Care Home: Belvoir Care Home

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What the care home does well Regular medicines audits are completed to help ensure that should any shortfalls arisethey can be promptly addressed. What the care home could do better: Care needs to be taken to ensure that clear and complete records are made of any G.P. or other healthcare professional advice to help ensure that any changes are promptly made and where needed, followed-up. The Controlled Drugs register needs to be kept upto-date to reflect the quantities of any controlled drugs stored at the home. Random inspection report Care homes for older people Name: Address: Belvoir Care Home 632 Halifax Road Rochdale Lancashire OL16 2SQ one star adequate service 28/04/2010 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Stephanie West Date: 2 7 0 8 2 0 1 0 Information about the care home Name of care home: Address: Belvoir Care Home 632 Halifax Road Rochdale Lancashire OL16 2SQ 01706377925 F/P01706377925 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Mandy Pepper Type of registration: Number of places registered: Conditions of registration: Category(ies) : Belvoire Care Home Limited care home 24 Number of places (if applicable): Under 65 Over 65 24 old age, not falling within any other category Conditions of registration: 0 The registered person may provide the following category/ies of service only: Care home only to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of service users who can be accomodated is: 24 Room 15 to be used only to accommodate the respite stay. Date of last inspection Brief description of the care home The home provides personal care and accommodation for 24 older people, including one respite stay bed. There are 14 single and five double bedrooms, with five of the bedrooms having the provision of en-suite toilets. A passenger lift to the first floor is provided. Care Homes for Older People Page 2 of 10 2 8 0 4 2 0 1 0 Brief description of the care home The home was originally two semi-detached houses, which were converted to provide one large home to which an extension was added at the rear of the building. There is a small garden and patio area to the rear and car parking is also available. The home is located on the main road between Rochdale and Littleborough, close to shops and other local amenities. A bus route to/from Rochdale passes the home regularly. The weekly fees are between 372. 64 pounds and 388. 98 pounds. Additional charges are made for private chiropody, dentistry, hairdressing, specialist equipment and dry cleaning. The provider makes information about the service available upon request in the form of a Service User Guide and Statement of Purpose, which are given to new residents. A copy of the most recent Inspection report is available within the home. Care Homes for Older People Page 3 of 10 What we found: This visit was carried out to look at the homes medication arrangements and the action taken to meet the requirements of our previous visits. The visit lasted approximately three hours and involved discussing the handling of medication with the manager and examination of medicines records and storage arrangements. This visit focused on medicines handling, other areas and requirements were not examined at this time. At the end of the visit feedback was given to the manager. Overall, we found that generally suitable arrangements were in place for handling peoples medicines, but care needs to be taken to ensure that the homes policies and good practice guidance are consistently followed. We looked at medicines administration. The medicines policies provided clear guidance to staff in the handling of medicines at the home and further training had been arranged to help ensure that staff knowledge of medicines handling is up-to-date. Since our previous visit care had been taken to clearly separate individual medicines administration records and to include residents photographs to assist with positive identification when administering medicines. The home had policies in place to support medicines selfadministration but no-one had currently chosen to do so. Medicines record keeping had improved to better support and evidence the safe administration of medicines as prescribed. Records showing the use of prescribed creams were more fully and clearly completed. Those for medicines prescribed when required included a record of the reason for use, and their effect was monitored and recorded. However, as seen at our previous visit, there could be clearer information within peoples care plans about the use of external preparations and when required medicines to help ensure consistency in their use, when needed. With the exception of a rare discrepancy, we were generally able to account for the handling of medicines in the home. Where discrepancies were found this was mainly in the handling of liquid medicines. For example, one record examined impossibly showed that more doses of a liquid medicine had been administered than recorded as received into the home. This needs to be addressed to help ensure that medicines are given correctly and can be accounted for. We looked at records of communication with healthcare professionals such as G.Ps and were concerned to find that some entries were missing. This meant it was not always possible to track any changes to peoples medicines. It is important that advice is clearly recorded to ensure changes are promptly made and where needed, followed-up. We found that medicines including controlled drugs were stored securely. But, entries had not been made in the homes controlled drugs register for the receipt and handling of a controlled drug administered by District Nurses. It is important that the home correctly maintains their Controlled Drugs register to reflect the quantities held in the cupboard at any time. Since our previous visit the manager has completed more frequent audits (checks) of medicines handling. It is important that this continues to help ensure that any concerns about medicines handling can be promptly identified and addressed. What the care home does well: Regular medicines audits are completed to help ensure that should any shortfalls arise Care Homes for Older People Page 4 of 10 they can be promptly addressed. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 5 of 10 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 3 14 People must not be admitted 28/05/2010 to the home without a thorough written assessment of peoples needs to help determine whether or not the home can meet their needs So that staff have written information to help them understand peoples needs and how to provide the right support. 2 4 14 People must not be admitted 28/05/2010 to the home unless it is determined that the home is suitable, and that their needs are best met in a care home for older people. So that people live in the right place where staff have the right training, background and experience to support them correctly. 3 7 15 All residents must have a 28/05/2010 written care plan that instructs staff on what care and support people need and how this should be provided So that staff know how to support people and so that people are given the right care and support. Care Homes for Older People Page 6 of 10 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 4 8 13 A suitable system must be 28/05/2010 implemented to prevent the resident identified from injuring themselves whilst in bed. So that residents are safe from injury whilst in bed. 5 18 13 There must be step by step 30/06/2010 procedures in the home at all times for staff to follow and suitable training in the Safeguarding of Vulnerable Adults. So that staff know what to do to protect people living in the home from abuse or neglect 6 19 23 All areas of the home must 30/06/2010 be well maintained, furnished and decorated, including carpets and furniture. So that residents live in a pleasant comfortable environment. 7 25 13 Residents must be protected 28/05/2010 from heaters that are too hot. So that residents are not at risk from burns from hot heaters 8 31 26 Regulation 26 visits must 28/05/2010 demonstrate that areas of improvement are identified and acted upon and these must be made available for the commission to inspect at Page 7 of 10 Care Homes for Older People Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action any time. To ensure efficient management and development of the home. 9 33 24 Effective quality assurance systems need to be developed to demonstrate thorough internal auditing is undertaken and involves those people living at the home ensuring a quality service is provided. 10 33 26 (5)(b) The provider needs to demonstrate to CSCI that Regulation 26 visits are undertaken so that we can be sure that he is fulfilling his responsibility in accordance with the law. 31/08/2007 30/06/2010 Care Homes for Older People Page 8 of 10 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 Clear and complete records 30/09/2010 must be made of any G.P. or other healthcare professional advice to help ensure that any medicines changes are promptly made and where needed, followed-up. 2 9 13 The Controlled Drugs register 30/09/2010 needs to be kept up-to-date to reflect the quantities of any controlled drugs stored at the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 9 of 10 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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