Inspection on 16/05/06 for Belvoir Care Home

This inspection was carried out on 16th May 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

Belvoir Care Home 01/07/10

Belvoir Care Home 28/04/10

Belvoir Care Home 27/07/07

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Belvoir Care Home 632 Halifax Road Rochdale Lancashire OL16 2SQ Lead Inspector Jenny Andrew Unannounced Inspection 16th May 2006 08:15 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 Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 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. Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Belvoir Care Home Address 632 Halifax Road Rochdale Lancashire OL16 2SQ 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) 01706 377925 01706 377925 Belvoire Care Home Limited Mrs Mandy Pepper Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home is registered for a maximum of 24 service users to include: up to 24 service users in the category of OP (Older People). The service should employ a suitably qualified and experienced manager who is registered with the CSCI. Room 15 to be used only to accommodate respite stay clients for a maximum period of four weeks at any one time. None undertaken since the new provider took over in October 2005. Date of last inspection Brief Description of the Service: The home provides personal care and accommodation for 24 older people, including one respite stay bed. There are 14 single and 5 double bedrooms, with 5 of the bedrooms having the provision of en-suite toilets. A passenger lift to the first floor is provided. 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 range from £318.01 - £333.01 as at May 2006. Additional charges are made for private chiropody, hairdressing, toiletries and meals out. The provider makes information about the service available upon request in the form of a Service User Guide and Statement of Purpose, which is given to new residents. A copy of the most recent Commission for Social Care (CSCI) inspection report is generally displayed within the office, but on this inspection, it was not. Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. There have been recent changes in the ownership of the home. Mr Joseph Heifetz bought the home in October 2005, but the existing manager has continued to work at the home. This is the first inspection the home has had since the new owner took over. This unannounced inspection took place over one full day with one Inspector. The inspector looked around parts of the building, checked the records kept on residents to make sure staff were looking after them properly (care plans), as well as looking at how the medication was given out. In order to obtain as much information as possible about how well the home looked after the residents, the manager, administrator, 5 residents, 3 relatives, 3 care assistants, the cook and visiting Care Manager, Doctor and District Nurse were spoken with. In addition comment cards were sent out before the inspection to relatives, residents and professional visitors to the home. Of these 8 resident, 4 relative/visitors and 1care manager questionnaires were returned. Other information, which has been received about the service, over the last few months, has also been used as evidence in the report. What the service does well: What has improved since the last inspection? Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 6 Before coming to live at Belvoir, residents were now being assessed to make sure the home could meet all their needs. The quality and choices of food had greatly improved since the new owner took over and residents spoken to all said they were happy with the food being served to them. More than half of the staff team had done formal training (NVQ levels 2/3), which meant they knew how to look after the residents properly. 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. Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 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 Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 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&3 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide were detailed and would enable any prospective residents to make an informed choice about the home. Residents are assessed before coming into the home to ensure their needs can be satisfactorily met. EVIDENCE: The manager stated the Statement of Purpose and Service User guide had been updated to reflect the change in ownership of the home. Copies of the updated documents had not however, been forwarded to the CSCI and this must be addressed. The files for the 2 most recently admitted residents were checked and each contained a full care management assessment. The Social Services Department had funded the placements for both these residents and the care managers had done detailed assessments, which gave the reader a very clear picture of the persons needs. Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 9 During the inspection, a care manager had telephoned the manager to say she wanted to make a placement at the home that day. Some information by telephone had previously been given to the manager but she requested the care manager brought a full assessment to the home for her to see, before agreeing to the placement. This was done and after reading the assessment, the manager agreed to the resident coming in to the home as she felt the home would be able to meet their assessed needs. As the home sometimes take people who fund themselves, a file for such a resident was checked to see if an assessment had been done. Whilst the manager had completed an assessment sheet, it was insufficiently detailed and would not enable a judgment to be made as to whether the home would have been able to meet her needs. A new assessment document should be compiled which details all the areas referred to in standard 3.3 and this should be completed before the resident is admitted. As the initial assessment forms the basis for the initial care plan, it is essential that the assessment contains as much detail as possible. The manager said she would formulate a new assessment document. Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 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 & 10 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Residents’ health and personal care needs were being well met but this was not always reflected in the documentation, which could result in staff being inconsistent in their approach. Personal support is offered in such a way as to promote and protect residents’ privacy, dignity and independence. EVIDENCE: Three care plans were checked including one for a resident who was on a respite stay. One of the plans was very detailed and gave an excellent picture of the needs of this resident. The other two needed to be more detailed and information from the pre-admission assessment documents needed to be added e.g. hard of hearing, low mood etc. One person had requested a daily bath but this was not documented on the care plan. The manager had advised staff to offer a daily bath but the resident said this was not happening. All residents spoken with did however, feel they were being well cared for by the staff team and felt their needs were being met. Two care plans had been signed and agreed by the residents, one of them had not but the manager was addressing this. Care plans were being regularly reviewed as were risk Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 11 assessments. Risk assessments for nutrition, general risks, skin care and falls were in place in all 3 files. Two files contained moving and handling assessments but one did not and this must be addressed. Where risk assessments showed residents to be at medium or high risk, the care plans addressed the risk areas. The manager said she would immediately undertake the moving/handling assessment and speak to the carer who had omitted to undertake one when the resident was admitted. Training in the use of the new Malnutrition Universal Screening Tool had recently been given to the manager and staff by a Dietician. The manager was in the process of implementing this for all new admissions and for those identified at risk. Residents’ weight was being regularly checked and for the very frail residents, body measurements were being done. All residents spoken with felt their health care needs were well met. One resident had requested to see a Doctor on the day of the inspection and her wishes were respected. Both the visiting District Nurse and G.P. were spoken with when they visited. The Doctor said she felt the care at the home was excellent. She said the manager and staff knew each person as an individual and were committed to providing the care needed. She also said that the residents always looked well cared for, the home was clean and there was never an odour. The District Nurse said the home always followed her instructions, the residents were well looked after and she was always escorted to the residents she was visiting by the manager or a senior staff member. All health care professionals visits to the home were recorded on each residents file, together with any action that needed to be taken. Several medication policies/procedures were in place, covering all required areas. However, areas were duplicated and the manager should review the policies and procedures to make them into a more user-friendly format for the staff to follow. Two medication rounds, done by the manager, were seen during the inspection. The Boots medication system was in place and the manager followed the policies/procedures. There were no residents taking their own medication at the time of the inspection but the manager said this was looked into as part of the admission process. Several residents on respite stays had continued to self-medicate after a risk assessment had been done. Satisfactory arrangements were in place in relation to the dispensing and storage of controlled drugs but no one was on any of these drugs at this inspection. A visit by a representative of Boots, to check the system, had been made in March 2006. Only minor shortfalls had been identified such as having photographs in front of the residents’ medication sheets and specimen staff signatures. These should now be implemented. At the last inspection, it was identified that two of the staff responsible for the administration of medication had not received any formal training. The Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 12 manager had experienced problems in getting the staff on relevant training. However, 3 staff, including a bank care assistant, had been booked on a Boots training course on 25 May 2006. The aims and objectives of the home reinforced the importance of treating residents with respect and dignity. Residents interviewed were all complimentary about how staff assisted them with personal care tasks and felt their privacy and dignity was respected at all times. This was also observed during the inspection. Residents were taken to the toilet without having to wait, toilet doors were closed and staff knocked on bedroom doors before entering. Relatives confirmed they were satisfied with the staff’s manner and attitude towards the people they visited. The care assistants interviewed were able to give good examples of how they promoted privacy and dignity in their daily care routines. All assistance with personal care was given in the privacy of service users bedrooms or bathroom. Service users were also able to meet visiting professional visitors and family/friends within the privacy of their own rooms. Evidence of this was seen at the time of inspection when a district nurse visited. The induction training programme, which is now done by all new staff, includes how to treat residents with respect and dignity. Residents are also encouraged to remain as independent as possible and this was observed during the inspection. Residents who were becoming less mobile were being encouraged to continue to walk, with the aid of their zimmer frames or walking sticks. The home was adequately equipped with necessary aids and adaptations, which promoted people’s independence. At mealtimes, whilst assistance was given where needed, residents were prompted by staff to continue to eat their meals themselves. Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 13 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 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Residents were encouraged and supported to exercise choice in their daily routines in relation to lifestyle and to maintain contact with their relatives but social stimulation was lacking and resulted in residents being unfulfilled. The dietery needs of residents were well catered for with a balanced and varied selection of food available at each meal. EVIDENCE: Since the last inspection, activities and stimulation for the residents had slightly improved but more work was stil needed in this area. The lack of social stimulation for residents has been an identified shortfall at this home over the last few inspections and action must now be taken to ensure that residents have support and assistance to engage in a varied range of activities. Whilst an activity programme was in place, it was not being followed and entries in an activity book, used to record both group and individual activities showed they were not being done on a daily basis. An external entertainer “Active Minds” was visiting the home once every 3 weeks and a fortnightly armchair exercise session was being done. Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 14 Three of the residents spoken with said there were times when they were bored and that they would like more things to take place. One person said they liked simple quizes and another person said she would just like staff to spend some time chatting with her. They all liked the armchair exercises and two people said they would like them more often as they felt they were doing them some good. Throughout the inspection, the majority of the residents, were spending a large part of their day asleep. Due to the numbers of residents living at the home, dropping, staffing levels had also been reduced. This had meant that staff were having to prioritise the residents physical needs rather than their social needs. No activities took place during the inspection. The manager must now take action to ensure the social as well as the personal care needs of residents are adequately met. The religious needs of the present resident group were being met. The Roman Catholic priest visited the home regularly to see 2 residents. In addition, a Church of England vicar visited who arranged to take people to church. All the residents spoken to felt the staff respected their preferred routines and lifestyles and evidence of this was seen during the inspection. They could get up when they wanted, choose to eat where they were sitting or at the dining tables and had the choice of 2 lounges as there were plenty of vacant chairs available. Other observations included a resident having chosen to come down from her room early afternoon as this was her choice, a staff asking where a resident wished to sit, being asked about choice of food, a resident being allowed to continue to have a sleep and their lunch being saved until later. Whilst residents may handle their own finances, at the time of the inspection, the relatives were tending to have control in this area. Discussion took place about advocacy arrangements. The manager had no leaflets displayed but said she would refer people to Age Concern should they have any problems. In order to ensure that residents receive independent support, if they do not have any close relatives, the manager should make leaflets available in the home. Relatives spoken to said they were made to feel welcome by the staff. They also said they were notified when their relative was ill or any changes to their condition were identified. Feedback from residents spoken to and responses on returned comment cards, was generally positive about the food. From checking choice sheets for the last 2 months, it was identified that the quality of meals had greatly improved, since the new owner had taken over. A variety of meat, fish, fresh and frozen vegetables and fruit were served daily. A choice of two meals were offered at lunch time together with dessert and either soup, sandwiches or a hot snack were available at teatime. The choice of meal on the inspection day was home made chicken broth and dumplings or a salmon salad followed by trifle. The Inspector sampled the chicken broth which was a tasty and filling meal. Boiled potatos were also added dependent upon residents choice. The salad was Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 15 varied with lettuce, tomatos, hard boiled egg, grated carrot, beetroot and chips being included. Since the manager and cook now had their own budget to work with, they were introducing different foods to the residents and also consulting them on what other food they would like to see on menus. When this trial period is over, the cook should formulate 4 weekly rotational menus, ensuring that meals continue to be nutritional and varied. Cooked breakfasts were enjoyed by several residents i.e. poached or boiled eggs, crumpets and bacon. A good selection of supper foods were offered, such as biscuits, sandwiches and home made potato cakes. Milky coffee had also been introduced as an optional daytime drink and several residents were enjoying this. The manager had requested the cook change to full fat milk and to use cream in some of her recipes to ensure that the residents with nutritional shortfalls, were receiving more calorific meals. Residents can choose when and where to eat and this was seen during the inspection. The special dietary needs of the residents were being met. One resident was poorly in bed and staff were assisting her with all her meals. Other residents needed some staff prompting and assistance to finish their meals and this was done in a sensitive way. Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 16 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): Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. An effective complaints system was in place which residents were familiar with. Adult protection training had improved since the last inspection and there was clear evidence that residents were being protected from abuse. EVIDENCE: A clear, easily understandable complaints procedure is in place which is included in the service user guide and statement of purpose. A copy of the guide is kept at the back of each of the bedroom doors and a copy of the statement of purpose is displayed in the entrance hall. One returned relative comment card indicated the person was unaware of the procedure and the manager may wish to display the procedure prominently in the entrance hall. The home ensures that all complaints are logged in a complaints book. Since the last inspection, 1 complaint had been recorded which was in the process of being investigated within the 28 day timescale. Residents spoken with all felt they could speak to any staff about problems and that they would be listened to. The staff interviewed were clear that any complaints made by relatives or residents would be reported immediately to the manager or senior staff on duty. The Commission for Social Care Inspection (CSCI) has had cause to investigate 1 complaint since the last inspection. The complaint consisted of 15 elements 6 relating to poor care practice (3 not upheld, I unresolved, 2 inconclusive) 3 to the environment (all upheld), 2 to food/drink (not upheld), lack of activities Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 17 (upheld), 4 to missing clothing/belongings and money (3 unresolved and 1 upheld with regard to incorrect information being mistakenly given to the complainant.) Throughout this investigation, the manager fully co-operated with the CSCI Inspector in order to resolve the problems. One Protection of Vulnerable Adult (POVA) referral had been made by the manager to the appropriate authority, which related to occurrences before the person was admitted to the home. Both the manager and staff were clear about the necessary policies and procedures to follow and a copy of the Rochdale MBC Protection of Vulnerable Adult manual was kept in the office, available to all staff. New staff files showed that Criminal Record Bureau and POVA first checks had been done before any new staff started work so as to ensure that the staff were suitable to work with vulnerable people. All but 4 carers had now undertaken the Rochdale MBC’s POVA training and evidence of this was seen on the staff training files. Those staff who have not done the training were to go on subsequent courses. Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 18 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 & 26 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The standard of decor and cleanliness throughout the home had improved and it was evident the new owner was committed to improving the environment for the residents. EVIDENCE: Since the new owner had taken over in October 2005, it was evident he had prioritised work on the environment. A written maintenance and renewal programme had not however, been written and this shortfall should be addressed. A maintenance book was however being used to identify any jobs which needed doing. Improvements were identified as follows: the hot water system, was now working effectively although the contractors were returning to the home to finish the work in one of the bedrooms; communal areas within the home had been re-painted and looked much brighter and cleaner; 4 bedrooms had been Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 19 re-decorated; new carpets had been fitted in the downstairs hall and corridors on both levels of the home; the fire door to one of the corridors had been changed to let more light through; new flooring had been fitted in the kitchen; a dishwasher had been purchased. Several positive comments were made by residents and relatives about the improvements being made. The residents and staff interviewed confirmed that the hot water problem had now been satisfactorily resolved. The manager acknowledged there was still work to be done but she was confident the provider would continue to upgrade the building. Residents said they could get around the home fairly easily and appropriate aids and adaptations were fitted in bathrooms, toilets and corridors so that residents could remain as independent as possible. Three residents bedrooms were seen. All needed the carpets cleaning. The home do not have their own carpet cleaner but share with another home. The manager must check all carpets within the home and arrange to have those in need of cleaning done without further delay. Some items of furniture were in need of repair. The furniture is not well made and doors and drawers are not properly fitting. In one room, when a drawer in the chest was closed, it immediately re-opened. The owner needs to do a furniture audit and prioritise rooms which need new furniture. Residents spoken with were satisfied with their bedrooms and said they had been able to bring small personal items in with them. A resident on respite had also brought in some small items so that she would feel more at home. An Environmental Health Officer had visited in March and left the cook a Safer Food folder which contained risk assessment documentation. The manager should monitor that the Cook is completing the necessary documentation. Infection control policies/procedures were in place. At lunch time, staff were seen to change protective aprons to blue ones for serving food. The premises were clean and liquid soap and paper towels were supplied in toilets and bathrooms. Paper towels were not however, provided in residents bedrooms, where staff assisted residents with their personal care needs. The staff did air some concerns over the practice of them getting residents up in a morning and then having to go into the kitchen to make drinks and breakfasts. When resident numbers had been higher, a care assistant was assigned to this task and did not assist with residents personal care. The manager and owner must ensure that a safe system is in place to ensure that effective infection control risk assessments are in place. Adequate laundry facilities were in place and individual baskets supplied for each residents clothes. Feedback from residents indicated that missing clothing was not a big problem and a part-time laundry assistant was employed. Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 20 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 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Whilst staffing levels were meeting the personal care needs of the resident group, their social and emotional needs were not being fully met. The team had a good balance of staff in relation to age and experience and more than half of the team had achieved their National Vocational Qualification (NVQ) levels 2/3, resulting in them having knowledge about how to care well for the residents. EVIDENCE: The home had several resident vacancies, and as a consequence staffing levels in a morning had been reduced from 3 to 2 carers plus the manager. The manager was spending some time on the floor, working alongside staff, but other management duties meant that a fairly high proportion of her time was spent in other areas, leaving only two staff on the floor. The dependency of the current resident group is mixed, but some of the residents have high dependency needs. From 3.00 p.m. two carers and a senior were on duty. Whilst the 2 rotas which were checked, showed that over a day, sufficient staff hours were provided, the staff were being kept busy looking after the residents personal care needs and did not have the time to organise social activities or to spend time chatting with the more mentally frail residents. As previously identified, many of the residents slept for a large part of the day, only awakening when staff assisted them to the toilet or to the dining room. Where one resident had requested a daily bath, this was not being done as staff said Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 21 they did not have the time. The manager said this was not the case and that she would address this with the staff. Feedback from the residents and from comment cards indicated they felt they were well cared for but that it would be better if the staff had more time to spend with them. For a small home, sufficient ancillary staff were employed e.g. laundry assistant, cook and domestic. Whilst the number of residents remain low, the manager must consider alternative options about how best to deploy staff in order to ensure the needs of the residents are fully met. Whilst 2 male residents were living at Belvoir, there were no male carers. The manager said that whilst they would like to recruit a male, the majority of applicants were female and therefore they did not have the choice of gender. A good age range and ethnic makeup of staff were however, employed for the all white client group. Information obtained from the pre-inspection questionnaire, completed by the manager, showed that staff turnover over the past 12 months was low, ensuring that residents received care from staff whom they had got to know and trust. Of the 16 carers employed, 7 had completed NVQ level 2,training, 3 had done Level 3 and a further 2 were in the process of doing their NVQ Level 2 training. The manager’s good practice of registering all new staff for NVQ training is commended and the home have now attained over 50 trained staff. Policies and procedures were in place for the recruitment and selection of staff and these were being implemented. Three staff files were checked, two of which were for recently recruited care staff. The files were in order and staff were not starting work until the necessary references and Criminal Record Bureau/POVA first checks had been done. As part of the induction process new staff are given a copy of the General Social Care Council “Code of Practice” and sign to say they have received one. This was seen in the files inspected. The homes in-house induction training was continuing as well as the implementation of “Skills for Care” induction training. The most recently recruited staff, who had already obtained her NVQ level 2 was due to start the units relating specifically to the home and resident group. The other files contained evidence that the previous induction training (TOPSS) had been done. It was however, noted that not all staff had yet undertaken all the necessary mandatory training or done refresher training. This was difficult to determine, as the manager did not have a training matrix showing what training each person had done and the date they had completed it. Such a matrix should be in place so that the manager can keep a check of when staff need updated as well as current training. A previous requirement that all staff receive a minimum of 3 days training per year had not been implemented for all staff. Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 22 Opportunities for staff to undertake training had however improved. The staff interviewed all felt they had benefited from the training they had been on and the manager was looking for other courses that would benefit the current resident group. Some staff had been identified to go on diabetes training, continence training was also being done and nutritional training had been delivered, in-house, by a dietician. Staff felt teamwork was good and confirmed that staff meetings were held at least 4 times a year. The manager said she tried to hold more meetings than this and minutes of the last 2 meetings were seen. Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 23 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 & 38 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The manager provided effective leadership and support to staff and was aware there were still areas to be improved upon which would benefit the residents. EVIDENCE: The manager was half way through the Registered Managers Award and was hopeful that she would complete it by Christmas 2006. She had been running the home for over 5 years and feedback from care managers, visiting health professionals, residents and relatives, indicated she was caring and committed to her role. Staff felt she had high standards, provided excellent guidance and support and was a fair and even handed manager. Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 24 The home had attained a quality assurance award “Investors in People”, in August 2003 and had been re-assessed in August 2005. The letter confirming the home had been successfully reviewed was seen. The home did however, still need to expand in the quality monitoring and reviewing process and a quality assurance policy had not been written. The new owner was not completing regular monthly reports about the home, known as Regulation 26 visits. These must be done and copies of the reports sent to the Commission for Social Care Inspection (CSCI), Horwich office, each month. Whilst a questionnaire had been formulated for feedback from residents on respite stays, permanent residents and/or their relatives were not regularly asked about whether they felt the care and services could be improved. The manager should implement such a system, including other relevant professionals such as care managers, district nurses etc. Meetings with the residents were said to take place on an informal basis but no minutes were taken. The manager should ensure that such meetings are minuted and that action is taken to show that any suggestions made have been implemented. Both the manager and administrator were aware that improvements in quality assurance were needed and said they would work together on this. A copy of the last CSCI inspection report was not on display within the home and this should be addressed. The finances of 3 residents were checked and all found to be in good order. The administrator had a good system in place where she recorded all income and expenditure. Receipts were obtained from the hairdresser and chiropodist identifying which residents had received a service from them. The home only acts as appointee for 3 residents, following the Department of Social Security’s guidelines. The pre-inspection questionnaire showed that with the exception of the 5 yearly electrical check, all maintenance records were in order and up to date. Random sampling was undertaken of the accident book, fire maintenance, public liability certificate and the Environmental Health Officer’s last report. The 5 yearly electrical check had been done on 23 January 2006. From checking the report it was identified there were 29 areas that needed attention, 18 for urgent remedial work to be undertaken and 11 for correction action to be taken. The manager had only found the electrician’s report when checking for the date of the last inspection for pre-inspection purposes. The previous administrator had filed the document away, without first showing it to the manager. This was why there had been a delay in taking action to address the shortfalls. The manager had discussed this with the owner who had asked for an estimate to be sent in, following which the work would be authorised. Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 25 From checking the staff training matrix, it was noted that whilst the majority of staff had undertaken all the mandatory training a minority had not. The manager was aware of the shortfalls and was in the process of addressing them. Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 26 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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 X X X 2 Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 27 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. Standard OP1 OP7 Regulation 4,5 15 Requirement The Statement of Purpose and Service User Guide must be forwarded to the CSCI office. Care plans must be detailed and relevant information from the pre-admission assessment must be included. Moving and handling assessments must be done upon admission All staff responsible for administering medication must receive training. (Previous timescale of 30.09.05 not met). The manager must ensure that the activities programme is implemented and that the activities are suitable for the current resident group. An audit of all bedroom furniture must be undertaken and where furniture cannot be repaired, it must be replaced. The carpets identified at the inspection, in the residents bedrooms, must be cleaned. The manager must ensure that a safe system is in place in a morning with regard to good DS0000065570.V291144.R01.S.doc Timescale for action 30/06/06 30/06/06 3. 4. OP7 OP9 13 18 30/06/06 31/05/06 5. OP12 16 30/06/06 6. OP19 23 31/07/06 7. 8. OP26 OP26 23 13 30/06/06 30/06/06 Belvoir Care Home Version 5.1 Page 28 9. OP27 18 10. OP30 18 11. 12. 13. OP33 OP33 OP38 24 26 13 hygienic practices to cut down the risk of cross infection. The manager must look at ways of deploying staff to ensure the holistic needs of all the residents are fully met. All staff must receive a minimum of 3 days training per annum, pro rata to their hours. (Previous timescales of 28.02.05 and 31.07.05 not met). A quality assurance policy must be written and implemented. Monthly visits must be made to the home and the report sent to the CSCI office. All remedial work identified in the 5 yearly electrical check report must be implemented . 30/06/06 31/08/06 30/06/06 30/06/06 31/07/06 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 OP3 OP9 Good Practice Recommendations A new assessment document should be formulated which includes all the areas referred to in standard 3.3. Resident photographs should be at the front of the individual medication administration sheets (MAR) and specimen staff signatures should also be obtained and held with the MAR sheets. At the end of the trial period, 4 week menus should be formulated. The complaints procedure should be displayed in the entrance hall. A maintenance and renewal programme should be drawn up by the owner and a copy sent to the CSCI Horwich office. A training matrix should be in place, showing what training each staff member has done and the date it was undertaken. As part of the quality assurance system, more DS0000065570.V291144.R01.S.doc Version 5.1 Page 29 3. 4. 5. 6. 7. OP15 OP16 OP19 OP30 OP33 Belvoir Care Home 8. 9. OP33 OP33 questionnaires should be sent out to relatives, residents and visiting professionals to the home. Residents meetings should be held and minutes recorded. The CSCI report should be displayed where residents and/or their relatives may see it. Belvoir Care Home DS0000065570.V291144.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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. 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