Inspection on 01/11/05 for The Bell House

This inspection was carried out on 1st November 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

The Bell House 09/05/06

The Bell House 14/07/05

The Bell House 29/11/04

The Bell House 24/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Bell House 61 Wilshaw Road Meltham Huddersfield West Yorkshire HD7 3DX Lead Inspector Karen Summers Announced Inspection 1st November 2005 08:30 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 The Bell House DS0000026265.V262761.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. The Bell House DS0000026265.V262761.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Bell House Address 61 Wilshaw Road Meltham Huddersfield West Yorkshire HD7 3DX 01484 850207 01484 852101 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) Mr Parvaiz Ahmad Dr Shireen Qureshi Ahmad Mrs Lynda Margaret Quinn Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places The Bell House DS0000026265.V262761.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th July 2005 Brief Description of the Service: The Bell House is a privately owned care home registered to provide accommodation and care for up to 24 older people. The establishment is situated in a rural area on the outskirts of the village of Meltham, with panoramic views over the surrounding countryside. Public transport is accessible with a bus stop directly outside the home. The property, an extended bungalow, is generally well maintained to an acceptable standard. all bedrooms being for single occupancy, with eight having the provision of en-suite facilities. Communal areas are spacious and comfortable, with a well ventilated smoking area for the user of the service users who smoke. Well maintained garden and grounds are povided for the use of service users in the warmer weather. The Bell House DS0000026265.V262761.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an announced inspection on the 1st November 2005, commencing at 8.20am and the duration of the inspection was 7.5 hours. Dr Ahmad, proprietor and Mrs Lynda Quinn, manager, were present throughout the inspection. The following inspection methods have been used in the production of this report; sampling of records, care plans, individual discussion with five service users, six relatives, one member of staff, a district nurse, an NVQ assessor/ facilitator, tour of the premises and document reading. What the service does well: What has improved since the last inspection? What they could do better: In relation to care documentation; a Tissue Viability assessment should be used to identify those service users who are at risk of developing a pressure sore, and the activities that individual service users take part in on a day-today basis should also be recorded. There should be a self-administration of medicine risk assessment and procedure to follow should a service user wish to administer their own medication. To prevent scalding, the pre-set valves on hot water taps should be set no higher than 43 degrees centigrade. The hand washbasin taps in service users bedrooms should be kept clean and the area of wall behind the hand-wash basins should be tiled, and sealed where the tiles meet the basin to enable them to be cleaned correctly. Areas of the home continue to be in need of redecoration and refurnished, and the provider has scheduled redecoration to take place by the end of the year. Eight members of staff had not had a fire lecture for nineteen months. Further training has been arranged for 8/11/05, then all staff will have had up to date training. The outstanding work regarding fire safety has also been identified to The Bell House DS0000026265.V262761.R01.S.doc Version 5.0 Page 6 take place. Failure to comply with this requirement may lead to further action being taken. 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 Bell House DS0000026265.V262761.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 The Bell House DS0000026265.V262761.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): EVIDENCE: These standards were not inspected on this occasion. The Bell House DS0000026265.V262761.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 The service user’s health, personal and social care needs are set out in an individual plan of care. Service users are treated with respect and their right to privacy is maintained. EVIDENCE: Lynda and her staff have worked hard in developing and up dating the care records, and they were comprehensive and informative. A tissue viability assessment (to identify the risk of developing pressure sores) should also be carried out at admission, using a recognised assessment tool and also be reviewed at regular intervals. Two of the service users who were spoken with said that the staff were kind, and that they could not do enough for them. Relatives also said that the care was good and that staff were friendly and kind. One relative requested a lock for their relative’s door, and a lockable drawer in their room, of which the owner agreed to provide. Medication housekeeping was of a good standard. There should be a self administration of medicines risk assessment and procedure to follow should a service user wish to administer their own medication. The Bell House DS0000026265.V262761.R01.S.doc Version 5.0 Page 10 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 - 15 Contact with family, friends and the local community are encouraged and maintained wherever possible. Until the activities that service users are involved in on a daily basis are recorded, there is no evidence to suggest that they take place. EVIDENCE: Service users are encouraged to maintain contact with their family and friends and they are always made welcome. Main events that take place in the community and inside of the home were recorded however; the relatives spoken with did not think that a lot of activities were taking place on an individual basis, and none had been recorded. Activities that take place with individuals on a daily basis should be recorded. The Bell House DS0000026265.V262761.R01.S.doc Version 5.0 Page 11 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): EVIDENCE: These standards were not inspected on this occasion. The Bell House DS0000026265.V262761.R01.S.doc Version 5.0 Page 12 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, 21, 25 & 26 Service users continue to live in a homely environment however, not all areas of the home are well maintained, clean and a pleasant place to live. Until the radiators and hot water pipes in service users areas are appropriately covered service users are potentially at risk of being burnt. EVIDENCE: The main lounges were comfortable and satisfactorily decorated however, the corridors, bathrooms and toilets are showing signs of wear, and wallpaper continues to be torn and lifting away from the wall on the east corridor. In the bathroom located opposite the office, and the adjacent toilet, the floor coverings have been renewed however, debris is starting to collect around the edge of the floor coverings and therefore the edges should be sealed to aid cleaning. The provider has confirmed that the decoration will take place by the end of the year. Unprotected hot water pipes and radiators in service users’ areas must be boxed in or, in the case of the radiators, be appropriately covered or have guaranteed low temperature surfaces. The provider has identified the work to be done in order of risk to service users, and has agreed to complete the work by June 2006. The temperatures of the hot water in The Bell House DS0000026265.V262761.R01.S.doc Version 5.0 Page 13 service users bathrooms is been monitored however, it should not exceed 43 degrees Centigrade. The washbasin taps in service users bedrooms had dirt around the base and in need of cleaning. Appropriate clinical waste bins were not in use in bathrooms and toilets, and the ones in use in the laundry did not have lids and were made of cardboard. Advice should be sought regarding these issues from the infection control nurse advisor. The Bell House DS0000026265.V262761.R01.S.doc Version 5.0 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 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): 28 - 30 Staff are trained and competent to do their jobs. Service users are supported and protected by the home’s recruitment practices. EVIDENCE: Eighty four percent of care staff have achieved an NVQ level 2, or equivalent, and a further four staff, including the manager have an NVQ level 4 in management and care. The NVQ trainer/ facilitator who was visiting was complementary about the level of dedication the staff had towards training. The registered person operates a thorough recruitment procedure ensuring the protection of service users. The Bell House DS0000026265.V262761.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 37 & 38 Service users’ rights and best interests are safeguarded by the home’s record keeping. EVIDENCE: The manager has an NVQ level 4 in management and care. Individual records and home records are secure up to date and in good order, and service users have access to their records and information about them held by the home. Eight questionnaires were received from service users and their visitors/ relatives and all without reservation were happy with the care they receive. Two of those returned said that the home does not provide suitable activities and one said that sometime suitable activities take place. The appropriate checks regarding fire prevention have taken place, and staff have had two drills per year. Unfortunately not all staff have had two fire lectures. Further training has been booked for the 8th of November then all staff will have had up to date training. The Bell House DS0000026265.V262761.R01.S.doc Version 5.0 Page 16 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 1 X 3 X X X 1 2 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X 3 2 The Bell House DS0000026265.V262761.R01.S.doc Version 5.0 Page 17 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 OP19 Regulation 23.-(2)(d) Requirement Timescale for action 31/12/05 2. OP19 16.-(2) (k) 3. OP19 23.-(4) The registered provider ensures that - all parts of the home are kept clean & reasonably decorated. (Identified at the previous inspection) A re-decoration programme of the areas that are showing signs of wear has been received – work identified to be completed by December 2005. The registered person must … 20/11/05 “make suitable arrangements for the disposal of general and clinical waste.” - Appropriate clinical waste bins are to be used, & advice should be sought from the control of infection nurse. 20/11/05 The registered provider is working with the fire safety officer regarding the work that is outstanding from Schedules 1 & 2 of his report. The provider is also waiting for the quote from the joiner to commence the work. (Identified at the previous inspection.) You are requested to confirm in writing when the work will be DS0000026265.V262761.R01.S.doc Version 5.0 The Bell House Page 18 4. OP25 13.-(4)(c) complete by 20/11/05. 13. -(4)(c)”unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. ”Standard 25.5 – UNPROTECTED HOT WATER PIPES AND RADIATORS in service users’ areas must be guarded or, in the case of the radiators be guarded or have guaranteed low temperature surfaces. (Identified at previous inspections.) The provider has identified the work to be done in order of risk to service users, and has agreed to complete the work by June 2006. 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. 2. 3. 4. 5. 6. Refer to Standard OP8 OP9 OP12 OP19 OP25 OP26 Good Practice Recommendations 8.3 - A Tissue Viability assessment should be used to identify those service users who are at risk of developing a pressure sore. 9.1 – There should be a self administration of medicine risk assessment and procedure to follow should a service user wish to administer their own medication. 12.3 – The activities that individual service users take part in on a day to day basis should be documented. 19. – The newly layed bathroom and floor coverings should be sealed at the edges to prevent the build up of debre and aid cleaning. 25.8 - To prevent scalding, the pre-set valves on hot water taps should be set no higher than 43 degrees centigrade. 26 – The washbasin taps in service users bedrooms had dirt around the base and in need of cleaning. - In relation to infection control, the area of wall behind the hand-wash basins should be tiled, and sealed DS0000026265.V262761.R01.S.doc Version 5.0 Page 19 The Bell House 7. OP38 where the tiles meet the basin to enable them to be cleaned correctly. 38.2 – All Staff should have two fire lectures a year. Further training has been booked for 8/11/05, then all staff will have had up to date training. The Bell House DS0000026265.V262761.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 The Bell House DS0000026265.V262761.R01.S.doc Version 5.0 Page 21 - 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. 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