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Inspection on 24/05/05 for Belvoir House Care Home

Also see our care home review for Belvoir House Care Home for more information

This inspection was carried out on 24th May 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The staff at the home have mostly worked together for a long time, which helps them work together well. The new owner of the home manages with the help of a deputy manager who has worked at the home for some time. The food is very good: "hot, plenty of choice and variety, fresh vegetables, a good choice of homemade puddings" and a good choice at teatime too. Residents are happy with the quality of care provided. They say that staff are "really lovely", "all of them are nice", "they look after us well".

What has improved since the last inspection?

The ownership of the home has changed since the last inspection and the new owner says he is keen to bring new measures into the home and make improvements. He has started renovating, re-decorating and renewing carpets and curtains. No new staff are employed in the home until a check has been made with the Protection of Vulnerable Adults list.

What the care home could do better:

More staff need to be on duty, especially in the mornings when additional help is needed. Residents said that if enough staff were on duty, they could provide more activities. There needs to be more activities and these need to be more varied. The residents` care plans are mostly well-filled in but need some other details adding to make them complete. The redecoration and improvement programme which has already been started needs to be planned carefully and kept going.

CARE HOMES FOR OLDER PEOPLE Belvoir House Care Home Brownlow Street Grantham Lincolnshire NG31 8BE Lead Inspector Vanessa Gent Unannounced 24 May 2005 10.00 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 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 C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Belvoir House Care Home Address Brownlow Street Grantham Lincolnshire NG31 8BE 01476 565454 01476 565454 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Barnby Gate Limited Mr Naraindranath Jagroo Care Home 24 Category(ies) of Old Age (OP) not falling within any other registration, with number category - 24 of places Belvoir House Care Home C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 30/12/04 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-cum-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 C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over eight hours, by one inspector. A brief tour of the premises took place. Three residents and one relative were spoken with; eight ladies chatted with the inspector during and after teatime; three staff, including the deputy manager were interviewed. The files (care plans) of three residents were examined and checked against other documents in the home (this is called case-tracking) and staff records were checked. The new home owner/manager has only been in post for one month and understands he has lots of work and organisation to do to maintain current good practices and improve conditions in the home further for the residents and staff. What the service does well: What has improved since the last inspection? What they could do better: Belvoir House Care Home C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 Page 6 More staff need to be on duty, especially in the mornings when additional help is needed. Residents said that if enough staff were on duty, they could provide more activities. There needs to be more activities and these need to be more varied. The residents’ care plans are mostly well-filled in but need some other details adding to make them complete. The redecoration and improvement programme which has already been started needs to be planned carefully and kept going. 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 House Care Home C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Belvoir House Care Home C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 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 standard(s) 2, 3, 4 The home thoroughly assesses prospective residents and informs them that they can meet their needs. Contracts of terms and conditions confirm this. EVIDENCE: Care plans demonstrate that the new provider/manager visits and assesses new residents and that the manager informs the resident or relative of the home’s ability to meet the needs of the resident. As well as the pre-admission assessment, the care plans contained a Community Care Assessment from Social Services, which, together with the pre-admission assessment, formed the basis of the care plans for this resident and provided staff with the knowledge to be able to care adequately for the resident. A terms and conditions contract was in place in each of the care plans examined, detailing the room to be occupied and dated and signed by all relevant parties. A relative said they “liked the happy environment when we came to look at the home & haven’t been disappointed”. Belvoir House Care Home C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 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 standard(s) 7, 10 The care plans give a good insight into the needs of the residents and how to manage those needs. A social history would give an even better ‘picture’ of the residents’ lives and needs. Residents are well-cared for, with staff being appreciated by both residents and relatives. EVIDENCE: Care plans are generally well-completed but no social history was seen in any care plans examined and most sections, including risk assessments, the activities of daily living and the care plan issues or needs are not dated on completion or when discontinued. The risk assessments are reviewed 3 – 6 monthly and the care plan issues monthly. The daily evaluation sheets describing all aspects of the physical, nutritional and emotional situations and events and the moods of the resident are wellcompleted and comprehensive and give a good ‘picture’ of the life of residents at the home. Residents say their privacy and dignity is respected at all times; staff were seen to knock at residents’ bedroom doors and wait before entering. Staff Belvoir House Care Home C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 Page 10 spoke with residents in a happy, polite manner and residents confirmed that this is the norm. Belvoir House Care Home C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 15 Activities are considered important by residents but are not in evidence enough for their liking and wishes. Visitors and relatives are made to feel welcome and part of the home ‘family’. The food is varied, freshly prepared and enjoyed by all residents. EVIDENCE: There is no designated activities organiser at the home. Residents say that only when five staff are on duty in the mornings do they ever get games and exercise and they would like more. Staff say they are often too busy but are keen to do more activities with the residents. The inspector watched staff, visitors and residents enjoying ‘olde tyme’ dancing to music in the lounge during the morning, with those unable to join in, clapping and foot-tapping. A visitor said it was “lovely but doesn’t happen often enough”, “they could do more with activities”, “staff are often too busy”. Visitors say they can visit at any reasonable time and are made to feel welcome. Although the lunch-time choice of food is limited, residents say they see what is on the menu for the following day and can and do order alternatives. Eight ladies who chatted to the inspector during and after tea said that “the food is very good, they’ve no complaints” and the sandwiches at teatime are “fresh, varied and delicious and the cakes are often homemade”. In residents’ rooms were a jug of water and bowl of fresh fruit. Belvoir House Care Home C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 Page 12 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 standard(s) Not inspected. EVIDENCE: Belvoir House Care Home C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19, 20, 22, 24 Residents live in safe and comfortable surroundings, both privately and communally and are happy with their environment. EVIDENCE: The new owner/manager has commenced some decoration and renewal of carpets, curtains and fabrics but says he needs time to settle in to determine the priorities of what needs doing and in which order. The hot water in the residents’ rooms is a safe temperature; radiators are not too hot to touch. The communal areas are adequate in size to meet the needs of the residents. Specialist equipment is installed such as grab rails, bath hoists and seats, hoists and slings, a ramp from the front door to street level. A call bell system is in use. Staff answered call bells quickly. The garden is easily accessed, safe and pleasantly set out. Where bedrails are used, authority for these has been obtained, dated and signed for. Bedrails are covered and safe for use. One resident stated that her room is “very comfortable”. It was personalised with photos and personal belongings and her own bed cover. Belvoir House Care Home C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Residents are well-cared for by a friendly, helpful team of staff and supported by the deputy manager and the new owner/manager. Residents wish to have more staff available to provided a greater variety of activities. EVIDENCE: Residents say that they feel there are insufficient staff on duty in the mornings to meet their wishes and needs for regular activities. They also say that the staff are “really lovely; all of them are nice; they look after us well.” A relative stated that there is a “good lot of staff; very friendly; helpful”. Staff state that they “work together in a good team” and that the manager and deputy manager support them in their work. Belvoir House Care Home C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 37, 38 The care and health and safety practices of the manager and staff ensure that the residents are kept safe at all times. EVIDENCE: Staff state that they are “sure they’ll get on with the new manager OK”. Residents say he is friendly and chats to them. The deputy manager is a first level nurse with thirty year’s experience in the care ‘industry’ and a managerial qualification. The owner/manager and deputy manager work closely together to manage the home efficiently. Staff say they respect the deputy manager who is very supportive. The owner/manager states that even though he is at the home every day, he intends to complete the Regulation 26 visits as required and to submit a report every month. Records seen for the safe maintenance of the premises are up-to-date, including fire and environmental health and health and safety. Accidents and Belvoir House Care Home C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 Page 16 falls are recorded in books used prior to the ones now recommended which do not comply with the confidentiality of information. Care plans are stored in a lockable filing cabinet. Requirements for making residents safe, as with covering bedrails and supplying a specialist toileting sling for the hoist, have been complied with since the previous inspection. Belvoir House Care Home C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 x 3 x 3 x x STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x 3 3 x x x 3 3 Belvoir House Care Home C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 Page 18 19 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. Standard 12 Regulation 16.2.n Requirement Sufficient activities must be provided to ensure the needs and wishes of the residents are met. The fabric and decoration of the home must be kept in a good state of repair. There must be an adequate number and skill mix of staff on duty at all times to meet the needs of the residents. Timescale for action 30/09/05 2. 3. 19 27 23.2.b 18.1.a 30/09/05 30/06/05 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. Refer to Standard 37 Good Practice Recommendations It is recommended that only one accident or incident is recorded per page in the accident book. Belvoir House Care Home C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection Unity House, The Point Weaver 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. Extracts may not be used or reproduced without the express permission of CSCI Belvoir House Care Home C53 C04 S2588 Belvoir House V228888 240505 Stage 4.doc Version 1.30 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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