Inspection on 24/01/07 for Belvoir Lodge

This inspection was carried out on 24th January 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

Similar services:

Hillside

Applegarth

122 Scorer Street

St Marys Nursing Home

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

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

CARE HOME ADULTS 18-65 Belvoir Lodge 243 Edwards Lane Nottingham NG5 6EQ Lead Inspector Rob Cooper Key Unannounced Inspection 24th January 2007 09:45 Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 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 Lodge DS0000068441.V328580.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 Adults 18-65. 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 Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belvoir Lodge Address 243 Edwards Lane Nottingham NG5 6EQ 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) 0115 9621315 0115 9622867 Scope - Terry Boardman (c/o Rutland House School) Paula Henderson Care Home 5 Category(ies) of Learning disability (5), Physical disability (5), registration, with number Sensory impairment (5) of places Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Belvoir Lodge Transition Service is registered to provide accommodation and personal care for a maximum of five (5) people aged between 16 years old and 25 years old, whose primary care needs are Learning Disability (LD) - 5, Physical Disability (PD) - 5, Sensory Impairment (SI) - 5 None Date of last inspection Brief Description of the Service: Belvoir Lodge is a five-bedded care home owned and managed by Scope, and situated in a converted bungalow. The bungalow is largely open plan to accommodate residents in wheelchairs, and there is an overhead tracking system for the hoist, so that residents can be moved easily from their bedrooms to the bathrooms. The entire bungalow is very well equipped with specialist bathing options and units within the kitchen that can be raised or lowered to accommodate wheelchair users. Currently the service is aimed at young adults who have either left school, or who are about to. The bungalow is situated on a main road with car parking spaces to the front. There is a bus stop right outside the bungalow, and the service is situated close to the City Hospital, and local shops, and other facilities. Fees: Currently range from £2,506 to £3,108 per week Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection – so that no one at Belvoir Lodge knew that the inspection was going to take place. The inspection took approximately three hours through the middle of the day with one Inspector present. The method used to carry out the inspection was to send out a questionnaire, which asked questions about the service, to gather statistics, such as how many service users there are, the numbers of staff etc. This was followed with a visit to Belvoir Lodge, where a method called case tracking was used; this involved identifying three residents and looking at their individual files and making a judgement about the quality of care they are receiving, and if their needs are being met. This was done by a partial tour of Belvoir Lodge, looking at the activities on offer, and talking to staff. Unfortunately the residents at Belvoir Lodge all have major communication difficulties, and profound learning disabilities which made it very difficult to gain their views on the service they are receiving. Therefore body language was observed, together with the staff approach to individuals to help gauge the quality of the service. Two members of staff were also spoken with to get their views on how resident’s needs are being met. What the service does well: The bungalow in which the service is located is very well equipped and maintained, and is designed to meet the needs of the people who live there. There are a number of aids and appliances to help people with restricted mobility, and issues around bathing, and the environment generally is clean, warm and homely. All of the residents at Belvoir Lodge have major communication difficulties, however the input of the speech and language therapist together with the staff means that there are some excellent examples of the use of communication aids to overcome these problems, and ensure that residents have choice, and are able to express their needs. Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 6 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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Prospective residents at Belvoir Lodge have the information they need to make an informed choice about where to live. Prospective residents at Belvoir Lodge have their individual aspirations and needs assessed. EVIDENCE: The Statement of Purpose and Service User Guide for Belvoir Lodge were both seen. The Statement of Purpose contains all of the information that Care Homes Regulations say that it should. Belvoir Lodge opened in September 2006, and as such the Service User Guide is a work in progress. The current document contains a great deal of useful information about the service being offered at Belvoir Lodge, however as day-to-day activities are being developed, this information is being updated, and the final version of the Service User Guide has not yet been arrived at. Three resident’s care files were seen as part of the case tracking process. Each file contained detailed assessments by a range of professionals, covering areas such as communication, mobility, and social skills. It was clear that the assessments had been completed before individuals moved into Belvoir Lodge, and that the assessments formed the basis on which their care is planned. Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 67&9 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Residents know their assessed and changing needs and personal goals are reflected in their individual plan of care at Belvoir Lodge. Residents at Belvoir Lodge make decisions about their lives with assistance if needed. Residents at Belvoir Lodge are supported to take risks as part of an independent lifestyle. EVIDENCE: Each of the three resident’s files that were seen, contained a clear plan of care, based on their individual assessments. Documentation within the files was clear, and identified resident’s needs and how they would be met. During the inspection the speech & language therapist was in the building, and they demonstrated how a scratch and sniff book – relating to colours was being used to aid choice and decision-making. In addition each resident had a communication book, in which there were choices identified, and these were further identified through a systematic method of working through the options. Residents at Belvoir Lodge currently all have major communications difficulties, Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 10 but the professional and consistent approach means that difficulties around choice and decision-making are minimised. Staff were seen working with individuals using the communication aids, and this was being done a respectful and caring manner, with residents appearing relaxed and happy. All three files contained detailed risk assessments covering both individual needs and risks, and more general risks related to everyday living. The risk assessments were clear and easy to understand, and followed a logical approach to the management of the risks. Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 & 17 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Residents are able to take part in age, peer and culturally appropriate activities. Residents at Belvoir Lodge are part of the local community. Residents at Belvoir Lodge have appropriate personal, family and sexual relationships. Resident’s rights are respected and responsibilities recognised in their daily lives. Residents are offered a healthy diet, and enjoy their meals and mealtimes. EVIDENCE: Belvoir Lodge have an activity book to record the activities that residents are involved in, with photographic evidence to support the activities taking place – as a digital camera is usually on hand to record activities. During the inspection there were a number of activities taking place within the building, and examples of resident’s artwork was also on display. Documentary evidence in files showed that there are a range of different activities organised Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 12 for residents. The observation of these activities was of a relaxed session, which seemed to be being enjoyed by both the residents and the staff. Belvoir Lodge is located on a main road approximately two miles from the city centre. Evidence seen within files shows that residents are using local community facilities, and spending time away from Belvoir Lodge engaged in activities. Some of the residents spend the weekend with their family away from Belvoir Lodge, and there is an open door policy for family visiting, although currently all of the residents at Belvoir Lodge are out of county placements, which means that their immediate family are not living in Nottinghamshire. Documentary evidence in the resident’s files evidenced that there is regular family contact. Two residents share a bedroom, which they have been doing for many years in residential care; the long-term nature of their relationship/ friendship is promoted by the staff at Belvoir Lodge. The profound nature of the resident’s learning disability means that staff do take responsibility for many of the tasks involved in everyday living, however as already identified the speech and language therapy department are working with the staff and residents to maximise communication, through which residents will be able to take more responsibility within their own lives. The kitchen has been equipped with worktops that are able to rise and fall, so that residents in wheelchairs are able to access them. The menus are interactive with pictures and signs and symbols used so that residents are able to make choices, and are involved in the process of choosing food. Food storage and preparation areas were seen to be clean and well organised, and records relating to food were found to be correct and complete. Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 & 20 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Residents at Belvoir Lodge receive personal support in the way that they prefer. Resident’s physical and emotional health needs are met at Belvoir Lodge. Residents, where appropriate retain, administer and control their own medication, and are protected by Belvoir Lodge’s policies and procedures for dealing with medication. EVIDENCE: The residents at Belvoir Lodge require a high level of personal support, through the use of communication aids, and hoists the staff are attempting to meet the personal care needs of the residents in a way that causes the minimum amount of upset. Belvoir Lodge is very well equipped with standing frames and hoists, and there is an overhead tracking system for moving residents easily from their beds to the bathroom. There was clear evidence of the staff having tried to personalise the bathrooms, to make them more comfortable for the residents. Within each of the three resident’s files that were seen, there were care plans relating to health care needs. These care plans identified the resident’s Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 14 specific needs, and how they would be met. There was an ongoing record in each of the files of healthcare professionals involvement, and a nurse calls at Belvoir Lodge on a daily basis, while the doctor will routinely visit weekly. A nurse is available for advice twenty-four hours a day, and documentation showed that resident’s healthcare needs are well catered for at Belvoir Lodge. Belvoir Lodge uses a monitored dosage system, which is supplied by Boots (the Chemists). This system provides each resident with a weekly card, which contains each dose of medication in a blister pack, for ease of the staff dispensing it. The records relating to ordering, dispensing, and where appropriate destroying or returning medication to the pharmacy was seen, and all found to be complete and correct, with no obvious errors or omissions. Medication was also seen to be stored securely. No resident at Belvoir Lodge self-medicates. Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Residents at Belvoir Lodge feel their views are listened to and acted upon. Residents are protected from abuse, neglect and self-harm. EVIDENCE: Belvoir Lodge opened in September 2006, and so far has not received any complaints. The complaints procedure is on display around the building, and forms part of the Service User Guide. Relatives are encouraged to air their views, when visiting and so far the feedback has all been positive. Staff training records were seen, and these showed that all members of staff have received training in child protection – with the age of the resident’s and the close links with the school, this training has so far been offered rather than safeguarding adults, although discussions with the manager identified that there are plans in place to offer safeguarding adults training to staff as the residents get older. Two members of staff were asked about training around issues of abuse, and both said they had received this training, and were aware of the procedure should they encounter abusive behaviour or practice. Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 27 & 30 Quality in this outcome area is excellent; this judgement has been made using available evidence including a visit to this service. Residents at Belvoir Lodge live in a safe, homely and comfortable environment. Resident’s bedrooms suit their needs and lifestyle. Resident’s bedrooms promote their independence. Resident’s toilets and bathrooms provide sufficient privacy and meet their individual needs. Belvoir Lodge is clean and hygienic. EVIDENCE: Belvoir Lodge is situated in a tastefully converted bungalow, the fixtures and fittings are to a high standard, and the design of the building has taken into account the needs of the residents, with an open plan design, and wide doors for access. There are many design features to help residents – ramped access to the front and rear, overhead tracking systems, double doors, and as already mentioned units within the kitchen which are able to raised and lowered to accommodate residents in wheelchairs. Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 17 All four bedrooms at Belvoir Lodge were seen, each one showed a good level of personalisation, with many of the personal items having been brought from home. The bedrooms are well equipped, and decorated in a style and colours scheme of the resident’s choosing. The one shared bedroom is large enough to comfortably accommodate two people and has screens to ensure that resident’s privacy and dignity are promoted. The bathroom at Belvoir Lodge are designed to meet the resident’s needs are located either en-suite, or directly across the corridor from the resident’s bedroom door (close enough to practically be en-suite). There is a range of bathing options available with Parker baths, and shower trolleys, and residents have expressed a preference, and use the type of bathing option they prefer. Each of the bathrooms had a good stock of gloves and aprons, and the toiletries being used were personalised and were of a good quality. On the day of the inspection Belvoir Lodge was found to be clean and tidy, with no odour or signs of stained carpets. Staff were seen cleaning and hoovering throughout the inspection, and the impression created was of a pleasant homely environment. Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32 35 & 36 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Residents are supported by competent and qualified staff. Residents at Belvoir Lodge have their individual and joint needs met by appropriately trained staff. Resident’s at Belvoir Lodge benefit from well-supported and supervised staff. EVIDENCE: The staffing rota was seen, and this showed a good skill mix through the staff team, and a level of different staff with levels of seniority and experience. Additional support is available (if needed) from other homes in the group locally, and this includes the services and advice of a qualified nurse. Staff training files were seen, and these showed that there was a good training programme in place for all staff, covering training issues relevant to the work being undertaken. Further discussions with one member of staff around training issues identified that this member of staff thought they had been well trained and had access to on-going staff training. Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 19 The staff files also contained information relating to formal supervision, and showed that staff have a regular formal supervision session with a senior member of staff. Discussions with one members of staff confirmed that there is regular (approximately) six weekly staff supervision. The staff member said they felt very well supported within their role, and that additional support was always available. Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 & 42 Quality in this outcome area is good; this judgement has been made using available evidence including a visit to this service. Residents at Belvoir Lodge benefit from a well run home. Residents are confident their views underpin all self-monitoring, review and development by Belvoir Lodge. The health, safety and welfare of residents and staff at Belvoir Lodge are promoted and protected. EVIDENCE: The manager of Belvoir Lodge is suitably qualified and experienced to be running the home, and has been through the Commission for Social Care Inspection’s own screening process. With communication being a major problem for the residents, there are not resident’s meetings as such organised within Belvoir Lodge. Instead there are one to one meetings, with the input from the speech and language therapist, Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 21 and individual issues are addressed, rather than taking a bigger group approach. A range of health & safety records were seen including those relating to fire and the Control of Substances Hazardous to Health (COSHH) these were all found to be correct and complete. One member of staff was asked about health & safety training, and they said that some of the training they had received was around health & safety issues, which was confirmed by the staff training records. Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 4 26 X 27 4 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Belvoir Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Lodge DS0000068441.V328580.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!