Inspection on 20/10/05 for Belvoir House Care Home

This inspection was carried out on 20th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Belvoir House Care Home 19/04/07

Belvoir House Care Home 21/04/06

Belvoir House Care Home 24/05/05

Belvoir House Care Home 30/12/04

Belvoir House Care Home 02/09/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Belvoir House Care Home Brownlow Street Grantham Lincs NG31 8BE Lead Inspector Mick Walklin Unannounced Inspection 20th October 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Belvoir House Care Home Address Brownlow Street Grantham Lincs NG31 8BE 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) 01476 565454 01476 565454 Barnby Gate Ltd Mr Naraindranath Jagroo Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2005 Brief Description of the Service: Belvoir House is a detached, nineteenth-century, stone property, raised above pavement level, situated approximately 200 metres from the town centre of Grantham and a variety of shops and amenities. The home is registered to provide personal care for twenty-four older people of both sexes. Accommodation is situated on two floors and is served by a shaft lift. There are sixteen single and four double bedrooms, one lounge/dining area and a separate lounge. An enclosed patio and garden area is situated at the front of the property. A ramped area gives direct access from the front door to the street. The home does not have its own car park. There is a payphone for the use of residents. Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 7 hours. A tour of the premises was conducted with the manager. The main method of inspection used was called case tracking which involved selecting four residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. Two visitors were also interviewed, and a range of other documents were inspected. What the service does well: What has improved since the last inspection? 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 Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 6 contacting your local CSCI office. Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 5. The procedure for introducing prospective new residents to the home is satisfactory, with sufficient assessment material being available for staff to meet their needs. EVIDENCE: Following an enquiry from a Social Worker, one resident was recently admitted directly from Grantham Hospital. The admission was originally for respite care, and because of the circumstances of the admission, it was not possible for her to visit prior to admission, although her relatives did. Assessment information from the hospital was received by the care home, together with a discharge summary. The home’s Statement of Purpose states that they aim to complete the assessment and care plan within 24 to 48 hours, and this was done in this instance. All admissions are for a trial period of two weeks. Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 9 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. Care plans provide a good range of information in a concise format, and prepared with the involvement of residents or their representatives. There are good arrangements with local health care services. The home should obtain a supply of the new style accident report forms. EVIDENCE: Care plans are of a satisfactory standard, containing concise information about residents care needs. Assessments are based on activities of daily living, and also include manual handling plans. A range of risk assessments are in place, including risk assessments and consent for cot sides. Files contain a care plan agreements, signed by the resident of their representative, and all care plans had been reviewed on a monthly basis. A record of GP visits is kept, which provides evidence that health problems are brought to the attention of the GP promptly. District nursing notes are also kept in the home. The home is still using the old type of accident reporting, which do not maintain confidentiality, and it is recommended that a supply of the new forms is obtained. Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 10 Medication is appropriately stored, and medication administration records are well kept. Staff confirmed that they use the Safe Handling of Medication course distance learning pack. Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 11 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, 14 & 15. Social activities and leisure opportunities have improved for residents, but a more comprehensive programme is needed. Visitors are well received by staff. Menus could offer a greater variety. EVIDENCE: The previous inspection report highlighted that there were insufficient activities available for residents. However, a system has been introduced to record activities on an individual basis, and this showed that there was an increase in activities available since the end of September. The manager is hoping to recruit an activity co-ordinator for around four and a half hours per week. Staff said that residents can be difficult to motivate and get involved in activities, and although there is no structured activity plan, they gave examples of sessions that they do provide. These include dancing, exercise to music, dominos and ball games. A Halloween party is being organised. Staff and residents gave examples of how choice is promoted relating to routines and daily living, and residents said that staff respect their choices. One resident said that he receives visitors twice a week, and that they are well received by staff, who are polite to them. Two people, who were visiting at the time, confirmed this. A payphone is situated in the hallway for residents. Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 12 A cook is employed for 35 hours per week, and a carer covers the other two days. Menus are on a two week rotation, and it is recommended that these be expanded to offer residents more choice and variety. A Social Worker commented that residents only have the choice of cereals and toast for breakfast. Staff explained that boiled eggs are available, and that grapefruit has recently been added to the menu. There is also more choice at tea time, following comments from residents. A menu board is situated outside the dining area, but this did not appear to be in use. Other comments included the fact that residents are sometimes sat at the table long before the meal arrives, and that the gap between lunch and tea can be short, with a long gap between tea and breakfast. Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Arrangements for complaints and adult protection issues are satisfactory, and staff are aware of the correct procedure to follow. EVIDENCE: No complaints have been recorded since 2001. The complaints policy is displayed in the entrance hallway, and staff demonstrated a knowledge of the procedure to follow. A copy of the Lincolnshire Adult Protection Committee policies and procedures are available for reference, and staff gave the correct answer to an adult protection scenario. The manager is at present reviewing training to check that staff are receiving updates. Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 14 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. The home provides a comfortable and homely environment for residents, but some carpets require replacement. EVIDENCE: The home was generally well maintained. Previous inspections had highlighted issues about some carpets which require replacement. The manager confirmed that these are on order, and should be fitted shortly. The home was clean and pleasant smelling at the time of the inspection. Two cleaners/laundry assistants are employed, and their roles rotate. Night staff also have a rota to clean some areas of the home. Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 15 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, 29 & 30. Staffing levels are not adequate at present, but new staff are due to be recruited in the near future to ensure that there are sufficient staff to meet the needs of residents. EVIDENCE: A Social Worker had passed on concerns to the Commission from relatives about staffing levels, and had discussed these issues with the manager. The manager confirmed that two new staff have recently been recruited, and that two other staff were being recruited. The manager is covering a lot of shifts at present, which is having an impact on his supernumerary time, and the organisation of the care home. Staff commented that “it is hard work at the moment” and that the staffing levels do have an effect on residents in that “we don’t always have time to sit and chat with them”. However, staff were observed to attend to residents needs promptly when they summoned help. There was evidence of a formal recruitment and selection procedure, but some documentation was missing, and this is covered in standard 37. Staff training was not fully inspected, but the manager is reviewing training needs to ensure that staff receive mandatory training updates. He is also approaching NVQ providers to ensure that staff have access to these courses. Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 16 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): 32, 33, 35, 36, 37 & 38. Staff feel well supported, although formal supervision should be on a more regular basis. Procedures for staff recruitment are not robust enough for the protection of residents. Some health and safety issues were identified. EVIDENCE: The manager is clearly committed to making improvements to the home, but lack of supernumerary time is having an impact on this. Staff said that they were involved and consulted in the running and organisation of the home. They said that they are express opinions and communication is good at all levels within the home. The manager and deputy were described as very approachable and supportive. A quality assurance questionnaire was circulated to residents in July 2005, and it is recommended that this be repeated on an annual basis to include the Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 17 views of residents, relatives and stakeholders. The manager said that there are plans to do this. Arrangements for accounting for residents personal money were satisfactory, and three balances checked were correct. Although staff said that they are well supported, formal supervision is not occurring. It is recommended that this occurs six times per year. Staff files did not contain evidence that pre-employment checks had been conducted for the protection of residents. Three staff files were examined. All three staff had been employed prior to obtaining satisfactory Criminal Records Bureau checks, and two had been employed with only one written reference. The manager said that he had misunderstood guidance given by an inspector about commencing staff with a POVAFirst check, and he was advised to contact his CRB Umbrella Body. There were no photographs on the residents files inspected, as required. Health and safety documentation was inspected during the previous inspection, and found to be up to date. Risk assessments were generally good, but it is recommended that these be reviewed more regularly. During a tout of the building, the following health and safety issues were identified: • • • • The storage and use of Steradent must be risk assessed. The laundry/boiler room is not locked. The boiler has hot pipes, which could potentially injure residents. The high seat on a downstairs toilet had a piece of metal protruding from it, which could potentially injure residents. Alcohol based hand sanitiser is situated in some areas of the home accessible to residents, and this must be risk assessed. Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 18 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 x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 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 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 3 x 3 2 1 2 Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP12 Regulation 16 Requirement The registered person must ensure that sufficient activities are provided to ensure the needs and wishes of the residents are met. (Some progress has been made on this requirement – timescale extended). The fabric and decoration of the home must be kept in a good state of repair. Some carpets require replacement. (Some progress has been made on this requirement – timescale extended). The registered person must ensure that the home has an adequate number and skill mix of staff on duty at all times to meet the needs of the residents. (Some progress has been made on this requirement – timescale extended). The registered person must ensure that the documentation outlined in Schedule 2 is obtained prior to employing staff. The registered person must DS0000002588.V259795.R01.S.doc Timescale for action 31/12/05 2 OP19 23 31/12/05 3 OP27 18 31/12/05 4 OP37 19 20/10/05 5 OP37 17 31/12/05 Page 20 Belvoir House Care Home Version 5.0 6 OP38 13(4) ensure that service user files contain a photograph of them The registered person must 30/11/05 ensure that the health and safety issues identified are attended to. 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 OP8 OP15 Good Practice Recommendations It is recommended that a supply of the new style accident forms be obtained, which have one accident reported per page. It is recommended that menus be expanded to offer residents more choice and variety, and that meal times are reviewed to ensure that there are sufficient gaps between meals. It is recommended that the home conduct an annual quality monitoring survey. It is recommended that formal supervision staff occurs six times per year. It is recommended that risk assessments be reviewed more regularly. 3 4 5 OP33 OP36 OP38 Belvoir House Care Home DS0000002588.V259795.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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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