarding alert to Social Services. At the time of writing this report this matter was still being pursued. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Belvedere offers some comfortable accommodation, but some facilities and furnishings did not promote the well being and safety of the residents. EVIDENCE: The residents spoken with were satisfied with the accommodation provided at Belvedere, some had personalised their bedrooms with their own belongings, which helped create a sense of home and ownership. One comment made was I find the home comfortable to live in”. The communal lounges were pleasantly decorated; furnishings were of a good standard and provided comfortable surroundings for the residents. Since the last inspection visit some Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 23 improvements had been made, for example, the floor covering in the walk in shower had been replaced and each resident had been provided with lockable facilities in their bedrooms. We made recommendations within our last inspection report that, for the wellbeing and safety of the residents, action should be taken to ensure the home provides suitable equipment and appropriate facilities. However, we again found there were several significant environmental matters in the home needing attention, for the benefit and well being of the residents. We had been informed that a resident had previously climbed out of the window in the small lounge, we found the restrictor not in use and the window opened fully. The seat part of some room dining chairs were loose and unstable, one resident pointed out that one chair we sat on was falling apart, the rungs coming out of the sockets, we therefore asked for this chair to be removed from the dining room as it was considered to be very unsafe and a risk to residents. One bed was seen to be fitted with a bedrail, this was broken, the deputy manager said this equipment was not being used. We found the garden type benches in the entrance hallway to be very unstable, presenting as a risk to residents. We found one toilet seat loose and hanging off the toilet, presenting as unsafe and a potential risk to residents using this facility. The first floor shower room, was untidy and dusty, there was a commode lid on the floor in the shower area, a razor on the shelf, bathing and cleaning products were accessible, which were considered were potentially hazardous to the residents, the door was not fitted with a suitable lock. We found two en-suite toilets were fitted with inappropriate locks which would not enable easy accesses to be gained in an emergency situation. We found one bathroom contained a ladder leading up to an open trap door in the ceiling into the illuminated loft space. On the wall behind the toilet in this bathroom was an unlocked door, this was large enough to climb through and was an air vent shaft leading down to laundry below. This bathroom was fitted with the type of lock which would not enable easy access in an emergency situation; we therefore considered this bathroom was poetically hazardous to the residents. The light fittings on one corridor ceiling were low enough to touch some peoples’ heads, which considered could be hazardous. We found the passenger lift was not very functional, for example, we were told people cant call lift when on top floor and one resident had got stuck causing them to ring for help on a mobile phone. We noted there was a significant jolt when the lift arrived on the ground floor, which may be destabilizing and disturbing for some people. We found that parts of the home were not clean, for example, ledges along the corridors were thick with dust, the carpets on the stairwells were dirty and covered in bits of paper and fluff, there were a lot of finger marks on the glass panels on doors, indicating they had not been cleaned for some time. There were crushed nuts all over the floor outside the shower room. We noted that Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 24 several dead house plants had been left in the kitchen which raised questions about food hygiene practices. There were no designated cleaning staff at the home with carers being responsible for providing this service as part of their daily duties. We made a requirement within our last inspection report about reducing the potential risk of infection; that action must be taken to ensure appropriate laundry practices are implemented. We found a new wash basin had recently been fitted in the laundry, there was a new cleaning product dispenser unit, but, this was not in use. Industrial type washers and dryers were available, bags had been provided for any soiled linen. There were some instructions on dealing with the laundry and records of staff meetings showed appropriate laundry practices had been discussed. However, there was no liquid hand soap or paper towels available which meant staff could not appropriately wash and dry their hands after dealing with the laundry, the deputy manager agreed to ensure such equipment was available. The deputy manager was not aware of the whereabouts of the homes infection control polices. We found unused laundry equipment including a rotary iron and old washing machine stored on the corridor. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 25 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 28 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing arrangements at Belvedere were not satisfactory in providing people with effective care and support. EVIDENCE: We received the following positive comments about the staff team from residents and relatives -“The staff are good and helpful” - “The staff are good morale boosters” - “Nothing is too much trouble for them” - “The staff appear motivated concerned and caring, always ready to listen and act if necessary” Our previous inspection visit raised significant concerns about the lack of sufficient nursing staff provision at the home, we received written assurances from the home owner; indicating that this matter had been resolved and would not reoccur. During this inspection visit, the owner told us that the home was “one hundred percent covered by nurses day and night”. We were then informed of an occasion where there had been no Nurse on duty in the home from approximately 12 Noon to 10pm at night. We were advised this situation Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 26 had occurred due to the fact that the Nurse on duty at the time was not fit to continue working and was sent home. This situation meant that for a number of persons living at Belvedere who require nursing care, there was no Nurse available in the home to direct, deliver and supervise their care. It was also apparent though the course of the inspection visit that the one nurse on duty at the home was unwell, was incapable of being involved in any care delivery and would not have been able to assist residents or staff in an emergency situation. Records showed that on some occasions Nurses were working excessive hours and due to this situation had been ‘sleeping in’ at the home rather than being on wakeful duty. The staffing situation relating to the Nursing staff was completely unacceptable. The expectation is that if there are any people at the home who require nursing care a Nurse will be on duty at all times, including having a nurse on ‘wakeful watch’ during the night time hours. During our previous inspection we had some concerns about staffing levels, we therefore recommended, that to ensure people are effectively and safely supported, staffing levels should be continually reviewed and adjusted accordingly. We found that there were insufficient staff; to provide effective care and support for the numbers needs and choices of the people living at Belvedere, this being highlighted in the previous outcome areas within this report. Four residents completing surveys indicated there were usually enough staff on duty, – in response to what the home could do better one person wrote, “Have more staff than what they do now”. At the time of the inspection there were 21 people living in the home, 12 had dementia and 4 had nursing care needs. Records and discussion showed staff training and development was on going, twelve carers had attained NVQ (National Vocational Qualifications) level 2, three had NVQ level 3. However, a lack of Nurse qualified staff in the home as previously mentioned, meant people using the service could not be confident there needs would be met by suitably trained and competent staff. We were advised during the inspection visit, that no new staff had been recruited since the last inspection; therefore we did not evaluate the homes recruitment practices or the initial staff induction training programme. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 27 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,37 and 38 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management and administration practices were not effective in ensuring the home is run for the benefit of the people using the service. EVIDENCE: During our previous inspection we had concerns about the management practices at the home; we therefore recommended that management arrangements be given attention, to ensure Belvedere is effectively run for the benefit of people using the service. We advised that the outstanding issue in Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 28 relation to a lack of registered manager needed to be resolved as soon as possible. We were concerned, that despite receiving written assurances from the home owner following the last inspection, along with some information provided within the AQAA (Annual Quality Assurance Survey) this inspection showed very limited improvement at the home and we found significant shortfalls in several key areas. Including, staffing, health and personal care and the environment, these matters were being ineffectively managed resulting in poor outcomes for people using the service; there was still no registered manager at the home. Within our previous inspection report we offered advice on effectively using the AQAA for the benefit of the residents, however, we found the AQAA provided some inaccurate information and did not identify many of the shortfalls we found at the home, nor were there any significant plans for making improvements. We were therefore unable to rely upon the content of this document as a credible source of evaluation and development planning at the home. Satisfaction surveys had been given to residents and relatives, comments had been acted upon as appropriate, the owner said the results had been discussed with staff and were to be collated. Advice was again offered on quality assurance processes and appropriate use of the AQAA. Also within our previous inspection report, we offered advice in devising several key policies and procedures to underpin the homes practice and provide instructions and guidance for the staff team, the owner had agreed to address this matter, however, we found the following policies and procedures were not available, contact with families and friends, first aid and accidents, nutritional screening, clinical procedures, quality assurance and staff code of conduct. We found several matters which had potential to be a risk to health and well being of the residents (as previously highlighted within this report). We also noted a number of residents using wheelchairs without foot rests being in place or properly used. However, the home owner showed a of lack appreciation of the risks involved and a limited sense of urgency to take action to resolve matters, in particular in relation to nursing staff provision. Some of our findings were also disputed, by the home owner, for example, we saw the treatment room door was left open, with unsafe equipment being accessible to the residents, however, we were told adamantly this door was always kept locked at all times . Following the inspection, the Commission received application to de register the nursing care status at the home. During the inspection we were informed that the Belvedere Nursing Home was “running at a loss” and that the owners other businesses were propping up the Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 29 home. The Commission had therefore concerns regarding the continued viability of Belvedere Nursing Home operated by Unlimitedcare Limited and requested further information and assurances in respect of this matter. Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 30 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 17 18 2 X X X X X X 2 STAFFING Standard No Score 27 1 28 1 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 2 X X 1 1 2 X 1 Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? Not able to assess previous requirement. 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 OP7 Regulation 15 Requirement Timescale for action 31/07/09 2 OP8 12(1) 3 OP9 13(2) A care plan must be in place for each person using the service. All care plans must accurately identify and address the health and social care needs of each person using the service. When the care needs of a person changes their care plan must be updated. This will ensure that nurses and care workers will know what they need to do in order to fully meet the needs of each person using the service. Action must be taken to ensure 17/07/09 the district nurse is contacted when a person using the service requires treatment from them. This will ensure that people receive the healthcare they need. Where people self-administer 17/07/09 medication written risk assessments must be completed and kept under review to help ensure people always receive any help they may need to administer their medicines safely. DS0000069343.V375790.R01.S.doc Version 5.2 Belvedere Page 32 4 OP9 13(2) 5 OP9 13 6 OP26 23 (d) 7 OP27 18 (1) (a) (3) 8 OP38 13 (4) A controlled drugs cupboard must be used to provide the right level of security for this class of medicines. Handling must be recorded and witnessed in a controlled drugs register. Effective arrangements must be put in place to ensure that all medication is safely administered to service users in accordance with the prescribers directions. This is to help protect service users’ safety and wellbeing. Effective arrangements must be put in place to ensure that the home is kept reasonably clean. This will provide residents with a pleasant and hygienic environment. Effective arrangements must be made to ensure there are at all times sufficient numbers of suitably trained and competent staff. Where nursing care is provided, this must include a suitably qualified registered nurse. This will ensure people receive effective and safe support. Effective arrangements must be made to identify and reduce potential risks and hazards in the home. This will promote the well being and safety of people using the service. 03/09/09 17/07/09 31/07/09 31/07/09 17/07/09 Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 33 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 OP3 Good Practice Recommendations A way of effectively assessing and recording needs and abilities should be devised and introduced, to ensure all needs are properly identified and planned for before people move into the home. When a care plan is reviewed the exact date and not just the month should be recorded, this will ensure a more effective monitoring process. To promote interesting and stimulating lifestyles for the residents, the home should continue to arrange and offer suitable activities, with particular consideration being given to the needs of people with dementia. To promote person centred care, care plans need to take proper consideration of peoples’ capacity, choices and preferences. Catering arrangements should continue to reviewed and developed, to ensure an effective response to group and individual preferences, healthy eating and independence. Choices should be routinely offered at lunch time. To ensure people are effectively and safely supported, staffing levels should be continually reviewed and adjusted accordingly. To protect people using the service, recruitment procedures and practices must always ensure all required checks are carried out prior to staff commencing work in the home. To ensure all new staff effectively trained; the induction programme needs to be further developed in line with current good practice. (Scils for care - www.scils.co.uk ) Management arrangements need attention, to ensure Belvedere is effectively run for the benefit of people using the service. The outstanding issue in relation to a lack of registered manager needs to be resolved as soon as possible. 2 3 OP7 OP12 4 5 OP14 OP15 6 7 OP27 OP29 8 9 OP30 OP31 Belvedere DS0000069343.V375790.R01.S.doc Version 5.2 Page 34 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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