Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 12/04/05 for Belvedere Lodge

Also see our care home review for Belvedere Lodge for more information

This inspection was carried out on 12th April 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home cares for persons with a Dementia who may display complex and at times repetitive behaviours. The organisation has worked proactively to provide the staff team with training and skills to deliver sensitive, appropriate care. After seeking professional advice, changes to the environment have been implemented to minimise confusion for the residents. This is good practice. The residents spoken with were happy with the care provided, and felt able to talk to the staff and manager. The visitors present during the inspection conveyed that they were happy with communication from the home in relation to the day-to-day care of their relative or friends. No restrictions were placed on visitors, unless agreed specifically in the care plan. Comprehensive care plans with advice and guidance from relevant professionals ensure care provision is delivered to a high standard.

What has improved since the last inspection?

The health care records included in the care file were detailed and recorded any health related interventions. This was a requirement from the previous inspection and implementation has improved the service provision. Communication links with a district nurse service has improved and the manager has prompted a meeting to discuss any areas of concern. This is consistent with good practice. A communication book used by visiting health professionals has been discontinued as the information recorded was inappropriate. The health care record, and district nurse observations, ensures information necessary to provide appropriate support to residents with health problems is communicated to the staff team.

What the care home could do better:

Through discussion with the management team, and a review of care file information, it was evident that appropriate care was provided. Risks are identified and strategies are put in place to minimise risks, however in some cases the risks identified and actions taken were not recorded in the appropriate place. Reviews of care plans did not reflect changes identified, and some records failed to indicate the high level of sensitive individual care being provided. There is a high incidence of incontinence in the home, and the management team have taken action to minimise the presence of odours. Many of the rooms have vinyl flooring fitted to ensure the utmost cleanliness, and contract cleaners regularly attend to deep clean the carpets. However one room did have a significant odour on the day of inspection and this needs immediate attention. The installation of a handrail at the edge of the patio would minimise any risk to the service users. The gated access to the kitchen should be closed at all times.

CARE HOMES FOR OLDER PEOPLE Belvedere Lodge 1 Belvedere Road Westbury Park Bristol BS6 7JG Lead Inspector Helen Taylor Unannounced 12 April 2005 9:30 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 Lodge Version 1.10 Page 3 SERVICE INFORMATION Name of service Belvedere Address 1 Belvedere Road Westbury Park Bristol BS6 7JG 0117 973 1163 0117 969 1973 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) Ablecare Homes Mr John Wilcox Care Home 20 Category(ies) of (DE(E)) Dementia - over 65 years of age. registration, with number of places Belvedere Lodge Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. Those residents currently accommodated, who do not have a Dementia, may continue to live at the home as long as their needs are met. 2. No new residents will be admitted in the OP category. 3. The agreed action plan is implemented to agreed timescales. Date Implemented: 27 August 2003. Date of last inspection 08/09/2004 Brief Description of the Service: Belvedere Lodge is a care home registered with the Commission for Social Care Inspection to provide accommodation and personal care to 20 persons aged 65 years and over with a Dementia. Although the registration relates to 20 persons with a Dementia, a condition of the registration permits those persons presently accommodated who may not have a dementia to remain accommodated in the home, as long as the home can meet their needs. All new admissions will focus on persons who have a Dementia.The home is situated in a busy suburb of Bristol convenient to local shops and amenities. It is located in a period property and adapted to meet the needs of the residents, with provision of a stair lift, ramped access, level rear gardens, and an environment aimed at ensuring those persons with a Dementia feel comfortable.The home is owned and operated by Ablecare Homes, and the manager Mr John Wilcox is one of the proprietors of the business. Belvedere Lodge Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an un-announced inspection conducted as part of the annual inspection process to examine the care provided, and monitor the progress in relation to requirements and recommendations from the last inspection conducted in September 2004. The Inspection took place over 8 hours. During the process three visitors, six residents, a visiting district nurse, two staff and three members of the management team were spoken to. The Inspector looked around some of the building. The following records were examined: • A sample of care files and associated information • Fire safety records • Staff supervision records • Staff training information • Handover sheets • Daily observation sheets • Quality assurance analysis What the service does well: The home cares for persons with a Dementia who may display complex and at times repetitive behaviours. The organisation has worked proactively to provide the staff team with training and skills to deliver sensitive, appropriate care. After seeking professional advice, changes to the environment have been implemented to minimise confusion for the residents. This is good practice. The residents spoken with were happy with the care provided, and felt able to talk to the staff and manager. The visitors present during the inspection conveyed that they were happy with communication from the home in relation to the day-to-day care of their relative or friends. No restrictions were placed on visitors, unless agreed specifically in the care plan. Comprehensive care plans with advice and guidance from relevant professionals ensure care provision is delivered to a high standard. Belvedere Lodge Version 1.10 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Belvedere Lodge Version 1.10 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 Lodge Version 1.10 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) 1,3,4,5. standard 6 is not applicable to this home. The admission procedure in place provides adequate safeguards to ensure there is a proper assessment of need prior to people moving into the home. Comprehensive information is available to service users and their representatives providing guidance on care provision, staffing levels and special needs catered for. The management team demonstrated care is provided based on current good practice, and reflects specialist guidance focussing on the needs of persons with a dementia. EVIDENCE: The statement of purpose and service user guide were available in the reception area of the home. Local authority care plans and assessments were seen on file. The home develop a comprehensive care plan from information provided prior to admission, and assessment during the trial period. Family members, friends and relevant professionals are involved in the development of care provision. Service users contribute to this process depending on their ability and level of understanding. The needs assessment covers all aspects of care as detailed in standard 3 of the National Minimum Standards. Belvedere Lodge Version 1.10 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 standard(s) 7,8,10. There has been a great improvement in recording interventions relating to the health care needs of the service users. The home was able to meet the health and personal care needs of the residents, in an individual and sensitive manner. Care is provided within a risk assessment framework; ensuring service users rights and dignity are upheld. EVIDENCE: One visiting heath care professional confirmed staff members follow advice and guidance provided. Examination of care files and associated information for example: • daily observation records • risk assessments • care plans • needs assessments • staff handover sheets Belvedere Lodge Version 1.10 Page 10 Care plans seen were detailed and provided evidence that relatives contributed to the development of individual care. Advice and guidance to staff was comprehensive and risk assessments and behaviour management strategies were seen to be in place. In some cases the high standard of care being provided, and strategies in place to minimise risk were not reflected in the plan of care. Some documentation seen was undated, and therefore it was difficult to assess whether or not a review or improvement of specific behaviour had taken place. Regular monthly summaries of care were recorded and local authority statutory reviews were also in evidence. Evidence was seen of advice being sought from relevant professionals in relation to individual care. A daily staff handover sheet ensuring that all staff sign to agree their knowledge and understanding of any changes or strategies employed in relation to any service user was seen. This ensures staff members are aware of their responsibility to provide appropriate care. The deputy manager has designated tasks to specific staff to ensure consistency of practice. Detailed records were seen, including individual staff signatures confirming the task has been completed. Belvedere Lodge Version 1.10 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 standard(s) 13. Contact with family, friends and outings in the local community are an integral part of the care provided at this home. EVIDENCE: Visitors were seen moving confidently around the home and confirmed good relationships with the staff and manager. Observation and discussion with three visitors provided evidence that staff encourage family contact. This was confirmed during examination of the care plans and daily observations sheets. Belvedere Lodge Version 1.10 Page 12 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) 16,17,18. The risk to service users of suffering any form of abuse is appropriately minimised. Complaints are taken seriously by the home, and immediate action is taken in relation to any suspicion or allegation of abuse. EVIDENCE: The complaints procedure is displayed in the entrance hallway and contains all components required by legislation. It also forms part of the service user guide and statement of purpose. A visiting family member confirmed they felt able to approach the manager in relation to any concerns. Policies and procedures are in place to minimise the risk to service users from any form of abuse. A director present during the inspection process provided evidence that a programme of training for staff on POVA was underway and three staff had attended. The deputy manager confirmed attendance on a comprehensive course designed for managers. Belvedere Lodge Version 1.10 Page 13 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) 19,20,26. The quality of furnishings and fittings in the home is good. Overall a warm, comfortable environment has been created, ensuring service users needs are met. Arrangements to ensure all parts of the home are risk and odour free need to be improved. EVIDENCE: A partial tour of the premises revealed one room with a strong odour. The home have taken action to reduce the incidence of odours and vinyl flooring is evident in some rooms. Contract cleaners attend regularly to deep clean the carpets, and domestic staff are employed on a daily basis. Further action is needed and a requirement will form part of this report. Policies, procedures, and staff training is in place to ensure the service users are safeguarded from any risks. However in the garden area (accessible to the service users) two risks were present: • A gate at the top of a stairway leading to the kitchen was open. Belvedere Lodge Version 1.10 Page 14 • The patio area leading to the lawn has a natural step down and could pose a risk to a person with dementia. The manager took immediate action to ensure the gate was closed, and advised a barrier would be installed to minimise any risk from the patio. The environment has been adapted to meet the needs of people with a dementia after advice was sought from appropriate professionals. Belvedere Lodge Version 1.10 Page 15 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) 27,30. A stable staff group who receive a high level of support from the management team provide consistent care. A clear induction, training and development programme ensures staff are competent and have a good understanding of the needs of the service users. EVIDENCE: Discussion with the management team, staff, service users and a review of documentation held by the home provided evidence that regular supervision sessions were held. Staff members spoken with confirmed a high level of support and training appropriate to the tasks they had to perform. The director was able to provide evidence that staff members were registered for the NVQ in Care programme. Further training in relation to the protection of vulnerable adults and first aid was part of the ongoing mandatory training staff members were required to attend. Service users and relatives spoken with did not raise any concerns about staffing levels in the home. A detailed staffing rota was seen. Belvedere Lodge Version 1.10 Page 16 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) 31,33,36,38. The manager is supported well by the deputy manager in providing clear lines of accountability to the staff team. Service users best interests are safeguarded by the homes robust policies and procedures, ensuring appropriate records are kept. There are systems and training in place to promote the health and welfare of the service users and staff. EVIDENCE: The registered manager is able to communicate a clear sense of direction, and has strategies in place to ensure staff develop the skills and expertise to undertake the tasks they are to perform. The deputy manager is progressing through the NVQ level 4 and demonstrated through the inspection process a commitment to providing a high standard of care. Three members of the care staff are also registered the NVQ training programme. Belvedere Lodge Version 1.10 Page 17 A review of the supervision records revealed a high level of formal support for staff members, including advice and encouragement to complete training organised. Records reviewed were up to date and in order, and were held securely in the home. The organisation’s head office supply a high level of administrative support. Belvedere Lodge Version 1.10 Page 18 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 2 x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x 3 x x 3 x 3 Belvedere Lodge Version 1.10 Page 19 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. 2. 3. Standard OP20 OP20 OP26 Regulation 23.2 (o) 23.2 (o) 16.2 (k) Requirement Ensure outdoor gated access to kitchen is kept closed at all times. Install a handrail at the edge of patio. Ensure all parts of the home are odour free. Timescale for action 30th April 2005 30th May 2005 30th April 2005 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 OP7 Good Practice Recommendations Care plans should reflect any identified changes of service users needs. Belvedere Lodge Version 1.10 Page 20 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG 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 Lodge Version 1.10 Page 21 - 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!