Inspection on 06/07/05 for Belvedere

This inspection was carried out on 6th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Belvedere 18/03/09

Belvedere 14/03/07

Belvedere 05/01/05

Belvedere 04/01/05

Belvedere 26/05/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOME ADULTS 18-65 Belvedere Bridgetown Hill Totnes Devon TQ9 5BN Lead Inspector Graham Thomas Announced 6 & 7 July 2005 th th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Belvedere Address Bridgetown Hill, Totnes, Devon, TQ9 5BN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01803 867161 NONE Katherine H L Finnigan The Very Rev Archpriest Benedict Ramsden, Mr Simeon Ramsden, Mrs Lilah Ramsden Mr. Stephen Escott Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 5th January 2005 Brief Description of the Service: Belvedere is a domestic property, situated in a residential area of the South Hams town of Totnes, close to local shops and facilities. It is part of the Community of St. Anthony and St. Elias which has a number of homes in the South Hams and Plymouth areas. In this report, the organisation will be referred to as the Community. Care is provided for up to three service users (currently all male ) under the age of 65 with mental health needs. The home has three single service user bedrooms and three rooms for staff to sleep in, some of which also provide office or administrative functions, a lounge and dining room, along with service areas. There is are substantial gardens at the rear of the property. Service users have access to a well-organised outdoor activities programme as well as arts activities provided by the Community. Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the course of this inspection, the inspector spoke with all three service users, three members of staff and the Registered Manager. Three relatives’ comment cards were reviewed as well as a pre-inspection questionnaire completed by the Manager. A tour of the home was conducted and care plans and other records were examined. What the service does well: What has improved since the last inspection? What they could do better: An extra bath/shower is needed so that there are enough for service users and staff. The bathroom needs redecorating. Staff need training about particular Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 6 service users’ needs. Plans are needed to show how staff training can meet national standards. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Service users are helped to make an informed choice about living at Belvedere. EVIDENCE: At the time of inspection, there had been no recent admissions to Belvedere. Discussion with staff, and the manager confirmed recorded evidence of a thorough pre-admission assessment. This includes meeting a prospective service user in their current placement, gathering information from referring authorities and pre-admission visits to the home. Goal-focussed care plans are formulated and files contained details of the Care Programme Aprroach. Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 Service users receive the support they need to meet their needs and make their own choices. EVIDENCE: Each service user has a clear, goal-focussed plan setting out social and healthcare needs, including any specialist support required. The plans showed evidence of response to the changing needs of service users. Restrictions on freedoms and choices are detailed in the care plans and risk management plans. The risk management plans also describe procedures for responding to challenging behaviours. These were due for review at the time of inspection. The plans showed evidence of regular reviews involving service users and professionals involved in supporting them. Relatives commented favourably on the way in which the home meets individual needs and choices. Proposals for the implementation of a key working system were discussed with the Registered Manager. Service users were seen being supported and encouraged to make day-to-day decisions concerning matters such as meals and activities. Care plans and discussion with service users provided evidence of assistance with longer term Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 10 decision-making. Information routinely provided to service users includes details of advocacy services. Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 16 and 17 Service users are well-supported to make choices about their own lifestyles. EVIDENCE: The service user group at Belvedere has a diverse range of needs, each requiring a high degree of support. None is currently in open employment. However, discussion with service users, staff and the Registered Manager as well as examination of care plans ,confirmed that service users have access to a range of activities. There is a well-organised outdoor activities programme. On the day of inspection, there was a visit to an indoor rock climbing facility. One service user played scrabble with a staff member, this being one of his favourite activities. The inspector was shown a vegetable patch in the home’s garden by one service user, which he was developing with the support of staff. The same service user was also cultivating cacti in his room. Another service user spoke of trips to the swimming pool, gym and sports centre. The town centre of Totnes is close to the home and service users are supported to use the range of amenities in the town including shops, cafes and pubs. One service user attends a local church. Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 12 Service users’ contact with their families and friends is maintained by telephone calls and visits to and from the home. The Community has its own transport which is used to support visits where necessary. At the time of inspection, one service user was looking forward to a visit from his family on his birthday. Each service user’s room is lockable and a key is offered for their own use. During the inspection, staff were observed respecting service users’ privacy and dignity. Helpful and supportive interactions between staff and service users were observed. There are clear rules in the home about smoking and alcohol. Service users are routinely involved in domestic tasks. Improved recording of menus and meals taken demonstrated a wholesome and nutritious diet in which service users are able to make positive choices. Food is purchased on a shift by shift basis in consultation with service users. The Inspector joined a lunchtime meal which was taken in a congenial atmosphere. The food was attractively presented and included fresh ingredients. One service user was being encouraged and supported to eat healthily and lose weight. Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 The personal and healthcare support provided by the home meets service users individual needs. EVIDENCE: Personal supports required by service users are detailed in their individual plans. These showed the involvement of a range of services appropriate to individual need including mental health services and general medical care. Service users dress and appearance reflected their own tastes and style. One service user described the support he receives in the home as “brilliant “ and relatives also commented positively. Care plan files showed access to a variety of general and specialist healthcare services according to individual need such as chiropody, optical and mental health services. One service user was being supported to lose weight through a programme of exercise and healthy eating. Systems concerning the use of medicines in the home were inspected. A monitored dosage system is in use. Records concerning the receipt, administration and disposal of medicines were found to be in order. Some homely remedies are in use and the home has obtained an approved list. Patient information leaflets are held in the home and there is a drugs information file available for staff reference. There were no controlled drugs in use at the time of inspection. Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 14 Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The concerns of service users and relatives are listened. Service users are offered adequate protection from abuse. EVIDENCE: Belvedere has policies and procedures concerning complains. The complaints procedure is made available to service users. This includes detail of how to complain directly to the Commission. In discussion, service users felt that staff would listen to their concerns. Relatives also expressed confidence in the home’s complaints procedure. One relative was not aware of the procedure and the home is advised to ensure that all relatives have received the relevant information. A recording system is in place for all complaints. Staff receive training in protecting vulnerable adults from abuse as part of their induction. The staff training programme also includes elements to enable staff to understand and manage challenging behaviour safely. All staff are subject to CRB / POVA checks as part of the recruitment process. There are policies and procedures in place concerning abuse and whistle blowing. Confirmation has been received by the Commission that banking arrangement for service users’ money protect their interests. Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 27 and 30 Service users live in an adequately clean, comfortable and safe environment. However, there are insufficient bathing/showering facilities. EVIDENCE: Belvedere is a converted residential property situated above the South Hams town of Totnes. The home is within easy reach of local facilities, shops, public houses and leisure centre. There are good local bus and train services and the home has access to a pooled vehicle for service user transport. The premises were generally well decorated, attractive, homely and comfortable. At the time of inspection, some work had recently been conducted on the electrical wiring system in compliance with a wiring check. Some minor restorative redecoration was therefore needed. The bathroom was rather shabby and also requires some decorative attention. Service users felt that their own rooms were adequately comfortable and met their needs. A fire safety risk assessment has been conducted. Water temperature regulation has now been installed. Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 17 The home has a bathroom and separate toilet on the first-floor and a toilet on the ground floor. All are lockable. The flooring in the upstairs toilet has been replaced since the last inspection. No individual room has en-suite bathing / showering facilities. Staff live at the home for a period of several days and therefore have to use the same bathroom facilities as service users. To this end to the home should provide additional bathroom facilities as more than three people share the current facility. This is an outstanding requirement from the last inspection. The laundry area, which is outside the main building, was clean on inspection. Cleansing gel is provided in this area in lieu of hand washing facilities. Since the last inspection, training has been arranged for staff in infection control procedures. The laundry area, which is outside the main building, was clean on inspection. Cleansing gel is provided in this area in lieu of hand washing facilities. Since the last inspection, training has been arranged for staff in infection control procedures. Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Service users receive support from a staff group which has good basic training. However, training for specific needs could be improved and training to national standards is insufficient. EVIDENCE: Planning for staff training is conducted centrally within the Community. All new staff receive intensive induction training for two weeks prior to working within the Community’s homes. This is followed by a period of further foundation training which is recorded in individual files held by staff members. The induction training includes elements concerning understanding mental health needs and other topics relevant to service users’ needs. Discussion with staff and individual files also confirmed that staff have access to training in health and safety topics including, for example first aid updates. There are less than 50 of staff qualified to NVQ level 2 or above and the home is very unlikely to meet this target by the end of 2005. At the time of inspection, the Registered Manager had completed the Registered Managers Award and was in the process of completing an NVQ level 4 in care. The home accommodates service users with specific individual needs and difficulties associated with acquired brain injury and autistic spectrum disorders. The Registered Manager has extensive experience and understanding of autism. However, it is recommended that staff should receive specific training in these areas. Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 19 Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 Service users have yet to contribute fully to an improved quality assurance system. The health and safety of service users is generally well safeguarded. EVIDENCE: A new quality assurance system was being introduced at the time of inspection. This is based on the use of information gathered during Providers’ visits and other data which feeds into regular quality assurance meetings. Consultation with service users takes place during the Providers’ visits though further formalised systems are envisaged, including a service user survey. The introduction of more structured quality assurance was beginning to show results in the modification of some systems in the home. For example, menu monitoring is now more detailed. Additionally, the Registered Manager identified proposed recording systems to link daily recording more closely to specific elements of individual plans. Health and safety records showed up to date checks in respect of: Fridge and freezer temperatures; fire equipment and alarms; fire drills; gas safety; electrical wiring and personal appliances; water temperature. An Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 21 assessment for legionella remains an outstanding requirement from the last inspection. Staff are trained in health and safety subjects including food hygiene, moving and handling and first aid. Training for infection control has been arranged. Hazardous substances are securely stored and data sheets are kept in the home. Since the last inspection window restrictors have been fitted on the upper floor. Policies and procedures for safe working practices and environmental risk assessments were available for inspection. Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 2 x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 4 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Belvedere Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 23 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 27 Regulation 23 Requirement The Home must provide additional Bathroom facilities, as staff on duty are required to live in on some shifts for several days, using the same facilities as service users. (Previous timescale of 19.3.05 not met) The Registered Manager must produce a plan as to how national staff training targets in respect of NVQ training will be met and supply a copy to the Commission The home is to supply a copy of the Annual development plan for the home to the NCSC (Previous timescale of 19.4.05 not met) A legionella risk assessment must be undertaken (Previous timescale of 19.3.05 not met) Timescale for action 31 Dec 05 2. 35 18 31 Oct 05 3. 39 24 31 Oct 05 4. 42 13 31 Oct 05 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 9 Good Practice Recommendations Individual service users risk assessments should be D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 24 Belvedere 2. 3. 24 35 reviewed. The homes bathroom should be redecorated / refurbished Training should be provided for staff concerning autistic spectrum disorders and acquired brain injury Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Belvedere D54-D07 S3650 Belvedere V224096 060705 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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