Inspection on 22/11/05 for Belvedere Lodge

This inspection was carried out on 22nd November 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 Lodge 24/09/09

Belvedere Lodge 05/10/07

Belvedere Lodge 02/05/07

Belvedere Lodge 27/07/06

Belvedere Lodge 12/04/05

Belvedere Lodge 08/09/04

Belvedere Lodge 01/04/04

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

CARE HOMES FOR OLDER PEOPLE Belvedere Lodge 1 Belvedere Road Westbury Park Bristol BS6 7JG Lead Inspector Helen Taylor Announced Inspection 22nd November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Belvedere Lodge DS0000026496.V256224.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 Lodge DS0000026496.V256224.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Belvedere Lodge Address 1 Belvedere Road Westbury Park Bristol BS6 7JG 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) 0117 9731163 0117 9691973 Ablecare Homes Mr John Wilcox Care Home 20 Category(ies) of Dementia - over 65 years of age (20) registration, with number of places Belvedere Lodge DS0000026496.V256224.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The agreed action plan is implemented to agreed timescales Those residents currently acommodated, who do not have a Dementia, may continue to live at the home as long as their needs are met No new residents will be admitted in the OP category Date of last inspection 8th September 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 Willcox is one of the proprietors of the business. Belvedere Lodge DS0000026496.V256224.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 as part of the annual inspection programme, and was conducted in one day. The last inspection took place in April 2005 and there were three requirements and one recommendation. It was noted during this inspection that all have been complied with. Evidence was gathered from a pre-inspection questionnaire, discussion with residents, staff members, visitors and the management team. Various records held in the home were examined. Mr John Willcox and Mrs Sam Hawker both directors of the organisation were present during the Inspection. Mr Willcox is also the manager of Belvedere Lodge. What the service does well: What has improved since the last inspection? The installation of warning signs, and a reminder to staff that the gated access to the kitchen area remains closed at all times, has improved the safety for those residents who regularly use the rear garden. A fence has been erected at the edge of the patio where a natural step is sited; this has improved the safety and wellbeing of those residents who use the rear garden. The home has made strenuous efforts to minimise unpleasant odours ensuring residents live in a comfortable environment. Belvedere Lodge DS0000026496.V256224.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 Lodge DS0000026496.V256224.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 Lodge DS0000026496.V256224.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): 1,2,3,4,5,6. Comprehensive information is available to service users and their representatives providing guidance on all aspects of care provision. The admission procedure provides adequate safeguards to ensure there is a proper assessment of need including trial visits, prior to people moving into the home on a permanent basis. Care practice reflects specialist guidance focussing on the needs of persons with a dementia. EVIDENCE: The home has in place a comprehensive statement of purpose and service user guide containing all information as detailed in the National Minimum Standards. The documents were available in the reception area. Information about the inspection process was also seen on display. Belvedere Lodge DS0000026496.V256224.R01.S.doc Version 5.0 Page 9 Admission to the home is normally through the care management approach, and local authority care plans and assessments were seen on file. The manager explained that local authority contracts were kept in head office, however each resident also receives a resident agreement setting out the terms and conditions more fully. A review of care file information indicated that reviews are held after the trial period to ensure any changes to the needs assessment are appropriately recorded. One report seen contained good evidence of individual choices being part of the overall plan of care. Three residents spoken with during the inspection process confirmed the home was meeting their needs, and the care provided was of a good standard. Belvedere Lodge DS0000026496.V256224.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9,11. Continual improvement in the care plans and associated information enables the home to provide consistent sensitive support based on the residents needs. The health care needs of the residents are well met with evidence of multidisciplinary working taking place, however this could be improved with consistent monitoring of health care records. The arrangements for the storage and administration of medication are good, with clear guidance in place for staff to ensure minimal risk to residents. EVIDENCE: A sample review of four care files revealed that each resident has a plan of care developed from the assessment process. The care plans seen provided evidence that advice and guidance is sought from various professionals, family members support the resident in contributing to the care plan. Belvedere Lodge DS0000026496.V256224.R01.S.doc Version 5.0 Page 11 Care is provided within a risk management framework, and there was evidence of risk assessments on file. The documentation seen during this inspection process was appropriately signed and dated by the person making the entry. The key worker completed regular monthly summaries of care provision. The health care records seen were comprehensive and contained guidance from the GP, District Nurse or other health care professional in relation to any observation required, for example monitor weight or monitor pressure areas. In one care file a request was made for weight to be monitored in July, and only one entry was noted for August, this indicated a weight loss, however no further entries had been completed. The format for the recording of skin problems was inadequate for recording daily checks on specific areas for any individual. The manager must review care files regularly to ensure adequate preventative measures are carried out appropriately, and develop a format for the recording of any specific health care monitoring requested by a health care professional. Generally the records reviewed indicated a sensitive approach to the provision of health care. Notifications received by the CSCI under Regulation 37 provide further evidence that the health care needs of the residents are being met. Two residents spoken with confirmed the staff are attentive and contact health professionals if any concerns arise. Those residents spoken with during the inspection confirmed they were treated with respect and their right to privacy was upheld. Observations of staff interacting with residents confirmed this. The provider explained care would be provided for a resident who was dying in consultation with the family and health professionals involved. Each case would be individually assessed to ensure the home could meet the individuals needs. A sample audit of the storage and administration of medication revealed no errors. Medication is dispensed from the pharmacy in a monitored dosage system. Only staff members who have received medication training administer the medication. Certificates of training were seen on file. A designated staff member administers the medication on each shift and maintains the records. Belvedere Lodge DS0000026496.V256224.R01.S.doc Version 5.0 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 the following standard(s): 12,13,14,15. The residents are encouraged and supported to take part in activities in the home and in the local community. An appealing balanced diet is offered which provides choice and caters for individual needs. EVIDENCE: The residents are encouraged to take part in activities organised in the home, although this is through individual choice. Each care file contained a record of activities the resident had taken part in, for example: a sing-along, a local walk and painting. In one residents file there was evidence of inclusion in the daily running of the home, and the resident was involved in folding towels. Encouragement in the day-to-day activies in the home within a risk assessment framework motivates the residents, and promotes a feeling of belonging. This is good practice and should be encouraged. It should be noted that those residents who have a Dementia and access the local community are supported by a staff member to ensure the safety and well being of the individual. Belvedere Lodge DS0000026496.V256224.R01.S.doc Version 5.0 Page 13 The Inspector had the opportunity to speak with two visitors to the home, who confirmed a high standard of care provision for their relative, who has been a resident for two years. The visitors confirmed good communication from the staff team on a regular basis. A review of the kitchen and menus indicated the provision of a balanced diet. The cook was able to demonstrate a good understanding of the dietary needs of the residents. Menu sheets were completed every day, and indicated that individual choice, likes, dislikes, and special dietary requirements were catered for. Key workers in consultation with the resident, would advise the cook of any changes to the menu to ensure the needs of each resident were met. All records necessary to ensure appropriate temperatures of kitchen equipment and foodstuffs were up to date and in order. The food storage area was well organised and clean. Menu sheets were provided with the pre-inspection information. Belvedere Lodge DS0000026496.V256224.R01.S.doc Version 5.0 Page 14 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): The home has a clear complaints system in place, and the risk of residents suffering any form of abuse is appropriately minimised. The home promotes and protects the legal rights of residents. EVIDENCE: Policies and procedures are in place to safeguard the residents from any form of abuse. All staff in the home have attended abuse awareness training delivered by the local council. Copies of the local council reporting protocol and whistle blowing procedures are also held in the home. During the induction programme new staff are supported to develop an awareness of the policies and procedures in the home. This is monitored during the supervision process. The home does not control the finances for any residents. Those residents who may have no relatives are provided with financial support by the local social services department. The director explained the home held only small amounts of money as requested by relatives. The money was held securely, and those records examined were up to date and in order. There are detailed policies in place that preclude staff from accepting gifts, or benefiting from residents wills. Belvedere Lodge DS0000026496.V256224.R01.S.doc Version 5.0 Page 15 A detailed complaints procedure was on display in the reception area. The complaints procedure is also contained in the statement of purpose and resident guide, which was also available in the reception hallway. The complaints record was not viewed on this occasion. The home provides staff with specialist training providing a good understanding of the needs of persons with a Dementia; ensuring appropriate interventions are used to manage repetitive or challenging behaviour. Any restrictions are fully recorded and discussed with family members and social workers. Postal voting is made available to all residents who may wish to exercise their legal right to do so. Belvedere Lodge DS0000026496.V256224.R01.S.doc Version 5.0 Page 16 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): 19,20,21,22,23,24,25,26. The residents live in a safe, homely, comfortable environment, with arrangements in place to ensure all areas of the home are well maintained. EVIDENCE: Belvedere Lodge has been adapted to meet the needs of the individuals accommodated. Mobility aids and environmental adaptations designed to reduce confusion have been implemented in the home. The communal areas are well furnished, and individual rooms have been personalised. The home was clean and tidy, and the residents conveyed to the inspector they were happy with the facilities on offer. In response to requirements from the previous inspection, notices have been put on the external gated access to the kitchen to ensure it is kept locked at all times, and a fence has been installed at the edge of the patio area to ensure the safety and well being of all residents. Belvedere Lodge DS0000026496.V256224.R01.S.doc Version 5.0 Page 17 The home has worked diligently to minimise odours and vinyl flooring is evident in some rooms. A recommendation was made that this area is monitored closely at all times and action taken where necessary. The manager explained the organisation planned to carry out a major refurbishment of the property in the near future, including the replacement of some furniture and fittings. This work will need to be planned carefully to ensure minimal disruption to the residents presently living there. Those residents spoken with confirmed they were happy with the facilities provided, and there was evidence that residents are encouraged to bring personal possessions when admitted to the home. The residents guide contains detailed information about individual choices. Information is also included about insurance in relation to residents personal belongings in the home. There are adequate toilet and bathing facilities. Although the toilet and bathing facilities were clean and tidy, and there were no odours, it was noted that the underside of the assisted bathing chair was not as clean as it could have been. It was recommended a system be put in place to ensure regular cleaning of this facility. There are no CCTV cameras. Belvedere Lodge DS0000026496.V256224.R01.S.doc Version 5.0 Page 18 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): 27,28,29,30. A robust recruitment procedure ensures that residents are protected from any form of abuse. Residents are supported by a staff team who receive training and supervision, enabling them to meet individual needs appropriately. EVIDENCE: The organisation operates a robust recruitment procedure ensuring all appropriate information is obtained prior to the start of employment. Records reviewed provided evidence that POVA 1st and CRB checks had been obtained. Documentation seen included application forms, job descriptions, references, and signed contracts of terms and conditions. A comprehensive induction and training programme is in place for all new and present staff. The director explained that food hygiene, fire safety and health and safety are all part of the induction training pack. The deputy manager, who is a qualified trainer, provides manual handling training. The local authority provides Protection of Vulnerable Adults training, and this links directly to the local protocol in place for reporting alleged incidents of abuse. Training in specialist areas is also provided for example: Dementia Awareness, Continence Management and Skin Care. Belvedere Lodge DS0000026496.V256224.R01.S.doc Version 5.0 Page 19 The organisation also has in place an NVQ programme; an external assessor visits once per month. The organisation has in place a training matrix to indicate when up dated training is required, and to monitor progress on induction, mandatory and NVQ courses. Staff members spoken with confirmed training provided was of a good standard. A training record was in place for each staff member, however certificates relating to the training were held in a separate file, and were difficult to locate. A recommendation was made to include each staff members training certificates in their individual file. Staffing levels were appropriate at the time of inspection. Those residents spoken with confirmed staff attend to their needs as necessary, and act quickly when the call alarm is used. Belvedere Lodge DS0000026496.V256224.R01.S.doc Version 5.0 Page 20 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): 31,32,35,36,37,38. The home is well managed, with policies and procedures implemented safeguarding the individual interests of the residents. A comprehensive training, development and supervision programme promotes consistent sensitive practice, ensuring the rights and well being of the residents at all times. Improvements in the storage of information would provide greater protection for residents and staff. EVIDENCE: The manager of the home is well supported by the deputy and there are clear lines of accountability in the staffing structure. There was evidence of good communication systems, with daily handovers, staff meetings and supervision taking place. Belvedere Lodge DS0000026496.V256224.R01.S.doc Version 5.0 Page 21 A review of staff information indicated a high level of regular supervision took place. The records were detailed and provided evidence that the deputy manager was monitoring each staff members knowledge of the contents of the policies and procedures. Two senior carers provide supervision to designated members of staff, and the deputy manager monitors this. It was noted that the supervision records were being stored inappropriately, in two separate places that were not secure. The manager is required to ensure all information relating to the running of the home is held securely, and appropriate facilities are available to senior staff for this purpose. The organisation has in place robust systems to ensure the health, welfare and safety of all individuals living and working in the home. The staff-training programme includes sessions on health and safety, fire safety, manual handling, and food hygiene. Care is provided within a risk assessment framework, and all accidents or incidents in the home are appropriately notified to the Commission. A review of the fire safety records revealed that all staff attend fire drills and training at regular intervals. The fire fighting equipment is tested regularly to ensure it is in working order. Belvedere Lodge DS0000026496.V256224.R01.S.doc Version 5.0 Page 22 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 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 2 3 3 Belvedere Lodge DS0000026496.V256224.R01.S.doc Version 5.0 Page 23 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. 2. Standard OP8 OP8 Regulation 13.4 (c) 13.4 (c) Requirement To ensure adequate preventative health measures are carried out as requested. Develop a format for recording specific health care monitoring requested by health care professionals. To ensure all supervision records are stored securely. Timescale for action 30/01/06 30/01/06 3. OP36 17 30/01/06 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. 3. Refer to Standard OP26 OP26 OP30 Good Practice Recommendations To monitor the incidence of odours in the home and take action where necessary. Ensure the underside of the assisted bathing chair is cleaned at regular intervals. To develop a file for each staff member containing certificates achieved during any training sessions attended. Belvedere Lodge DS0000026496.V256224.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Bristol North LO 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 DS0000026496.V256224.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. 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