Inspection on 14/11/05 for Belvedere House

This inspection was carried out on 14th November 2005.

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

The inspector 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 House 31/01/08

Belvedere House 29/10/06

Belvedere House 18/05/05

Belvedere House 08/11/04

Belvedere House 07/06/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Belvedere House Belvedere House Weston Acres, Woodmansterne Lane Banstead Surrey SM7 3HA Lead Inspector Deavanand Ramdas Announced Inspection 14th November 2005 10:00 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 House DS0000033885.V255430.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Belvedere House Address Belvedere House Weston Acres, Woodmansterne Lane Banstead Surrey SM7 3HA 01737 360106 01737 353436 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) The Royal Alfred Seafarers` Society Mr Anirood Sowamber Care Home 56 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number disorder, excluding learning disability or of places dementia (2), Old age, not falling within any other category (56), Physical disability (2), Physical disability over 65 years of age (15), Sensory impairment (2), Sensory Impairment over 65 years of age (5) Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Out of the 56 (FIFTY SIX) beds registered 15 (FIFTEEEN) may be used for Physical Disabilities/Elderly (PD(E)) Out of the 56 (FIFTY SIX) beds registered 2 (two) may be used for service users under the age of 65 (SIXTY FIVE) Out of the 56 (FIFTY SIX) beds registered 3 (THREE) may be used for Respite Care Out of the 56 (FIFTY SIX) beds registered 5 (FIVE) may be used for Sensory Impairment/Elderly (SI (E)) Out of the 56 (FIFTY SIX) beds registered 12 (TWELVE) may be for Dementia Care of the elderly DE (E) 8th November 2004 Date of last inspection Brief Description of the Service: Belvedere House is a purpose built home standing in spacious, quiet and attractive grounds close to Banstead Village. The home provides accommodation for fifty-six service users who require personal and nursing care. Accommodation is provided on two floors and all bedrooms are single with en-suite facilities. The home has large lounges, spacious dining rooms, kitchens and laundry facilities. Private parking is available. In the grounds are self-contained flats that are occupied by tenants. These flats are exempt from inspection by the Commission of Social care Inspection. Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out by one inspector over a period of six hours. A partial tour of the premises took place and staffs, service users and relatives were spoken to. Documents and care records were examined. The inspector would like to thank the manager, staff, service users and relatives for their input during the supervision. Comment cards and a CSCI business card were left at the home for information. What the service does well: What has improved since the last inspection? Policies and procedures and other documents have been reviewed and updated that has resulted in staff and service users having up to date information. The statement of purpose and the complaint policy have been updated. Improvements have been made in infection control and the home have antibacterial hand wash that is widely available to staff and service users. Reporting has improved and the Commission is informed of notifiable incidents without delay in order to safeguard the welfare of service users. Care plans are regularly reviewed and updated by staff to ensure service users needs are identified and met. One relative commented ‘we are pleased with the overall level of care but occasionally a few more details about changes to medication and care would be appreciated’ Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,5&6. The arrangements for offering contracts to service users are satisfactory ensuring service users tenancy rights are protected. The arrangements for trial visits are satisfactory ensuring service users and their relatives have the opportunity to visit and ‘drive the home’. EVIDENCE: The home had an admission agreement that is offered to service users on admission. The inspector sampled agreements and noted they were signed and dated by the manager, service users or their representatives. The home had a policy on guidance for staff on trial visits and the admission of a new resident dated April 2004. The manager stated the home offered trial visit that is reflected in the admission agreements. The manager stated the home supported service users and relatives to visit and assess the suitability of the home. The manager remarked trial visits would be for a period of 2 weeks after which they would be a review. The manager stated the home did not offer intermediate care and this standard was not assessed. Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9&11 The arrangements for the storage of medications at the home must be improved to ensure service users medications are safe. The arrangements for dying and death of a service user are satisfactory however the home must offer additional training to staff to ensure they have up to date knowledge and skills to support service users. EVIDENCE: The home had a policy on administration of medications dated 2004. The home has in place arrangements for the disposal of medications and the manager stated a policy is currently being formulated. Medications were kept in a designated room and stored in a metal cupboard secured to the wall. The inspector noted the home stored some medications in a drug cupboard that was inappropriate that was discussed with the manager and action has been required in respect of this matter. The inspector sampled records and noted individual prescription sheets have a recent photograph of service users and medications administered were dated and signed by staff. The manager stated the home had controlled drugs. The inspector sampled the controlled drugs register and noted the records were up to date and accurate. One service user had been administered a controlled drug on the 14/11/05 that was recorded Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 10 and the balance of 22 tablets correct. The home had a fridge for storing medications and a record of daily temperature was kept. The inspector noted temperature readings were within normal limits. The inspector sampled training records and noted registered nurses had current registration with the nursing and midwifery council. The home had a policy on Dealing with death care practice guidelines dated April 2004. The inspector noted the admission agreement of one service user indicated his funeral arrangements. The manager stated the home had a guest room where relatives could stay to support a service user during their final hours. The manager commented the home had contact with Princess Alice Hospice who provided support to service users receiving palliative care. The inspector noted a letter written by a relative thanking staff for the way they had supported her relative who had recently died at the home. The manager stated she had had attended a training course in care of the dying and their families that is an approved training course. The manager stated not all staffs have training in dying and death. This was discussed with the manager and action has been required in respect of this matter. One staff stated more training in this area would be good. Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13&14 The arrangements for activities at the home are adequate ensuring service users social, religious and recreational interests are satisfied. The arrangements for social contact are satisfactory ensuring service users maintain links with their family and friends. The systems at the home ensure service users are supported to exercise control over their lives. EVIDENCE: The home had a policy on living, working and recreation dated April 2004. The manager stated the home employed an activities organiser who is contracted to work 25 hours a week. The home has a monthly activities schedule. The inspector sampled November 2005 and noted a wide range of activities. The inspector noted a resident outing to a remembrance service was followed by a pub lunch at a local pub that was attended by 14 residents. The activities organiser kept at attendance list that was up to date. The inspector sampled service users care plan and noted interest in personal activities and hobbies were identified. One service user commented the atmosphere is generally relaxed with plenty of internal and external activities. The manager stated the home employed local staff and the inspector noted the bar staff lived in the local village. Service users are able to see their relatives in the privacy of their bedrooms and the manager’s office. The manager stated a lay preacher visited the home weekly and did a service monthly. One Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 12 service user commented we have church service regularly. The manager commented a local company had involvement in developing the garden. The inspector noted the garden wall had been painted that was a new feature and a service user commented the garden was lovely. The manager stated service users are able to bring personal possession to the home that is kept in their bedrooms. The manager stated the two service users had their finances managed under the court of protection and relatives were involved in their care. The manager stated finance records were kept at head office and service users are able to ask for information. The home had an access to records policy dated 2004. Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17&18 The complaint process is adequate with complaints information widely available to staff, service users and relatives. The arrangements for the protection of service users are satisfactory ensuring the legal rights of service users are safeguarded. The policies and procedures and staff training at the home must be improved to ensure the welfare of service users are protected. EVIDENCE: The home had a complaints policy dated April 2004. The home had a complaints book that was sampled. The inspector noted the last complaint was made on 2/8/05 and management action had been taken. The complaint policy is displayed in the foyer for information. The home has a policy on advocacy dated 2004. The manager stated on admission service users would be asked to fill in an electoral register form. The manager commented service users used the postal voting system to vote and the home provided transport to take service users to the local polling station to vote. The home has a policy on abuse of vulnerable adults dated April 2004 that reflected whistle blowing. The inspector sampled a personnel file and noted staff had training in whistle blowing and adult protection procedures that was signed and dated 14/10/05. The home had a local authority (Surrey county council) policy on the protection of vulnerable adults that was out of date. This was discussed with the manager and action has been required in respect of this matter. The company policy on vulnerable adults must be updated to include the category of professional abuse. The manager stated not all staff had attended POVA training. This was discussed with the manager and action has been required in respect of this matter. Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 14 Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19&26 The arrangements for maintenance of the home are satisfactory ensuring service users live in a safe environment. The arrangements for hygiene at the home are adequate ensuring the home is clean and pleasant for service users. EVIDENCE: On the day of the inspection the home was clean, well ventilated and free from mal odour. The manager stated funding was agreed for the communal areas in the home to be decorated. The inspector noted the maintenance engineer was present at the home and was doing general repairs. The gardens were well maintained, private and secure with wheelchair access and the grounds were neat, tidy and attractive. One service user stated we had a fire works display in the grounds and management was there. The home had infection control measures and the inspector noted staff washed their hands regularly. Antibacterial hand wash, gloves and aprons were widely available. The home had industrial washing machines, sluices and dryers and employed a laundry assistant and cleaners to maintain the hygiene of the home. The manager stated the home had a contract with a waste disposal company to dispose of Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 16 clinical waste. One service user stated the home standard of hygiene in the home is very good. Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27&28 The arrangements for staffing at the home is satisfactory ensuring there are sufficient numbers of staff to meet the needs of service users. The arrangements for staff training are adequate ensuring staff have the knowledge and skills to meet the needs of service users. EVIDENCE: On the day of the inspection the staffing level was adequate. The inspector noted the manager was on duty, two registered nurses, nine carers, four domestics, a chef/manager, a kitchen assistant, a laundry assistant, a maintenance engineer, an activities organiser, an administrator and a porter that was reflected on the duty roster. The manager stated the home had 30 employees and commented the staffing levels were adequate but if necessary they can be increased to meet service users changing needs. The inspector noted the home monitored the hours worked by agency staff to ensure consistency of care. One relative commented the care service is excellent at all times with occasional poor service from temporary staff that are less careful. The manager stated fifteen staffs had the NVQ qualification, two are working towards the qualification and five are due to start the programme in December 2005. The manager remarked staffs are seconded to Carshalton College to do the training that is paid for by the company. The inspector sampled staff files and noted one staff had a certificate of unit credit equivalent to NVQ Level 3 in Care dated May 2005. A staff stated the company is quite good in offering training and a service user commented staffs are genuinely caring and patient with service users especially those most in need. Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 18 Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35,36&37. The arrangements for managing the home are satisfactory ensuring service users live in a home that is well run. The systems in place for quality assurance are adequate ensuring the home is run in the best interest of service users. The financial procedures at the home are adequate however a copy of the business plan must be made available at the home. The systems for managing service users’ money are adequate ensuring service users financial interests are safeguarded. The arrangements for staff supervision are unsatisfactory and improvements must be made to ensure staffs are appropriately supervised. Policies and procedures at the home are adequate ensuring service users rights and best interests are safeguarded. EVIDENCE: The home has a manager that has a professional nursing qualification and is currently doing the registered managers award. The manager has been in post Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 20 since September 2005 and has sent an application for registration to the commission. The manager stated she had a participative management style and commented communication of management decisions is very important in maintaining management stability. A reviewing officer remarked he found the home to be extremely well run and organised with the atmosphere warm friendly and vibrant. The manager stated she is satisfied with the level of supervision and support from her line manager. The home had a quality standards manual that was kept in the office for information. The home had a residents survey file that was sampled. The inspector noted a survey was done of service users, professionals and relatives in November 2004 and the results were available for information. The home also used comment cards to obtain feedback about the home from relatives, service users and other professionals. The inspector noted the home met the requirements identified in the inspection report. The manager stated funding has been agreed to decorate the communal areas in the home. The home has regular service users meetings and the minutes of meeting were sampled. The inspector noted the last meeting was held on the 27/9/05 and attended by twenty-three service users. The minutes were signed and dated by the manager. The home had a financial plan dated 2006-07 and a certificate of employers liability insurance due to expire in February 2006. The home did not have a copy of the business plan that was kept at head office. This was discussed with the manager and action has been required in respect of this matter. The home had a finance manual dated April 2005. The manager stated the home had a petty cash system and records were kept of all transactions that were sampled. The inspector noted the last entry was made on the 14/11/05. Service users monies were managed separately from the petty cash system and the manager stated the system worked well. The inspector sampled No. 3 account ledger and noted the last entry was made on the 13/11/05. The home has a safe that is kept in the office to store money and valuables and the keys are kept with the administrator and manager. The home had a policy on staff supervision dated 2004 and a list with the names of staff and their named supervisors dated 2/11/05. The manager stated all named supervisors had attended supervision and appraisal training course on the 5/10/05 and a\new format for recording supervision would be implemented. The inspector sampled supervision records and noted supervision of staff was not taking place regularly. This was discussed with the manager and action has been required in respect of this matter. The home had policies and procedures that were amended, reviewed and updated. The inspector sampled care records, and recruitment files and noted they were up to date. The manager stated sensitive records are stored in a locked cabinet in the manager’s office. Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 21 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 3 X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 2 3 X Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard NMS-OP 9 Regulation 13.2 Requirement Timescale for action 20/12/05 2 NMS-OP 30 18(1)(a) (c) 3 NMS-OP 36 18(2)(a) The registered person must ensure a drug cupboard is provided for the safe storage of medications. The registered person must 01/03/06 ensure the staffs training plan include bereavement training and training in the local authority (surrey county council) procedures for the protection of vulnerable adults for all staff working in the home. The registered person must 20/01/06 ensure that staffs have frequent and regularly supervision at least six times a year that is recorded. 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 NMS-OP Good Practice Recommendations The registered person should obtain an up to date copy of DS0000033885.V255430.R01.S.doc Version 5.0 Page 23 Belvedere House 2 3 NMS-OP NMS -OP the local authority (surrey county council) procedures on the protection of vulnerable adults. The registered person should consider updating the policy on vulnerable adults to include the category professional abuse. The registered person should consider having a copy of the business plan available at the home for inspection and a copy sent to the commission for information. Belvedere House DS0000033885.V255430.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 House DS0000033885.V255430.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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