Inspection on 27/07/07 for Belvoir Care Home

This inspection was carried out on 27th July 2007.

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 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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Belvoir Care Home 632 Halifax Road Rochdale Lancashire OL16 2SQ Lead Inspector Jenny Andrew Unannounced Inspection 26 July 2007 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.V343912.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. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 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 F/P 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), Physical disability (1) of places Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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); up to 1 service user in the category of PD (Physical Disability) between the age of 60 and 65 years. 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. 2nd November 2006 2. 3. 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 five double bedrooms, with five 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 £334.98 - £354.98 as at July 2007, the highest fee being for a single en-suite bedroom. Top-up charges of £10 for a single room and £5 for a double en-suite room are charged. Additional charges are made for private chiropody, dentistry, hairdressing, specialist equipment, dry cleaning and some trips out. 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 Commission for Social Care (CSCI) inspection report is displayed in the entrance hall. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The staff at the home did not know this visit was going to take place. The visit lasted seven and a half hours. The inspector looked around parts of the building, checked the records kept on service users, to make sure staff were looking after them properly, as well as looking at how the medication was given out. The files of three members of staff were also checked to make sure the home was doing all the right checks before they let the staff start work. In order to obtain as much information as possible about how well the home looked after the residents, the manager, seven residents, the administrator, three care assistants, the cook and five relatives were spoken to. Before the inspection, comment cards were sent out to residents and relatives/carers asking what they thought about the care at the home. Seven residents and five relatives filled the cards in and returned them to the CSCI. Information from these has also been used in the report. We also asked the manager to give us some information about how she felt about what they needed to do better, what they have improved upon, and what they do well. A random inspection was done on 2nd November 2006 to check whether the requirements made at the last key inspection had been done. There were still six requirements outstanding at that time. On this inspection they had all been addressed. What the service does well: Before new service users came to live at the home, the manager made sure they had all the right details about them, so that they were clear that the home was the right place for them to live and that their needs would be met. The manager and staff at the home offered a friendly, homely service where residents were given choices on a daily basis. The residents spoke well of the staff team, making the following comments: “I’ve every confidence in the staff”, “You don’t need to complain to have things attended to”, “They’re fine”, “Very obliging”, “They go out of their way for you”, “Marvellous”, “Very good” and “The girls are superb”. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 6 The home was good at making sure residents’ health was well taken care of by sending for district nurses and other health care workers whenever they felt they were needed. Residents said they felt well cared for and safe. Relatives’ feedback was also good about health care, with the following comments being made: “The staff were very caring when my mother came out of hospital”, “I’ve not noticed any bad practices whilst visiting”, “I feel the staff work well together with a management team I trust”, “My husband’s health has deteriorated and the staff are always very kind to him”, “I feel they look after my relative to the best of their ability” and “I am very satisfied with how my husband’s health needs are attended to”. The manager and staff team knew how important it was when looking after people, to make sure their privacy and dignity were upheld, to allow them to do as much as possible for themselves and to have choices in their daily routines. Two relatives commented “the residents are treated with respect by the staff” and “residents are treated with dignity, especially when asking if the toilet is needed”. Half of the staff team had now completed their NVQ level 2 or above qualifications, which meant they had been trained in how to look after older people well. What has improved since the last inspection? Information in the Service User Guide and Statement of Purpose had been updated so that any new people would have the right information to decide whether the home was right for them. Each resident had been given a copy of the Service User Guide. At the last inspection a requirement was made for care plans to be more detailed. It was evident that a lot of time and effort had been spent on rewriting the care plans, as they now gave the reader a real picture of the personal, health, social and emotional needs of each person. This meant the staff had all the right information they needed to care for each person. Where residents were felt to be at risk, the manager had written easily understandable detailed risk assessments showing how the risk could be managed so that the resident would be kept as safe as possible. The majority of the staff had received either external or in-house training in respect of food hygiene, infection control, health and safety, moving/handling and fire. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 7 Staff were not starting work until all the right checks had been made so as to try and make sure they were employing people who were safe to work with the residents. A Quality Assurance policy had now been written so that the manager and staff could measure how well they were doing in meeting the needs of the people for whom they cared. 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. The summary of this inspection report can be made available in other formats on request. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 8 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.V343912.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The admission procedure and the information provided would enable potential residents to have a clear idea about the services offered and to be sure that their needs could be met. Standard 6 was not assessed, as the home did not provide intermediate care. EVIDENCE: At the last key inspection, it was identified that the Service User Guide and Statement of Purpose did not contain all the required information. Both documents had now been reviewed and contained information that would help people to decide on whether or not the home was right for them. The good practice of including the summary from the Commission for Social Care Inspection’s (CSCI) last inspection report is acknowledged. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 10 The documents were on display in the entrance hall, together with a full copy of the last CSCI inspection report. Each resident had been given a copy of the service user guide and these were seen behind each bedroom door. Improvements were noted in respect of the information now recorded on the pre-admission documentation. This document included details not only about the person’s health and personal care needs but also in respect of religion, personal history, hobbies/interests and likes/dislikes. One also recorded details of the person’s attorney. Assessments for three residents were checked, two for people on respite stays and one for the most recently admitted permanent resident. All three files contained Service Delivery Agreements and level 3 assessments from the Local Authority who were funding these placements. The manager had also introduced a system whereby any new referrals would be visited in their own homes or in hospital, so she would have first hand knowledge of their health and personal care needs. In respect of the people on respite, the manager said both admissions had been emergency ones and therefore she had not been able to visit prior to admission. However, the home’s assessment documents had been fully completed on the day of admission and the Local Authority had faxed their assessments through the previous day. The manager had visited the permanent resident prior to her admission and full details were recorded on the assessment record. When residents’ health deteriorated to the stage when the staff felt unable to meet the person’s needs, the manager would request a re-assessment from the appropriate health care professional. In discussion with staff, it was identified that due to the deteriorating mental health of one person, this had recently happened and the person had been moved to a home more equipped to meet their needs. This good practice is acknowledged. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. There was a clear consistent care planning system in place, which provided staff with the information they needed to meet the needs of the people for whom they cared. EVIDENCE: Three care plans were checked, including two for people who were on respite stays. At the last inspection, a requirement had been made for the care plans to be more detailed with important information from the pre-admission assessments also to be included. It was evident the manager had put a great deal of time and effort into the reviewing and updating of the care plans with a new format having been introduced. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 12 The three care plans were comprehensive and detailed people’s likes/dislikes and preferences in respect of daily living. One care plan noted “likes to wear jewellery” and another had recorded the emotional state of one resident, together with the reasons so that the staff would know how best to meet their needs. The plans for the people on respite stays were as detailed as those for the permanent stay residents. The plans were written in consultation with the residents and/or their relatives, with signed agreements to the plans being held on file. The care plans were being reviewed on a monthly basis. The residents spoken to during the inspection confirmed they were being well cared for and the support they described as needing matched what was on their care plan. All those spoken with were satisfied with the bathing/showering arrangements and where residents refused a bath or shower, this was recorded on their file. Comprehensive risk assessments were in place for falls, skin care, moving/ handling, dependency, nutrition and any other risks that were pertinent to the individual. Where residents were assessed as being at high or medium risk, a care plan was in place showing the action needed by staff to reduce the risk. One person had a care plan in place in respect of pressure area care. This person and her relative were spoken to and both were satisfied with how she was being cared for. The resident said staff were changing her position in the night and during the day, as per the district nurse’s instructions. A chart was kept in her room that confirmed this. The district nursing service had supplied a special mattress and the records they required staff to complete in respect of pressure area care, were up to date. The home had implemented the Malnutrition Screening Tool and upon admission this was completed and the person’s weight recorded. Records showed that residents were being weighed in accordance with their assessments. Where any dietary problems were identified, the community dietician was consulted. A health care visit sheet, held on each person’s care plan file, recorded any visits made by GP’s, district nurses, dieticians, podiatrists and opticians. Action to be taken following the visits was recorded. The optician was visiting the home on the day of the visit. The systems in place for the receipt, storage, recording, handling and administration of medication were satisfactory. The Medication Administration Records (MAR) examined were up-to-date and where residents had not been given medication, the code letter had been inserted. A new protocol was in place in respect of medication such as creams and painkillers, which may not necessarily be needed on a daily basis. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 13 In the main, controlled drug records were accurate and storage arrangements appropriate. One record identified that due to a spillage of liquid, there had been some mix-up in staff knowing exactly what to record for the remaining medicine. The care assistant and manager sorted this out during the visit. The Boots pharmacist had undertaken a medication audit on 22 June 2007 and had found everything satisfactory. The manager or senior carers were responsible for giving out medication. All had undertaken the necessary training. Two staff had recently been signed up with Manchester College to undertake an in-depth, managing and safe handling of medication distance learning course. At the time of the inspection, there was no-one managing his or her own medication. This was discussed as part of the admission process. All the people spoken to felt they were treated with respect and dignity and that staff ensured their privacy needs were met when they helped them with washing and dressing. The staff spoken with were able to give examples of how they promoted this in their daily routines. These included: closing toilet, bathroom and bedroom doors, closing curtains, encouraging people’s independence when washing/bathing, knocking on doors before entering and keeping people covered up when helping with personal care needs. The home had several double bedrooms, some of which were currently being occupied by two people. These rooms were equipped with full-length privacy curtains and the staff said they always used them when helping residents to dress and undress. Approximately half of the staff had undertaken NVQ Levels 2/3 training and were very aware of the principles of good care practice. Staff always assisted residents to their bedrooms when health care professionals called to see them and this was observed during the visit. Two returned relative questionnaires also commented upon how well staff maintained people’s privacy and dignity when assisting with personal care tasks. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents were able to follow their preferred routines and make daily choices in respect of lifestyle preferences but social activities could be further improved in order to provide social stimulation to the people living at the home. EVIDENCE: A requirement was made at the last key inspection for an activity programme to be written and implemented. The programme was displayed and included activities to suit the needs of the people presently living at the home. An entertainer now visited the home weekly to play the organ and sing and another organisation “Active Minds” visited fortnightly when games and quizzes were enjoyed by the resident group. The staff had spent time with some of the residents doing photograph collages of past events held at the home. These had been displayed to help people remember what had taken place. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 15 An activity book was kept, in which staff recorded what individual or group activities had taken place. From checking through the book, it was evident that staff were spending some time on an individual basis with residents, chatting and having discussions and also doing some group activities, such as bingo, singsongs, skittles and crafts. New talking books had also been purchased which some of the residents were said to enjoy. During the last two months, there were several instances where recordings had not been made. The staff spoken to said it was difficult to motivate many of the residents, as they did not want to join in organised activities but just liked chatting. Two of the residents spoken to identified they did sometimes get bored and one person identified how much she had enjoyed assisting with the planting of flower tubs for the outside of the home. She said she had been promised flower arranging but this had not been forthcoming. Another person indicated more quizzes would be welcome, as she really enjoyed those done by the “Active Mind” entertainer. The staff spoken to confirmed they spent what free time they had chatting with residents but felt they did not have the right skills to get people motivated to do other activities. The manager should now consider how best to meet the needs of those residents who need more mental stimulation. There had been no trips out organised this year but the manager said they were trying to arrange for a meal out in Rochdale for those who wished to attend. No date for this had yet been set. It was relatives who tended to be the ones responsible for taking people out into the community. The religious needs of the present resident group were said to be being met. A Church of England vicar visited on a regular basis, but at the time of the visit, the manager said the Catholic priest was not visiting, as there were no practicising Catholic residents living at the home. Details of people’s religious needs were identified as part of the pre-admission assessment and had been recorded on the care plans seen. 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 two lounges as there were vacant chairs available. Other observations included a resident having chosen to come down from his room in the afternoon, a staff asking where a resident wished to sit and being asked about choice of food. One resident, who shared a room, had advised the manager that she was continually being disturbed by the other person during the night. As a result, the resident’s relatives had been consulted and this person had been moved to her own single bedroom so that she would not disturb anyone. The outcome for both parties was satisfactory. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 16 Whilst residents may handle their own finances, at the time of the inspection, the relatives were tending to have control in this area. One of the care plans seen recorded the involvement of an Enduring Power of Attorney. 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. One person said “when you call the staff are very friendly”, one questionnaire said, “I have always been treated in a friendly manner by all the staff when I have visited with drinks and biscuits being offered” and another said, “they always offer you a drink”. One relative was particularly complimentary about how welcome she was made, adding “I’ve also had several meals at the home and the food is excellent”. Feedback from three returned questionnaires confirmed satisfaction in respect of staff supporting residents to live the lives they chose and two said this was usually the case. Since the last key inspection, new four-weekly menus had been introduced. These included the suggestions which had been made at the residents’ meeting held in February this year. The menus were varied and nutritious and choices were offered at each meal. The main meal was at lunch time with a lighter meal being offered at tea. It was noted that the desserts at lunch and tea were not recorded on the menu. They were, however, listed on the choice sheets which were completed on a daily basis. From checking the choice sheets, it was determined that a variety of milk and fruit based puddings were being served. Feedback from residents spoken to was positive about the food, with the majority describing it as “good”, “fine”, “alright”, “very good”, “lovely” and “smashing”. Two suggestions for improvement were made which were to plate meals up on warm plates and offer more pieces of meat such as chops and steak. The improvement in quality of food since the new provider took over had been maintained and the cook had recently been awarded a bronze award. Mealtimes were unhurried and the tables were appropriately set. Several residents chose to eat where they were sitting in the lounge or in their bedrooms and this was not a problem. The special dietary needs of the residents were being met. Residents said they were given supper drinks and could have biscuits or toast. The choice of meal on the inspection day was home-made meatloaf, boiled potatoes, cauliflower, carrots and gravy or egg and chips. The inspector sampled the main meal. The meatloaf was extremely tasty and the fresh vegetables were not over cooked. The dessert was semolina pudding with jam. The teatime choices were oxtail soup, assorted sandwiches (cheese, beef paste, ham and salad, or tuna and salad) or jacket potato with beans followed by coconut or lemon tart. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 17 The inspector arrived at the home whilst breakfast was being served. Whilst the majority were having cereals and toast, some were enjoying poached eggs and one person was having a bacon sandwich which he was really enjoying. 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.V343912.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. An effective complaints system was in place which relatives and residents were familiar with and staff training and good recruitment practices ensured that residents were protected from abuse. EVIDENCE: A clear, easily understandable complaints procedure was in place which was included in the service user guide and statement of purpose. A copy of the guide was kept at the back of each of the bedroom doors and a copy of the statement of purpose was displayed in the entrance hall. Feedback from the returned resident comment cards indicated they all knew how to make a complaint. This was also confirmed from speaking to the residents. One person said “If I have any grumbles I tell one of the staff and they sort it” and another said “you can tell anyone if you have any problems”. The five relative returned questionnaires also recorded they knew how to make a complaint. One person wrote, “I would speak to Mandy the manager who would deal with it”, another person said, “So far I haven’t had any concerns about my mother’s care and had no reason to complain” and one commented, “You don’t need to complain to have things attended to, you only need to have a word with someone”. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 19 Since the last inspection, two complaints had been recorded in the home’s complaint book and appropriate action to address the complaints had been taken. The staff interviewed were clear that any complaints or allegations 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 not had cause to investigate any complaints at the home since the last inspection. There had been no protection investigations over the last 12 months, although the manager was clear about the necessary policies and procedures to follow. 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. Seven carers had now undertaken the Rochdale MBC’s POVA training and evidence of this was seen on the staff training files. Those staff who had not done the training were to go on subsequent courses and the manager was awaiting dates for these. As the home had a DVD on abuse, it is recommended that those staff who have not undertaken the training watch the DVD and complete the questionnaire, accompanying it. This will raise their awareness of the issues prior to them attending a more in-depth course. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Whilst the home provided a comfortable and safe environment for the people living there, some areas were in need of re-decoration and refurbishment in order to provide a more pleasant place in which to live. EVIDENCE: Several improvements were noted in the building, since the last inspection. New drawers, wardrobe and lockable cabinet had been provided for one of the ground floor bedrooms, two new commodes and two shower chairs had been purchased, one bathroom had been re-decorated and a new washer and drier had been supplied. The manager also said the owner had plans in place to totally refurbish both shower rooms. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 21 It was evident that the owner was gradually upgrading the premises but there were still many areas where re-decoration, new carpets and replacement furniture were needed. One of the first floor bedrooms was malodorous and the manager said even though they were cleaning the carpets daily, it was a constant problem. Discussion took place about providing non-slip alternative flooring, with the consent of the resident and/or their relative. Feedback indicated relatives were also aware of this malodour. Another double bedroom that was inspected had clearly not been re-decorated and re-carpeted for many years and whilst it was clean, it was in need of upgrading. In one of the bedrooms, there was no hanging space for clothes as the wardrobe had been fitted with shelves. The person’s clothes were hanging from the wardrobe handle and hanging space for this person must be provided. The manager said the owner had successfully applied for a Government capital grant and would be prioritising many of these areas upon receipt of the grant money. Residents spoken with were generally satisfied with their bedrooms and said they had been able to bring small personal items in with them. They 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. Whilst there was a small garden area around the home, at the present time, if residents wanted to spend time outside, they had to be supervised due to the steep steps. The manager had asked for a small section to be fenced and a patio area provided so that people could have the freedom to wander in and out at their leisure. She was hopeful this would be done before the end of the summer. An Environmental Health inspection had taken place on 27 February 2007 and the report was seen. The report included comments such as “the kitchen is well managed” and, “good records produced”. No requirements were made. During the inspection, the Greater Manchester Council fire department rang the home to make an appointment to do their inspection on 21 August 2007. Since the smoking regulations had come into force, the staff had to smoke outside the building. Only one resident presently smoked and this person now had to smoke in a storeroom, supervised by a member of staff. Whilst it had a window, the room was small and not a pleasant environment in which to spend any time. Discussion took place about other possibilities and the manager was to look into this. From walking around the building, it was seen to be clean, although on the day of the inspection, the domestic, who was also a senior carer, had been asked to cover the floor so the manager could spend time with the inspector. This meant that only basic cleaning duties were carried out. This is commented upon further in the staffing section below. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 22 Infection control policies/procedures were in place and the staff were observing these. Liquid soap and paper towels were supplied in bedrooms, toilets and bathrooms so that staff assisting residents with their personal care needs could wash their hands before leaving the person’s bedroom. In a morning when people were getting up for breakfast, one person was assigned on kitchen duties so that there was less risk of spreading any infections. At the time of the visit one resident had an infection. Staff were clear about the precautions they needed to take to ensure the infection was not passed on and these practices were being observed. The manager had recently signed up four care assistants with Manchester College to do an in-depth control of infection distance learning course. Adequate laundry facilities were in place and individual baskets supplied for each resident’s clothes. The part-time laundry assistant was on long-term sick and the care assistants were responsible for undertaking laundry duties. Two comments were made, one from a resident and one from a relative about clothing going missing. One resident said she had found someone else’s clothing in her wardrobe. It is recommended that a temporary laundry assistant is employed. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Sufficient trained staff were on duty throughout the day to ensure the needs of the people living at the home were well catered for. EVIDENCE: From checking staff rotas and speaking to care staff and residents, it was evident that since the last key inspection, staffing levels had been reviewed and sufficient staff were now on duty, on each shift, to ensure the residents’ personal care needs could be well met. The staff spoken to confirmed they worked well together as a team. One carer was under 18 and she was spoken with during the visit. She confirmed that her main duties were assisting at breakfast and other meal times, chatting to residents and spending some time on social activities. She said that she did not assist with personal care duties and would not be doing so until she was 18 in three months’ time. She had a caring manner with the residents and it was evident she enjoyed her job. The residents spoke well of the staff team as a whole. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 24 Since the domestic had left, a carer or senior carer was responsible for cleaning the home but this was not highlighted on the staff rota and it gave the reader an inaccurate picture of the care staff on duty. The manager agreed to ensure this was indicated on future rotas. Whilst there is no reason why care staff cannot be designated to undertake domestic duties, one problem was highlighted during the visit. This was in respect of using the designated carer/ domestic for caring duties if a carer rang in sick without any notice or when any other problems arose, thus taking them away from their domestic chores. Whilst the home was clean, feedback from two questionnaires indicated they felt the cleanliness of the home was not as good as previously and one relative was clearly not aware that carers were doing designated cleaning duties. They had commented, “If the cleaner is off, the staff have to help out which takes them away from other duties”. The manager said she would review the current system. The laundry assistant was on long-term sick and the carers were currently responsible for the washing and ironing of clothes. Two residents commented that getting their own laundry returned was sometimes problematic and they sometimes got clothes back that belonged to someone else. The manager said she had already identified these problems and was currently addressing them. Whilst several 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. The men spoken to did not see this as a problem and commented upon how well they were cared for by the staff team. A good age range and ethnic makeup of staff were, however, employed for the all white client group. Information obtained from the Annual Quality Assurance Assessment form, completed by the manager, showed that staff turnover over the past 12 months was fairly low, ensuring that residents received care from staff whom they had got to know and trust. 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 were given a copy of the General Social Care Council “Code of Practice”. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 25 Of the 18 carers employed, nine had completed NVQ level 2 training or above, equating to 50 of trained staff. Of these, three had completed their Level 3 and another carer was currently undertaking it. A further three carers were presently doing their NVQ Level 2 training. The administrator had also successfully completed her NVQ level 2 in care training and on occasions would help out with social activities. It was clear the management team were committed to ensuring the staff received the right training to equip them to do their jobs well. Whilst the manager had implemented Skills for Care training for new staff, they were not always completing this training within the first 12 weeks of employment. The record for one of the staff who had started working at the home in May was not able to be checked as she had taken it home to complete. From checking the training matrix, it was seen that all but the newest staff had completed all the required mandatory training. The training had either been done in-house or externally. From checking individual training files however, it was noted that whilst certificates were in place for the in-house training, the questionnaires, which were a tool for assessing competency, had not been completed. As the questionnaires were a way of demonstrating the staff had understood the training and were part of the DVD training pack, they should be utilised. The training matrix showed that all the care staff had undertaken moving and handling training. However, only six had completed in-depth external moving/handling training, which would properly equip them to move and handle people safely. The manager said those who had watched the DVD, had then been shown by herself how to move and handle people and use the various handling equipment. Whilst the manager had many years of experience, she had not completed the in-depth four-day moving/handling facilitator’s course to equip her to train staff to the required competency level and if she is to continue assessing competency, this needs to be arranged. However, following the inspection, the manager confirmed that those staff who had not received in-depth moving/handling training would be trained by the company facilitator, two weeks from the date of this inspection. The manager was successfully sourcing new external training courses for the staff team, such as medication and infection control. She also said that as soon as the Rochdale MBC Social Services new training programme was available, she would be booking as many places as possible for the different courses on offer. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 26 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home was being well managed which was reflected in the outcomes for residents with regard to the quality of care they were receiving. EVIDENCE: Since the last key inspection, the manager had completed the Registered Manager’s Award and was awaiting verification, which she was hopeful would take place in August. She had been running the home for over six years and feedback on this and previous inspections, from care managers, visiting health professionals, residents and relatives, indicated she was caring and committed to her role. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 27 One relative commented on this inspection, “she’s really on the ball”. Staff commented; “she has high standards, “is good at listening to staff and residents”, “is firm but fair”, “brilliant with the residents and looks out for them” and “gives good support to the staff”. Residents spoken to commented about her as follows: “She’s always around to speak to”, “You can tell her about anything and she’ll put it right” and, “Mandy is very good indeed”. 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 on the last inspection. Following the last key inspection when a requirement was made in respect of quality, the manager had now implemented a quality assurance policy/ procedure. Regular audit checks were taking place in respect of medication, care plans and fire. In addition, a wider range of people had been circulated with feedback questionnaires in respect of the service the home was offering to residents. Returned questionnaires were seen from the visiting district nurse, GP and practice nurse, as well as from relatives and residents. Where comments had been made about how the service could be further improved, there was nothing recorded about whether the suggestions had been taken on board. The manager gave examples where she had done so and said she would, in the future, record action taken to implement suggestions. Whilst the manager said the area manager regularly visited the home, only two Regulation 26 visit reports, dated January and February 2007, were held on file. Copies of the monthly Regulation 26 visits must be sent to the home and be available for inspection. Since the last key inspection, one resident meeting had taken place in February 2007. The manager should consider holding more frequent meetings. Staff meetings had been held regularly and minutes of the last five meetings were seen dating from July 2006 – April 2007. Staff were receiving supervision by the manager with brief recordings taken of the meetings. Training needs were identified as part of these one to one meetings. All residents spoken with were happy with the arrangements regarding personal monies. Where the home had involvement with residents’ monies, appropriate records and receipts were held. The finances of three residents were checked and all found to be in good order. Receipts were obtained from the hairdresser and chiropodist identifying which residents had received a service from them. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 28 Provision of health and safety training had improved, with the majority of the staff having either received external or in-house mandatory training in respect of infection control, moving/handling, food hygiene, fire and first aid, all of which were in order. The manager had just ordered a new bath seat for the fixed hoist, due to a small crack having appeared. Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 29 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 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 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 30 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 Standa Regulation rd OP27 17(2) Requirement The staff rota must clearly show which staff are responsible for domestic duties in order that the rota accurately reflects the hours provided to meet residents’ needs in keeping the home clean. 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. Timescale for action 17/08/07 2 OP33 26 (5)(b) 31/08/07 Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 31 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 OP10 OP12 Good Practice Recommendations Hanging space for clothes should be provided in the identified bedroom in order for the privacy and dignity of that person is upheld. The staff should ensure that the residents’ social needs are met on a daily basis and ensure they incorporate residents’ suggestions such as flower arranging and quizzes on the activity programme. All staff should receive protection of vulnerable adult training so they will know what to do if such an incident arises. The provider should undertake a full audit of the building, identifying areas that are in need of re-decoration and flooring and furniture that is in need of replacement and implement the refurbishment programme over the next 12 months. A temporary laundry assistant should be appointed to cover for the person on long-term sick. The Skills for Care induction training should be completed within the first 12 weeks of employment. Where mandatory training is undertaken in house, the questionnaires accompanying the DVD’s should be completed so that the manager can assess the staff have understood the training. 3 4 OP18 OP19 5 6 7 OP27 OP30 OP30 Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Belvoir Care Home DS0000065570.V343912.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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