Inspection on 27/07/06 for Belvedere Lodge

This inspection was carried out on 27th July 2006.

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 22/11/05

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 Vanessa Carter Key Unannounced Inspection 27th July 2006 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.V302085.R01.S.doc Version 5.2 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.V302085.R01.S.doc Version 5.2 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.V302085.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Those residents currently accommodated, 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 The agreed action plan is implemented to agreed timescales Date of last inspection 22nd November 2005 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 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. The cost of placement at the home is between £400-450 per week and is dependent upon assessed need. Additional costs are made for a range for services and these are detailed in the Homes Brochure. Prospective residents are able to find about the home by requesting a copy of this from the Home Manager. Belvedere Lodge DS0000026496.V302085.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over 6 hours and was completed in one day. The manager was present during the inspection and participated in the process. Evidence was gained from a whole range of different sources, including: • Information provided by the manager in the pre-inspection questionnaire • Information taken from resident survey forms • Directly speaking with residents • Case tracking a number of residents • Speaking with care staff • A tour of the home • Examination of some of the homes records • Observation of staff practices and interaction with the residents. The overall analysis is that the home is a good place in which to live and to work. What the service does well: What has improved since the last inspection? The storage of some of the homes “private” records has improved and only those staff who have the authority to do so, can view these. The home has met the requirement for a health monitoring form to be put in place where appropriate, and examples of their use were seen being used, for a number of residents. Belvedere Lodge DS0000026496.V302085.R01.S.doc Version 5.2 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.V302085.R01.S.doc Version 5.2 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.V302085.R01.S.doc Version 5.2 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 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives are provided with information about the home, and placement is only offered after a full assessment of care needs has been completed. EVIDENCE: No changes have been made to the statement of purpose and service users guide, since the last inspection and both contain all information as detailed in the National Minimum Standards. The documents are available in the front entrance of the home. Belvedere Lodge DS0000026496.V302085.R01.S.doc Version 5.2 Page 9 Each resident is provided with a statement of terms and conditions upon admission and where a local authority officer arranges placement, a schedule 1 is drawn up. The manager visits any prospective resident, so that an assessment of their needs can be made. Placement is not offered to any person whose needs the home cannot meet. Assessments by the manager were seen on file. Three residents said in the resident survey form that they had been provided with information about the home prior to moving in and that they had been given a statement of terms and conditions (a contract). Placements are arranged on a month’s trial basis with a review taking place at the end of this period with all necessary parties. One person said that their relative had made all necessary arrangements for them to live at the home. It is a condition of registration that any new persons admitted to the home will have dementia care needs. The home has had four new admissions since the last inspection, and each person meets this criteria. Belvedere Lodge DS0000026496.V302085.R01.S.doc Version 5.2 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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some minor improvements in the homes care planning processes will ensure that information kept about each resident is clearer, however the residents are well cared for. EVIDENCE: Four care plans were looked including that of one person who had recently been admitted to the home. The plans each contained guidance for the staff on how identified needs should be met. For two people, the plans had been written by the social services department but had been reviewed on a monthly basis on Ablecare paperwork. For the other two people their care plan was recorded upon the “Ablecare Homes Care Plan”. These plans were much clearer and presented a much better picture of that persons needs. It would be good practice for all residents to have their care needs recorded using the same format. The residents have signed their care plan reviews, where this was appropriate – for one person this has ceased some months ago, due to deterioration in their mental health. Belvedere Lodge DS0000026496.V302085.R01.S.doc Version 5.2 Page 11 The care plans are supported by a number of risk assessments in respects of nutrition, skin integrity, and mobility and handling profile. For each person the level of risk associated in moving and transferring is determined and a safe system of work devised. The home has put in place documentation to record any healthcare needs that need to be monitored. There was clear evidence of any actions taken by the staff in respect of any changes. A record is maintained of any contact with GP’s, District Nursing Services, CPN’S, chiropody, opticians and dentists. One relative commented on their survey form that “my relative is happy and well looked after. I have no problems with the home”. Another relative stated that they were always kept informed of any changes. A review of the homes medication systems showed that they have safe procedures in place for the ordering, receipt, storage, administration and disposal of all medicines. Those staff that are responsible for administering medications have had training to ensure they are competent. The staff were observed going about their duties in a friendly and calm manner and responding to the residents in a familiar style. The residents were treated with respect and two incidences were noted where the staff handled situations where personal care intervention was required, in a discreet manner. Belvedere Lodge DS0000026496.V302085.R01.S.doc Version 5.2 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are able to participate in a range of stimulating and meaningful activities, and are offered a balanced diet. EVIDENCE: The residents are able to choose whether they want to participate in any activities that are arranged. In each person’s care plan a record of activities the resident had taken part in, is maintained. After each event, staff will record how successful the activity was, for example: enjoyed, did not enjoy, lost interest or refused. Examples include sing-alongs, local walks and shopping trips, group talks and chair exercises. There has recently been a trip out to see birds at the Wildfowl Centre in Slimbridge. One resident said they liked to dance and they enjoyed the music. Whilst the residents were having lunch, one started singing and they all joined in. During the afternoon the residents were served ice cream cornets and one resident reminisced that it reminded them of their childhood. One resident who was becoming increasingly agitated, was helped to settle by the staff by being included in a card game with other residents. Belvedere Lodge DS0000026496.V302085.R01.S.doc Version 5.2 Page 13 Those residents, who were able to, were seen moving around the home independently and going out into the garden. The home has an open visiting policy and visitors can come in at any reasonable time. There were no visitors to the home during the inspection visit. The home provided copies of two weeks menus as part of the pre-inspection information, and residents are provided with a balanced diet. A roast meal is served twice a week. There is only one planned choice per day but residents are able to have an alternative if necessary. The cook had a good understanding of the dietary needs, likes and dislikes, of each of the residents. Belvedere Lodge DS0000026496.V302085.R01.S.doc Version 5.2 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): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be assured that any concerns they have will be listened to and acted upon, and that they will be protected from coming to any harm. EVIDENCE: The homes complaints procedure is included in the homes statement of purpose and a copy is posted in each bedroom and the main reception area. Residents spoken with during the course of the inspection said they would talk to the staff if they were not happy about anything. CSCI received a complaint from a member of the public and passed this directly to the homes management team. The matter has been resolved and the home has taken the appropriate action to bring about a resolution. The home has policies and procedures in place to ensure that the residents are safeguarded from any form of abuse. Staff have attended adult abuse awareness training delivered by the local council. A copy of the Bristol City Council “No Secrets” guidance is kept with all other day- to- day paperwork. Staff spoken with during the inspection demonstrated a good awareness of adult abuse issues and of their responsibility in reporting any bad practice. Belvedere Lodge DS0000026496.V302085.R01.S.doc Version 5.2 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, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is safe and well maintained and is equipped to meet their needs. EVIDENCE: Belvedere Lodge is a three storey end-of-terrace Victorian property. It has been operating as a care home since the late 1980’s when it was set up, by the Willcox family. The communal rooms are all on the ground floor. There are two lounges, one large and one small, and a separate dinning room. Both lounges have just been redecorated and supplied with new chairs. The carpet and curtains are due to be replaced. Belvedere Lodge DS0000026496.V302085.R01.S.doc Version 5.2 Page 16 Two toilet rooms are located by these communal areas. Stairs lead down to the basement where a number of bedrooms are located and the kitchen. Stairs also lead up to the first floor – they are wide and the fact that a stair lift is in situ does in no way impede the way for users of the staircase. The remainder of the bedrooms are located on the first and second floors. Some of the bedrooms have ensuite facilities – either a toilet or a toilet and wash hand basin. There are also 2 shower rooms and I assisted bathroom. Two bedrooms are for shared occupancy. All windows throughout the house have restricted opening and those velux windows at the side of the property, have steel netting installed so that items cannot be thrown out of the openings. Some rooms have door guards fitted so that the doors can be left open, rather then wedged. For one person this was important, as they preferred to remain in their bedroom but liked to be able to hear what was going on elsewhere in the house. All the bedrooms are fully furnished but residents can bring in items of furniture and can personalise their rooms as they wish. Each room has a lockable drawer but the manager stated that most residents have not requested the keys. The home has one cleaner who works each weekday. The home looked clean and tidy but there was noticeable malodour in one of the shared rooms. The manager is liaising with the relatives to see if the carpeting can be changed for more appropriate flooring. Belvedere Lodge DS0000026496.V302085.R01.S.doc Version 5.2 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, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are cared for by staff who are skilled and competent to meet individual needs appropriately, but safe vetting and recruitment procedures must be used to ensure that residents are not looked after by unsuitable workers. EVIDENCE: The home employs a team of care staff, plus domestic and catering staff, led by the manager and the deputy. The staff team work the same shifts each week. A number of shifts are vacant but covered “in-house”. There has been no use of agency staff and this means that residents will be cared for by staff who are familiar with their needs, and are known to them. The home currently has only two members of staff who are trained to at least an NVQ level 2, but two others are working towards achieving the award. At this point in time, the home will have achieved a 30 ratio of trained members of staff. One staff member spoken with during the inspection was hoping to start NVQ2 soon, in the next cohort. The home should continue to commit to the NVQ training programme to ensure they meet the 50 target. Belvedere Lodge DS0000026496.V302085.R01.S.doc Version 5.2 Page 18 There has been only one new member of care staff employed since the last inspection visit. An examination of their personnel file evidenced that the home does not completely follow safe vetting and recruitment procedures – the new staff member commenced work before their POVAfirst check was known. . The files of two staff who had started at the home last year, evidenced the same. The home has been instructed that this practice must cease, as there is the potential that residents could be placed at risk from unsuitable workers. All new staff will complete an induction training programme at the start of their employment, to ensure that they are aware of the homes procedures and are competent in the areas of their work. The programme for the new worker was not available however completed plans were seen for other staff. Every staff member has a training file, and the certificates of training courses they have attended are retained in these. It was evident that the staff group have received training in a wide range of relevant subjects. Dementia care training, and protection of vulnerable adult (POVA) training, has been attended by most staff. Belvedere Lodge DS0000026496.V302085.R01.S.doc Version 5.2 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, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is well managed and run in their best interests but some improvements are needed with risk management processes. EVIDENCE: The home manager has been running the home since the late 1980’s and is experienced in the care of the elderly and those with a dementia. A deputy manager, who has also worked at the home for many years, supports him in the role, along with the manager’s daughter who is also a director of Ablecare Homes. 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.V302085.R01.S.doc Version 5.2 Page 20 The home completed an annual service satisfaction survey in April and the results showed that in general the residents were happy with the service received. The survey covered meals, choice of activities arranged, home arrangements, involvement in care planning and ability to express any concerns or complaints. The home has good administrative systems in place to manage any monies they hold on behalf of the residents. A number of the accounts were checked against the records held and they tallied. Staff confirmed that they receive regular supervision and a sample of the records kept, were examined. The records were detailed and provided evidence that the deputy manager was monitoring each workers performance, and knowledge of the residents and home procedures. The supervision records are now being securely stored. 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. A review of the fire safety records revealed that all staff have attend fire drills and training at regular intervals. The fire fighting equipment is tested regularly to ensure it is in working order. Where bed rails are used to maintain a residents safety whilst in bed, the home must complete a risk assessment to ensure it is the most appropriate method of maintaining safety, and does not present further hazards. Also consent must be obtained, and their use must be clearly stated in the plan of care. It is very good practice that the home complete risk assessments each time trips out from the home are arranged, both on a group basis or as an individual outing. This evidences that the staff take the residents safety seriously. Belvedere Lodge DS0000026496.V302085.R01.S.doc Version 5.2 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Belvedere Lodge DS0000026496.V302085.R01.S.doc Version 5.2 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 OP29 Regulation 19 Requirement POVAfirst clearance must have been received on all new staff before employment commences. The use of bed rails must always be risk assessed and consent for their use be obtained. Timescale for action 07/08/06 2. OP38 13(4) 07/08/06 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. Refer to Standard OP7 OP28 Good Practice Recommendations Each resident should have their care needs recorded on an “Ablecare Homes Care Plan”. To achieve a 50 target of care staff trained to at least NVQ level 2. Belvedere Lodge DS0000026496.V302085.R01.S.doc Version 5.2 Page 23 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.V302085.R01.S.doc Version 5.2 Page 24 - 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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