Inspection on 01/07/10 for Belvoir Care Home

This inspection was carried out on 1st July 2010.

CQC found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Belvoir Care Home 28/04/10

Belvoir Care Home 27/07/07

Belvoir Care Home 16/05/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 03/09/2010.

Random inspection report Care homes for older people Name: Address: Belvoir Care Home 632 Halifax Road Rochdale Lancashire OL16 2SQ one star adequate service 28/04/2010 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Stephanie West Date: 0 1 0 7 2 0 1 0 Information about the care home Name of care home: Address: Belvoir Care Home 632 Halifax Road Rochdale Lancashire OL16 2SQ 01706377925 F/P01706377925 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Mandy Pepper Type of registration: Number of places registered: Conditions of registration: Category(ies) : Belvoire Care Home Limited care home 24 Number of places (if applicable): Under 65 Over 65 24 old age, not falling within any other category Conditions of registration: 0 The registered person may provide the following category/ies of service only: Care home only to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accomodated is: 24 Room 15 to be used only to accommodate the respite stay. Date of last inspection Brief description of the care home The home provides personal care and accommodation for 24 older people, including one respite stay bed. There are 14 single and five double bedrooms, with five of the bedrooms having the provision of en-suite toilets. A passenger lift to the first floor is provided. Care Homes for Older People Page 2 of 11 Brief description of the care home The home was originally two semi-detached houses, which were converted to provide one large home to which an extension was added at the rear of the building. There is a small garden and patio area to the rear and car parking is also available. The home is located on the main road between Rochdale and Littleborough, close to shops and other local amenities. A bus route to/from Rochdale passes the home regularly. The weekly fees are between 372. 64 pounds and 388. 98 pounds. Additional charges are made for private chiropody, dentistry, hairdressing, specialist equipment and dry cleaning. The provider makes information about the service available upon request in the form of a Service User Guide and Statement of Purpose, which are given to new residents. A copy of the most recent Inspection report is available within the home. Care Homes for Older People Page 3 of 11 What we found: This visit was carried out to look at the homes medication arrangements and the action taken to meet the requirements of our previous visit. The visit lasted approximately five hours and involved discussing the handling of medication with the manager and examination of medicines records and storage arrangements. This visit focused on medicines handling, other areas and requirements were not examined at this time. At the end of the visit feedback was given to the manager. Overall, we were concerned to find that weaknesses in the recording of medication handling identified at our previous visit remained to be addressed in order to better support and evidence the safe handling of medicines at the home. We looked at medicines administration. All staff handling medication had completed certificated training and consideration was given to the times medicines were given to help ensure people get the most benefit from their medicines. Residents photographs and divider sheets were used between individual medicines administration records to help with positive identification when administering medicines but several of these were missing. It is important that individual records are clearly segregated to help reduce the risk of errors. We looked at how information within peoples care plans supported medicines administration. We were concerned that in some cases there was no clear written guidance for staff about the use of medicines prescribed when required. Similarly, there was a lack of written information about the use of prescribed creams for example, when and where they may be needed. On occasion records were not completed to show that creams had been applied. It was of concern that, as seen at our previous visit, where people chose to self-administer medication risk assessments had not been completed and there was a lack of information about how safe self-administration was supported. We looked at how medicines were recorded and were concerned to find a lack of clarity in the medicines administration records that made it difficult, and sometimes impossible to account for (track) the safe handling of medicines at the home. We found several examples where the homes pre-printed medicines administration records were used for longer than the 28 day period intended and occasional examples where duplicate records of administration had been made on the same day. There were also some gaps in the medicines administration records where administration or, the reason for nonadministration was not recorded. On occasion it was evident that where quantities of medication were received into the home outside the main monthly this had not been recorded. We were concerned that the current medication administration record for one person did not list four of their currently prescribed medicines and that it was not possible to tell whether these medicines were being given correctly. Records for another person stated only Ear Spray but not the name of the medication and those for a third person continued to list a painkiller that had been stopped in hospital. Weaknesses in the medicines record keeping need to be addressed to reduce the risk of errors in medicines handling. We looked at medicines stocks and storage. We found that all medicines were safely locked away but were concerned that stock control needed to improve to reduce the risk that out-of-date medicines may accidentally be used. The home had purchased a chiller for medicines that need refrigerated storage but the temperature was not monitored and Care Homes for Older People Page 4 of 11 recorded. It is important that temperature checks are made to ensure the chiller keeps the right temperature. An in-house audit (check) of medicines handling was completed annually, but the manager said there were plans to complete them more often. This is recommended to help ensure that concerns about medicines handling can be promptly identified and addressed. What the care home does well: What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 5 of 11 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 3 14 People must not be admitted 28/05/2010 to the home without a thorough written assessment of peoples needs to help determine whether or not the home can meet their needs So that staff have written information to help them understand peoples needs and how to provide the right support. 2 4 14 People must not be admitted 28/05/2010 to the home unless it is determined that the home is suitable, and that their needs are best met in a care home for older people. So that people live in the right place where staff have the right training, background and experience to support them correctly. 3 7 15 All residents must have a 28/05/2010 written care plan that instructs staff on what care and support people need and how this should be provided So that staff know how to support people and so that people are given the right care and support. Care Homes for Older People Page 6 of 11 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 4 8 13 A suitable system must be 28/05/2010 implemented to prevent the resident identified from injuring themselves whilst in bed. So that residents are safe from injury whilst in bed. 5 9 13 When people manage their 28/05/2010 own medication there must be an assessment of any risks involved, what needs to be done to minimise the risk and what monitoring staff must do to ensure the medication is taken So that people take the correct medication and remain as healthy as possible. 6 9 13 There must be a clear and 28/05/2010 accurate systems for recording and administration of medication that includes how to manage medicines that are dispensed in different ways and when there is a surplus. So that medicines can be checked to ensure that they are being given correctly. 7 18 13 There must be step by step 30/06/2010 procedures in the home at all times for staff to follow and suitable training in the Safeguarding of Vulnerable Adults. So that staff know what to Care Homes for Older People Page 7 of 11 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action do to protect people living in the home from abuse or neglect 8 19 23 All areas of the home must 30/06/2010 be well maintained, furnished and decorated, including carpets and furniture. So that residents live in a pleasant comfortable environment. 9 25 13 Residents must be protected 28/05/2010 from heaters that are too hot. So that residents are not at risk from burns from hot heaters 10 31 26 Regulation 26 visits must 28/05/2010 demonstrate that areas of improvement are identified and acted upon and these must be made available for the commission to inspect at any time. To ensure efficient management and development of the home. 11 33 24 Effective quality assurance systems need to be developed to demonstrate thorough internal auditing is undertaken and involves those people living at the home ensuring a quality service is provided. 30/06/2010 Care Homes for Older People Page 8 of 11 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 12 33 26 (5)(b) The provider needs to demonstrate to CSCI that Regulation 26 visits are undertaken so that we can be sure that he is fulfilling his responsibility in accordance with the law. 31/08/2007 Care Homes for Older People Page 9 of 11 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 9 There should be sufficient written guidance to staff on how to administer when required and variable dose medication so that the correct dose is given at the right time Care Homes for Older People Page 10 of 11 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 11 of 11 - 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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