Inspection on 03/09/08 for Belvedere

This inspection was carried out on 3rd September 2008.

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

Belvedere 25/11/09

Belvedere 03/06/09

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 26/11/2008.

CARE HOMES FOR OLDER PEOPLE Belvedere Wellington Street Accrington Lancashire BB5 2NN Lead Inspector Mr Jeff Pearson Unannounced Inspection 3rd September 2008 09:30 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 Belvedere DS0000069343.V367080.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.V367080.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.V367080.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 (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 13th September 2007 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. Staff or on duty 24 hrs per day to provide for the individual needs of the residents. 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.V367080.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.V367080.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 1 star. This means people using this service experience adequate quality outcomes. An unannounced inspection, which included a visit to the service, was conducted at Belvedere on the 3rd & 4th September 2008. The visit took over 15 hours and was carried out by one inspector. A random unannounced inspection had been carried out at the home on 28/12/07. Random inspections are short, targeted inspections which may focus on specific issues that have come up or check on improvements that should have been made. This random inspection had been carried out to look at the handling of medication, the findings were that medicines record keeping at the home needed to improve to show that medicines are handled safely for the well being of the residents. A report following this inspection will be made available from the Commission, to members of the public or other enquirers on request. The people living at the home and staff were invited to complete surveys, to tell the Commission what they think about the care and service provided at Belvedere, some were received at the Commission. Before the visit, the manager 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 registered person, staff and relatives. Various documents, including policies, procedures and records were looked at. Most parts of the home were viewed. Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? To provide people with more suitable information, some improvements had been made to the homes guide. To help ensure peoples’ health and wellbeing, medicines were being more safely administered. To help inform residents of the food being provided, the day’s menu was being displayed in the dining room. Some additional activities had been introduced, for the benefit of the residents. Residents discussion meetings were being held, which gave people opportunity to be involved in day to day matters. To make sure managers and staff do the right thing to protect people living at Belvedere appropriate training had been provided. Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 8 What they could do better: The management of the home needed to be improved; to make sure the home is run in the best interest of the residents. Some recruitment practices needed improving to better protect the residents living at Belvedere. To help make sure peoples are considered properly, there should be a better way of finding out about their needs and abilities before they move into the home. The resident’s individual care plans needed to include full details of all their needs and how they are to be met, to ensure staff know exactly what to do for each person. To make sure people are properly and safely supported with their medication, some medication practices, instructions and guidelines needed some improvement. So that new staff have a clear understanding of their role, improvements were needed with their initial training. To make sure people are properly and safely supported, staffing levels should be continually reviewed and adjusted as necessary. Arrangements needed to be made to make sure the home has proper facilities and equipment to meet the residents’ needs. Improvements were needed with laundry arrangements, for the dignity and well being of the residents. Catering arrangements should continue to be reviewed and developed; to make sure healthy diets and choices are promoted. Please contact the provider for advice of actions taken in response to this Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 9 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.V367080.R01.S.doc Version 5.2 Page 10 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.V367080.R01.S.doc Version 5.2 Page 11 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): 3 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The admission process did not fully ensure peoples’ needs; abilities and preferences were known and planned for, before they moved into the home. EVIDENCE: Residents completing surveys indicated they had received enough information about the home prior to moving in. The service user guide had been reviewed and up dated since the last inspection; the guide was readily available in the homes office. A notice was displayed in the entrance hallway clearly advising people to ask for this information. The guide appeared to include appropriate information, but the information was a bit wordy and not very plainly written. It was therefore suggested the guide be reviewed with the residents, perhaps as an activity. One deputy manager said people were always advised to come and look around the home prior to making a decision about moving in. Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 12 The manager explained the assessment process, which involved her visiting people in their own environment, gathering information by speaking with the prospective resident and relevant others, also looking at various records, for example Social Services assessments. The manager said some records had been made in her notebook, with information then being relayed to the nursing and other staff at Belvedere. This meant there was no documented evidence to clearly show peoples’ needs had been fully considered and planned for before they moved into the home. It is considered good practice to have sufficient prompts and recording systems to ensure all needs, abilities and lifestyles, are fully assessed and planned for prior to a person’s admission. The manager said it was her intention to utilise the initial section of the care planning process, as a tool for carrying out pre admission needs assessments. Records showed assessments had been completed on admission; taking into consideration peoples’ individual needs abilities and wishes in matters such as, mobility, communication, personal hygiene, medication, mental condition, also specific food needs and preferences. Risk assessments had been completed on matters such as pressure areas, nutrition and moving and handling. Some consideration had also been given to social care needs and preferred routines. At the time of this inspection visit, Belvedere did not provide intermediate care. Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 13 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): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health and personal care practices and procedures were not completely effective in ensuring people’s individual needs are sensitively met. EVIDENCE: Residents spoken with were generally satisfied with care and attention they received at Belvedere; one comment made was “I am looked after very well”. Four of the residents completing surveys indicated they always get support needed, two said they usually did. Care plans were looked at as part of ‘case tracking’ The care plan in use provided scope for peoples’ individual needs to be identified on a range of relevant matters, such as nutrition, mobility and mental health. However, not Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 14 all plans were well organised to ensure important information is easily accessible, some were insufficient in detail and did not provide clear instructions for staff to follow in order to properly respond to peoples’ individual needs. For example, one person did not have a care plan for a particular medical condition, personal hygiene, or an identified emotional need. Some care plans seen were also lacking in instructions for responding to social and behavioural care needs and relationships. This meant that provision of care is largely dependant upon staff memory, with a potential for a lack of continuity and care needs not being properly met in a person centred way. Records showed that systems were in place to monitor and review care plans. Case tracking showed; specific assessments had been completed in relation to pressure areas, nutrition, manual handling and risk of falls. Although some healthcare needs were not properly included in the care plan process, records and discussion showed people were getting attention from healthcare professionals such as GPs, District Nurses and Chiropodists. All residents completing surveys indicated they always get the medical support they needed. One relative commented, “I am always kept informed about any changes” The medication trolley was being kept secure in the dining room, it was advised it would be safer and more convenient to keep the trolley in the treatment room; this matter was actioned during the inspection. Medication policies and procedures were available, there was no policy guidance on covert administration, when required or variable dose items or procedures directing staff to assess peoples ability to self administer. The manager took action to address some of these matters during the inspection visit. There were no specific records of consent in relation to administering medication, it was therefore suggested these be agreed with each resident or representative. Medicine administration records looked at were accurate, clear and up to date, a system of auditing practices had been introduced to good effect. The homes policy was not to keep ‘homely remedies’, which meant people may experience some discomfort, for example during the night. Senior care staff responsible for administering medication had received training, the nurse qualified staff were also to update their skills by receiving further training. The residents spoken with did not express any concerns about how they were treated; all those completing surveys indicated staff always listen and act upon what said, one comment was, “They always listen to me no matter what”. A relative spoken with said, “They treat my mum as every one else, as very important, with love, respect and dignity”. There were ongoing issues about people getting the wrong clothes and items going missing, it was apparent some action had been taken to improve matters, but sustained improvements were needed to promote dignity of personal possessions. Observations during the inspection showed people were being supported to maintain their appearance, privacy needs were generally being respected; staff were seen Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 15 knocking and awaiting a reply before entering bedrooms and they spoke with residents in a courteous manner. Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Belvedere had opportunities to make choices, join in activities and had lifestyles that generally matched their expectations. EVIDENCE: The residents spoken with indicated they were generally happy living at the home, two comments made were “I’m very comfortable” and “It’s perfect” Routines seemed flexible, people were being enabled to get up and go to bed when they wished, they could also spend time in their rooms “I go to my room after tea to watch TV” explained one person. Residents meetings were being held, which provided opportunity to be consulted and involved in day to day matters. Two staff were responsible for arranging activities. Residents’ surveys indicated they were “usually” happy with the activities available. A notice board indicated the days planned activities; staff said this was flexible in response to people’s preferences. A group of residents and visitor were seen playing dominoes. Staff said some kind of activity was held each afternoon, sometimes this cold be sitting chatting. A gardening project had been Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 17 introduced; some residents had been to a garden party. The importance of arranging suitable activities for people with dementia was discussed with the manager; a ‘memory lane’ pack had been obtained. As previously indicated, relationships and social care needed to be better reflected in the care planning process, to make sure all needs are effectively addressed. The AQAA (Annual Quality Assurance Assessment) showed the promotion of independence, activities, a regular newsletter and the gardening project to be matters for future development. 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, “I can visit whenever I want”. Representatives from local churches were visiting the home, some on a regular basis. The residents spoken with were happy with the food provided at Belvedere they said, “The food is quite good” and “meals are decent” This response was also reflected in surveys, one person wrote, “my choice is always respected” However, one comment was made about the lack of choice and variety, fresh vegetables and more traditional food. Frozen and some tinned vegetables were being used, however, the manager explained there had been difficulties contracting a suitable supplier, but this matter was being pursued. Some choices were routinely offered at teatime, but these were not always being reflected in records kept. Ways of promoting healthy eating and a balanced diet was discussed with the cook and manager. As a choice of meal was not always routinely offered at lunch, ways of providing regular options was discussed with the manager and cook; action was taken to provide more scope for choice during the inspection. Mealtimes were flexible, for example breakfast was served up until 11:30 am, and light meals were being made at night in response to individual requests. Hot and cold drinks were being offered throughout the day, including freshly ground coffee. Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 18 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): 16 and 18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Policies, procedures and practices provided safeguards for people using the service and supported the complaints process. EVIDENCE: Residents completing surveys and those spoken with indicated they knew how to make a complaint. One relative said, “If I had the slightest concern, I would take action” The complaints procedure was included in the contracts of residence and service user guide. The procedure, included appropriate information, but indicated that complaints were to be made in writing and was not very ‘user friendly’, it was also advised Social Services contact details be include in the procedure. The manager took action in response to this matter during the inspection. Operational policies were in place and seen, based upon responding to medium, serious concerns. Ongoing and previous complaints were discussed with the manager. Advice was offered in relation to the management of complaints, in particular, remaining impartial, devising investigation strategies and ensuring systems make proper provision for the recording of interviews, discussions and all action taken. All staff completing surveys indicated they were aware of how to respond to concerns or complaints made by residents Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 19 and others. The staff ‘reporting bad practice’ procedure included appropriate information, including contact details for Social Services and the Commission. Residents’ surveys indicated they knew who to speak to if they were not happy, one commented, “They always give me reassurance”. Since the last inspection, all staff had received POVA (protection of vulnerable adults) training and this was to continue. Safeguarding policies and procedures were available, the manager and staff spoken with expressed a good understanding of the action to be taken in relation to allegations, incidents and suspicions of abuse. However, we had not been notified of some specific matters, which had been referred to Social Services, the manager agreed to take action in response to this matter. Issues of restraint, use of bedrails and also missing persons were discussed with the manager. Although the use of bed rails were being considered individually as part of a risk assessment process, there were no specific policies and procedures in relation to these matters. It was therefore advised such guidelines be introduced as soon as possible; the manager took action in response to this matter during the course of the inspection. Recruitment practices at the home did not fully protect the residents (See Staffing) Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 20 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): 19, 21 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home offers comfortable accommodation, but lacked some facilities, equipment, and appropriate practices to 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. The communal lounges and dining area were pleasantly decorated; furnishings were of a good standard and provided comfortable surroundings for the residents. General security arrangements were reviewed and found to be satisfactory. Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 21 There were a several significant environmental matters in the home needing attention for the benefit of the residents. For example, some bedroom doors were fitted with inappropriate locks which did not always enable access in emergencies, call points had not been fixed in toilets, bathrooms and communal areas, none of the residents had been provided with lockable facilities, the flooring in one shower room needed replacing, the seat in the visitors toilet was broken. The manager took action to address most of these matters during the inspection, however, some matters remained ongoing. The home was found to be clean and mostly free from unpleasant odours, however, the Commission had received information indicating bedrooms were not always being effectively cleaned in response to peoples’ individual needs and behaviours. This matter was currently being investigated. Three residents completing surveys indicated the home was always fresh and clean, three indicated that it usually was. Suitable laundry equipment was available, some reorganisation was being carried out in the laundry room, to enable a new rotary iron to be installed; this had resulted in the hand washbasin being removed temporally. A matter in relation to hygiene and infection control was discovered during the inspection; some napkins used at mealtimes were foul smelling, which raised significant questions about the homes laundry practices, which needed immediate attention. Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 22 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): 27,28,29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing arrangements at Belvedere were not completely satisfactory in providing people with effective care and support. EVIDENCE: Residents spoken with made positive comments about the staff team, one person said they were “Very obliging” another commented, “I couldn’t say anything wrong about the staff”. A relative spoken with said, “The warmth and affection from staff is incredible, they have a genuine liking for older people” At the time of the inspection, there was no nurse qualified night staff on duty for three nights of the week, which is unacceptable. The manager had taken some action to address this matter; recruitment was ongoing and arrangements had been made for a nurse to provide a sleep-in on call service, as an interim measure. Written protocols were produced instructing night staff to be vigilant in monitoring nursing care residents and contacting the sleep-in nurse. The Commission was notified following the inspection visit, that this matter had been resolved. Comments were received implying there were insufficient staff deployed in the lounge area to provide assistance for the residents. One person wrote, “There are sometimes long delays from buzzing Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 23 and staff responding”. This matter was discussed with the manager who explained the arrangements in place to cover the home and at the time of the inspection a member of staff was seen to be based in the lounge area, however, the manager agreed to pursue this matter. There was no cook on duty at teatimes, with designated care staff having to assist with food preparation and serving. This raised questions on providing safe and effective support for the numbers and needs of the people accommodated. The manager said she would look into this matter to ensure appropriate support was provided. Improvements had been made with staff training; most of the care team had NVQ (National Vocational Qualifications) level 2 or above, others were working towards NVQ level 2 or above. Training courses in most safe working practices, such as Health and Safety, First Aid and Moving and Handling, had been completed and were going. The manager said arrangements were being made to provide dementia care training and there was an indication within the AQAA (Annual Quality Assurance Assessment) that providing training on ‘dealing with aggression’ was a plan for improvement. The recruitment records of the most recently employed staff were examined. Not all appropriate checks had been carried out for the protection of the residents. For example, one person had worked at the home for a short period without POVA (Protection Of Vulnerable Adult) clearance, statements about the applicants mental and physical health had not been obtained, details of any criminal convictions or cautions had not been requested, in respect of one applicant only verbal as apposed to written references had been obtained. The application form in use did not ensure full and satisfactory information was obtained. The manager took action to improve recruitment practices during the inspection. The staff induction programme for new employees was very brief, it did not fully demonstrate new employees had received and understood initial orientation training on matters such as fire safety, health and safety, organisation and worker role, the principles of care and needs of the residents. The cook had not received any induction training. By the 8th September 2008, the manager had forwarded a revised induction training programme to the Commission, this included further details, but was not specific in making sure effective training would be given and staff ability and awareness of their role confirmed. Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 24 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): 31,33 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management and administration practices were not completely effective in ensuring the home is run for the benefit of the people using the service. EVIDENCE: The registered person was acting as manager at the home and had attained the Registered Managers Award. She expressed a keen commitment to provide a good service and was very proactive in her response to the inspection findings. Residents, staff and relatives made positive comments about her Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 25 approach and caring nature. Some progress had been made to provide better outcomes for people living at Belvedere, for example staff training had improved. However, the inspection highlighted significant shortfalls several key areas, including staffing and care planning, which were of concern to the Commission and therefore in need of improvement. It was also of concern, that the issue of ensuring there is a registered manager at the home had not yet been resolved. The manager said satisfaction surveys had been given to residents and that residents meetings had been used to gather feedback, comments had been acted upon as appropriate. The AQAA (Annual Quality Assurance Survey) completed by the manager, did not provided sufficient detail to show how the home was performing and was not reflective of the findings of this inspection. This meant the Commission was not assured that operational systems, particularly in relation to continuous improvement, customer satisfaction and quality assurance, were being effectively managed. It was advised the results/findings of quality surveys be included as evidence within the AQAA. Ensuring enough details are noted and using the AQAA proactively, for ongoing quality assurance and developing the service was discussed with the manager. The AQAA showed several key policies and procedures had not been devised and introduced, the manager agreed to address this matter. Arrangements were in place for staff to receive training in safe working practice subjects. The homes AQAA indicated the servicing and checking of equipment and installations. Health and safety policies and procedures were available. As previously indicated in this report (See Environment) some matters in relation to health and safety and infection control were in need of attention. Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 26 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 X 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 8 9 10 11 2 X 2 X X 2 X 2 2 3 2 2 X STAFFING Standard No Score 27 2 28 4 29 1 30 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 2 Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 27 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 OP26 Regulation 13 (3) Requirement To reduce the potential risk of the spread of infection, action must be taken to ensure appropriate laundry practices are implemented. 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. (Outstanding from previous inspection of 13/09/07) Timescale for action 17/10/08 2. OP29 19 (1) Schedule 2 17/10/08 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. All care plans are to be in sufficient detail to provide clear DS0000069343.V367080.R01.S.doc Version 5.2 Page 28 2. Belvedere OP7 3. OP9 4. OP9 5. OP12 6. 7. 8. 9. 10. OP15 OP19 OP27 OP30 OP31 guidance to staff, of the actions to be taken, to meet the residents’ personal, health, behavioural and social care needs. To promote safe practice for the wellbeing of the residents, medication policies and procedures should be updated in line with current good practice. And should include covert administration and when required or variable dose items. Consideration should also be given to the availability of ‘homely remedies’ in accordance with current good practice guidance. To show proper consideration has been given to promoting independence, each person’s ability/inability to manage their own medication should be considered as part of a risk assessment process. This then being reflected in the homes medication policies. 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. Catering arrangements should continue to reviewed and developed, to ensure an effective response to group and individual preferences, healthy eating and independence. For the wellbeing and safety of the residents, action should be taken to ensure the home provides suitable equipment and appropriate facilities. To ensure people are effectively and safely supported, staffing levels should be continually reviewed and adjusted accordingly. To ensure all new staff effectively trained; the induction programme needs to be further developed in line with current good practice. 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. Belvedere DS0000069343.V367080.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo, Liverpool L22 OLG 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.V367080.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!