Inspection on 18/05/05 for Belvedere House

This inspection was carried out on 18th May 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Belvedere House 31/01/08

Belvedere House 29/10/06

Belvedere House 14/11/05

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 Weston Acres Woodmansterne Lane Banstead, Surrey SM7 3HA Lead Inspector Mr Deavanand Ramdas Unannounced 18 May 2005 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 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 v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Belvedere House Address Weston Acres Woodmansterne Banstead Surrey SM7 3HA 01737 360106 01737 353436 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) The Royal Alfred Seafarers Society Mr Anirood Sowamber Care Home 56 Category(ies) of DE(E) - Dementia over 65 (10) registration, with number MD - Mental Dissorder (2) of places OP - Old Age (56) PD - Physical Disability (2) PD(E) - Physical Disability over 65 (15) SI - Sensory Impairment (2) SI(E) - Sensory Impairment over 65 (5) Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 2. Out of the 56(FIFTY SIX) people registered 15(FIFTEEN) may be used for physical disabilies/elderly (PD(E)). 4. Out of the 56 (FIFTY SIX) beds registered 2(TWO) may be used for service users under the age of 65(SIXTY FIVE). 5. Out of the 56(FIFTY SIX) beds registered 3(THREE) may be used for respite care. 3. Out of the 56(FIFTY SIX) beds registered 5(FIVE) may be used fir sensory impairment/elderly(SI(E)). 1. Out of the 56(FIFTY SIX) beds registered 10(TEN) may be for dementia care of the elderly DE(E). Date of last inspection 8th November 2004 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 offers care for fifty six service users who require personal and nursing care. Accommodation is provided on two floors in single rooms, all with en-suite facilities. The home has large lounges, spacious dining rooms, kitchen and laundry facilties. Parking is available in the grounds. In the grounds are self-contained flats that are occupied by tenants. These flats are exempt from inspection by the Commission for Social Care Inspection. Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by two inspectors over a period of 5 hours. A partial tour of the premises took place, staff and service users were spoken to and care records and other documents were inspected. What the service does well: What has improved since the last inspection? What they could do better: The home must have better supervision of the staff who are on duty to ensure they are doing their job properly. The home must also make regular checks to ensure the environment is kept safe for service users. Important documents like the Statement of Purpose must be readily available in the home. Care plans must be done within 48 hours of an admission and must also be reviewed monthly. The home must ensure the Commission is informed of any infectious disease in the home. Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 Page 6 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 v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 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 standard(s) 1,3,4 Service users and prospective service users were not provided with sufficient information to make an informed choice about the home. The system for the assessment of service users is good ensuring that the home is able to meet service users’ needs. EVIDENCE: At the time of the inspection the home was not able to find the Statement of Purpose. A service user’s guide was sampled and it contained a range of useful information such as a description of the services the home provided, the philosophy of care and the complaints procedure. The information was well written and clearly presented. The service user guide viewed was dated 2005. The complaints section needed to be updated. The home had a Mission Statement and a Philosophy of Care that was displayed in the main foyer for information. The inspectors looked at care plans and found they contained a comprehensive needs assessment covering areas such as, personal care, health care, behaviour, emotions, sexuality and spiritual fulfilment. There was evidence that indicated nursing care was assessed and planned by qualified nursing staff and medical care was sought as necessary. The home was found to have an Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 Page 9 Assessment of Needs Policy. One service user remarked, ‘I am quite happy and satisfied with the treatment and care I am getting’. Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 There is a care planning system in place to adequately provide staff with the information they need to satisfactorily meet service users needs. However, there is a need for care plans to be completed within 48 hours of an admission and for such plans to be regularly reviewed and updated. Personal support in the home is offered in such a way as to promote and protect service users’ privacy, dignity and independence. EVIDENCE: One of the care plans had a pre admission assessment, reason for admission to the home, dependency assessment, likes and dislikes, clinical fall risk assessments and Waterlow risk assessments. The medication risk assessment indicated the service user was capable of self-medicating and his medications were kept in a locked drawer in his bedroom. The service user was seen by a GP on the 16. 5. 05. There was evidence that the daily progress charts had been dated and signed. The inspector noted the care plan was dated 1. 3. 05 there was no evidence to indicate it had been reviewed. A new admission to the home had no pre-admission assessment and no risk assessment was in the care plan. Another care plan had a full assessment of needs, risk assessments were reviewed monthly, signed and dated. There was evidence to indicate the service users view had been taken into account when the plan was reviewed on the 15. 5. 05. Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 Page 11 During the inspection, the inspector observed staff to respect the privacy and dignity of service users. The Acting Manager was observed to knock on service users bedroom doors and sought permission before entering their bedrooms. Other staff had been observed to address service users by their preferred names. The home had a trolley phone that service users were able to use to make private telephone calls. The inspector noted the key to the medicine trolley was left unattended by a member of staff. Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 The meals in this home are generally good offering both choice and variety and catering for special dietary needs. EVIDENCE: The home had spacious dining rooms and dining tables had attractive tablecloths. Tables were appropriately laid with knife, fork, spoons, napkins and condiments. The home had a menu that offered a choice of meals. On the day of the inspection, the menu was displayed on the wall by the dining room. The lunch menu was roast pork, apple sauce, roast potatoes and a range of vegetables. Dessert was jam tart or fresh fruits. Fruit juices were provided. Meals were well presented and liquified meals were appealing. The inspector observed mealtime was unhurried and staff offered assistance to service users. One staff was observed sitting next to a service user, talking to her whilst feeding her lunch. There was positive interaction between staff and service users. One service user commented, that rice was not cooked properly and potatoes and peas were hard. Another service user remarked, meals were generally good. The inspector found evidence to indicate the food was of a good standard. The home had regular service users meetings where issues about food had been discussed. The home has a policy on menu planning and serving meals. Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 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 standard(s) EVIDENCE: These standards were not assessed. Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 Page 14 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 standard(s) 19,20,21,22,23,24,25,26 The standard of the environment is good providing service users with an attractive place to live in. EVIDENCE: The building was well maintained. It had extensive grounds that were well kept, private and easily accessible. There was a large paved patio area in the back garden. The Manager stated, The Relatives Support Group had raised money to be used to develop the gardens. The home had a good standard of décor. The foyer, dining and lounge areas were well furnished. Carpets throughout the home were clean and the home was found to be free from mal odour. The heating, lighting and ventilation were adequate. The Manager stated, air conditioning would be installed next week. Bedrooms had en-suite facilities and were found to be clean, well presented and personalised with family photographs, radio, television, ornaments, and cards. One service stated his bedroom was cleaned daily. Another remarked, her bedroom was nice and comfortable. The home had adaptations and aids fitted such as grab rails, hoists and assisted toilets and baths to help service Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 Page 15 users to maintain their independence. An aid call system was in use throughout the home. During the inspection, the cord activating the aid call in one of the bathrooms was tied to a grab rail and not easily accessible to service users. The manager was notified this would be an immediate requirement. The laundry facilities were inspected and found to be satisfactory. The home had two industrial and one domestic washing machine and two industrial dryers. The home employed two full time laundry staff. The manager stated, staff had received relevant training. There was evidence of infection control measures operating within the laundry. The inspector noted anti-bacterial hand wash was not available in the laundry nor was it widely available in the home. The manager stated, anti-bacterial hand wash was available only in two bedrooms. Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29,30 The standard of vetting and recruitment practices are good with appropriate checks being carried out in order to protect service users. The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their roles. EVIDENCE: The inspectors checked staff recruitment files that contained an application form, two written references, a job description, terms and conditions and an enhanced CRB disclosure. One staff that recently joined the company had started her induction programme. Areas completed on the induction checklist had been dated and signed. The inspectors sampled staff training records that were found to be up to date. The training records were well presented and easily understood. There were various notices in the staff room advising staff of when training would be taking place. In the office were a number of training videos to do with infection control, food hygiene, risk assessment, abuse in care homes, health and safety and moving and handling. The inspector interviewed a number of staff that stated they were clear about their job roles. Staff wore different coloured uniforms that reflected the role they had within the team. Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 38 The manager is supported well by the senior staff in providing leadership throughout the home, with all staff demonstrating an awareness of their role and responsibilities. EVIDENCE: The home had an acting manager in post. The style of management was observed to be open, transparent and supportive. Staff stated, the management is good and everything is running smoothly. The manager stated there is regular supervision and that she provided clinical supervision for registered nurses. However, she remarked she was behind with her supervision. Staff stated the home had team meetings every two months. The inspector checked the minutes that confirmed meetings were held on a regular basis and they were well attended by staff. One staff commented, the home offered good experience and you can learn a lot. Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 Page 18 During discussions staff stated they would like the management to make more information available about the Commission and the work they do and for the information to be made available in the staff room. During the inspection, it was observed bedrooms doors were wedged open using chairs and bins. When asked by the inspector about the status of MRSA, the acting manager stated, there were two cases of MRSA at the home. This had not been reported to the Commission. The acting manager was notified the fire doors being wedged open and the non-reporting of an infectious disease would form immediate requirements. Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 2 3 3 3 2 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x 3 x x x x x 2 Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 Page 20 No 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 1 Regulation 4(2) Requirement The registered person must supply a copy of the Statement of Purpose to the Commission without delay and must make a copy of it available on request for inspection by service users and any representative of a service user. The registered person must ensure that the complaints procedure is updated and reference made to NCSC is amended to CSCI. The registered person must keep the service user plan under review and ensure it is reviewed monthly. The registered person must ensure suitable arrangements to prevent infection and the spread of infections by providing an appropriate anti-bacterial agent to be used for hand washing. The registered person must give notice to the Commission without delay of the occurrence of any infectious disease including Methylin-Resistant Staphylococcus Aureus (MRSA) The registered person must make suitable arrangements for Timescale for action 01.06.05 2. 1 5(1e) 01.06.05 3. 7 15(2b) 01.06.05 4. 26 12(1a) 13(3) 01.06.05 5. 8 37(1b&e) 18.05.05 6. 9 13(2) 18.05.05 Page 21 Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 7. 38 23(4a,ci) 8. 22 12(1a&b) 9. 3 14(1a) the safe administration of medicines by ensuring the keys to the medicines cupboard and medicines trolley must be kept on the person of the designated nurse at all times and never left unattended. The registered person must make adequate arrangements for containing fires by ensuring bedroom doors are not wedged open. The registered person must make proper provision for the health and wefare of service users and must ensure the bell cord to the aid call system is always accessible to service users. The registered person must not provide accommodation to a service user unless, the needs of the service user have been assessed by a suitably qualified person. 18.05.05 18.05.05 01.06.05 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. 2. Refer to Standard OP 30 OP 30 Good Practice Recommendations That the care home obtain an up to date copy of the Care Home Regulations 2001 and Amendments. That the care home provides information to staff on the role of the Commission for Social Care Inspection. Belvedere House v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 Page 22 Commission for Social Care Inspection 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 v220542 h58_s33885_belvedere house_v220542_180505_stage42.doc Version 1.30 Page 23 - 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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