Inspection on 09/03/08 for Rosewood Villa

This is the latest available inspection report for this service, carried out on 9th March 2008.

CSCI found this care home to be providing an Good service.

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

Rosewood Villa 31/03/06

Rosewood Villa 29/09/05

Rosewood Villa 31/03/05

Rosewood Villa 20/08/04

Rosewood Villa 12/03/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Rosewood Villa 106 - 108 Broomy Hill Road Throckley Newcastle Upon Tyne Tyne & Wear NE15 9LP Lead Inspector Glynis Gaffney Key Unannounced Inspection 09, 10 & 16 March and 13 April 2008 14:00 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 Rosewood Villa DS0000000453.V360642.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 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. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosewood Villa Address 106 - 108 Broomy Hill Road Throckley Newcastle Upon Tyne Tyne & Wear NE15 9LP 0191 267 2373 0191 264 3497 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) Mrs Mary Watson Position Vacant Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st March 2007 Brief Description of the Service: Rosewood Villa is located in the centre of Throckley close to local amenities and bus routes. Street parking is available. Rosewood Villa provides care and support for 17 older persons, some of who have dementia. Nursing care is not provided. The bedrooms are spread over the ground and first floors. There are 13 single and two double rooms. The home has a range of communal spaces including a dining room, a large lounge, a small reception area, and a conservatory. The premises are well maintained with a pleasant patio area to the rear of the building. The home is nicely decorated and furnished throughout. The fees charged range from £373 to £404. Information about fee charges is included in the service user guide. Extra charges are made for hairdressing, newspapers, a television licence, dry cleaning, private chiropody services, and outings. A copy of the most recent inspection report is available at the entrance to the home. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use this service experience good quality outcomes. How the inspection was carried out: Before the visit: We looked at: • • • • • Information we have received since the last key inspection visit on the 01 March 2007; How the service dealt with any complaints and concerns since the last visit; Any changes to how the home is run; The acting manager’s view of how well they care for people; The views of people who use the service and their relatives, staff and other professionals. The Visit: An unannounced visit was made on the 9 February 2008. inspection we: • • • • • • During the Talked with some of the staff, the acting manager and provider; Looked at information about the people who use the service and how well their needs are met; Looked at other records which must be kept; Checked that staff have the knowledge, skills and training to meet the needs of the people they care for; Looked around the building to make sure it was clean, safe and comfortable; Checked what improvements had been made since the last visit. We told the manager what we found. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 6 What the service does well: Staff are kind, respectful and considerate and they have developed warm and caring relationships with the people in their care. People are satisfied with the care and support they receive. There is a pleasant atmosphere within the home. Staff surveyed said: We have ‘up to date training. Also, support is given to residents, relatives and staff if needed. We meet the needs of each individual in our care. We have good care plans that are up to date.’ There is someone in management to go to for additional advice if needed.’ ‘The manager and all staff are good at reporting changes and keeping care plans up to date.’ ‘The manager and Mrs Watson are very good on making sure that all staff have Criminal Records Bureau checks before they start work at the home.’ ‘I was given a full induction when I started and everything was shown and explained to me.’ ‘I think that the service could not do any better as it is a lovely home and all the residents are well looked after. The home and rooms are always clean.’ ‘Rosewood Villa provides a home from home.’ Staff communicate with people in a positive manner. It is evident that staff are very proud of the standard of care they provide. The menu for each day is displayed in the dining room. The dining room is nicely decorated and furnished, and the tables are attractively set at each meal. The home is clean, tidy and provides a domestic and homely atmosphere. The building and grounds are well maintained. People’s bedrooms are pleasantly decorated and have been personalised. The kitchen is clean and tidy. Visitors are made to feel welcome. A complaints record is made available to visitors in the reception area. People wishing to live at the home are visited by the acting manager to make sure that Rosewood Villa is able to meet their needs. People are also encouraged to visit the home before making a decision to accept a place. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 7 Relatives who returned surveys said: ‘Staff do the following things well – care for residents, use a personal approach, have knowledge of residents and show genuine concern.’ ‘There is a great feeling of real care and warmth is apparent during my visits to the home. They always seem to have time to sit and chat with my mum when she needs it.’ What has improved since the last inspection? An acting manager has been appointed. The maintenance person has completed a course that will enable him to test the safety of the home’s electrical equipment. Some of the carpets in people’s bedrooms and in the communal areas have been replaced. Areas of the home have been redecorated. An awning has been fitted at the front of the building. Additional external seating has been provided. A new system has been introduced to improve the way in which maintenance tasks are carried out and recorded. Two part time activities co-ordinators have been employed and provide a range of activities throughout the week. This allows care staff to spend more one to one time with people living at Rosewood Villa. The provider has arranged for more statutory training to be provided in-house. This has led to more cost effective training that is easier to deliver. Over 50 of the home’s care staff have now obtained a recognised qualification in care. Regular meetings are now being held with people living at the home to ascertain their opinions about how Rosewood Villa is run. Minutes of these meetings are being kept. The home’s brochure has been updated and a mini-brochure has been introduced. The provider and acting manager have completed their first quality audit of the home’s performance against the national minimum standards. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 8 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. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 9 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 Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The arrangements for assessing people’s needs before they move into the home are good. This means that the home has access to all of the information it needs to make an informed decision about whether to offer a place at Rosewood Villa. EVIDENCE: Admissions into the home do not take place until a full needs assessment has been completed by social services. A copy of each person’s social services assessment and care plan is obtained before they are admitted. The home also carries out its own pre-admission assessment before reaching a decision about whether to offer a place. A copy of the home’s in-house assessment had been placed on each person’s care record. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 11 A relative who returned a survey said ‘I was encouraged to visit the care home before my mum went to live there. I was offered the opportunity and encouraged to speak with other families who had parents living at the home. This helped to allay some of my anxieties. I was also encouraged and supported to bring my mum for a visit. She was welcomed warmly and treated with respect and dignity.’ Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The health care needs of people are satisfactorily met enabling them to lead healthy and comfortable lives. People feel valued and able to retain control over the way they want to live their lives. EVIDENCE: Care plans have been devised for each person. For example, in one of the records examined, care plans covering washing, dressing, continence care, moving and handling, social activities, religious beliefs, and health care have been devised. Six monthly placement reviews have not always been carried out for each person. However, people’s care plans are reviewed in-house on a monthly basis. Checks of the quality of information held in people’s records are also completed on a regular basis. Where able, people have signed their care plans to confirm their agreement with the contents. Care records are kept secure at all times. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 13 Due to significant changes in the resident population, the key worker system has not been in operation for some time. The acting manager said that she intends to re-introduce key working as soon as possible as the home now has a more stable resident group. People are provided with access to optical and chiropody care on a regular basis. Medical care and nursing input is arranged as and when people require this. Monthly weight checks are completed. In the sample of three care records checked, a nutritional risk assessment has been completed for each person. However, the nutritional risk assessment recommended by the Commission has not been used. People’s susceptibility to developing pressure sores has been risk assessed. However, in two of the assessments checked, although people had been identified as being at risk, care plans had not been devised. The assessments had been regularly reviewed. People developing pressure area care needs are referred to the relevant community nursing team. The home is able to access the equipment required to manage people’s pressure area care needs. Pressure sore management works well within the home as no one has developed a sore in over five years. There was one occasion when an individual returned from hospital with a pressure sore. This appeared to have been well managed with the support of local health care professionals. A falls risk assessment had only been completed for one person. The acting manager said that falls prevention is well managed within the home as evidenced by the low incidence of falls. During the visit, staff were observed providing people with the assistance they needed to mobilise safely. Assistance with mobility was provided in a supportive manner. A tour of the building did not identify any hazards that might cause trips and falls. The home has a medication policy that provides staff with guidance on how medication should be handled. Medication records are satisfactorily completed. All medication is safely locked away. Staff were observed to follow good hygiene practices when administering medication. All staff administering medication have received training. The majority of staff have completed a 12week learning-distance course in handling medicines safely. Staff are not undertaking any simple nursing health care tasks. Staff provide personal care in a kind, considerate and helpful manner. Staff respect people’s rights to privacy and dignity. For example, staff quietly asked people if they wished to use the toilet or change their clothing following an evening meal. Staff ensure that toilet and bathroom doors are closed when in use. Staff knock on people’s bedroom doors before entering. People said that they could see their visitors in private if they wished. People looked well cared for and smartly dressed. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 14 Relatives who returned surveys said: ‘My mum needed a lot of 1 to 1 support initially to adjust. The staff were marvellous and spent many hours supporting and listening to her anxieties…the staff were patient, caring and did not try to diminish her feelings in any way. They were loving and supportive at all times.’ ‘There is a genuine attempt to find out things which are important to residents and to ensure that their care plans and records are updated so that all staff are aware and can implement.’ Staff ‘respect people’s privacy and allow them to participate in the decision making process.’ Of the seven staff that returned surveys, six said that they are ‘always’ given up to date information about people’s needs. One person said that this is ‘usually’ the case. Of the six people living at the home who returned surveys: • • • Six said that staff ‘listen to them and act on what they say’; Five said that staff are ‘always’ available when you need them. One said that this is ‘usually’ the case; Six said that they ‘always’ receive medical support when they need it. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. There are suitable arrangements to provide people with opportunities to participate in social activities. This means that people are able to lead stimulating and fulfilling lives that reflect their personal preferences. EVIDENCE: The home has devised a programme of weekly activities. A copy of the programme has been placed in the main lounge area. A different activity is offered every morning and afternoon. For example, on a Tuesday afternoon people are offered the opportunity to join in armchair exercises. During one visit to the home a musical exercise session was underway. This was an energetic event and people really appeared to enjoy the session, including staff. On a Thursday, people have the opportunity to visit the hairdresser and have a manicure. The acting manager said that there are occasions when the programme is not followed as staff try and take account of what people actually want to do on a particular day. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 16 The provision of activities has been strengthened by the appointment of two activities co-ordinators. More structured activities are now provided each weekday between 10 am and noon. Some people also attend a local day centre that offers opportunities for them to engage in a range of activities such as rock climbing. People are able to make choices about how they spend their time. For example, one person likes to spend time walking or sitting outside at the front of the building. Staff patiently supported the individual concerned to do this on a number of occasions throughout one afternoon. Volunteers from the Pat-a-Dog scheme also visit Rosewood Villa to give people opportunities to enjoy continued contact with pets. Birthdays and festive occasions are celebrated. Birthday cakes and celebratory meals are held. Over Christmas, some people attended a pantomime and children from a local school visited the home. People are provided with opportunities to participate in external events. For example, all people had recently visited the Beamish Museum. Ms Hadaway said that an outing to Boulmer and a further trip to the Museum have been planned. Information about people’s past social histories, hobbies and interests is obtained wherever possible as part of the admissions process. The acting manager said that social needs assessments are carried out following people’s admission into the home. Care plans addressing people’s social care needs have been devised. However, people’s social needs had not always been clearly identified. Visitors to the home are made to feel welcome and are always greeted by a member of staff. Refreshments are offered. A relative who returned a survey said ‘I am encouraged to visit my mum as often as I want. I am always given a warm welcome and updated on any concerns.’ It is the home’s policy to support people to maintain control of their own financial affairs. Lockable facilities and day-to-day support with managing personal monies and valuables are provided as and when needed. People are encouraged to bring their own personal possessions with them when moving into the home. In the bedrooms visited, it was evident that people had been encouraged to personalise their own private spaces. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 17 The home has a four-week rotating menu that offers people three full meals each day. Alternatives to the main meal choices are available. Hot and cold drinks and in-between meal snacks are provided throughout the day. Staff ensure that jugs of water and juice are placed in people’s bedrooms. China, tablecloths, and serviettes are colour co-ordinated and the tables are always attractively set. Details of the breakfast, lunch, tea and suppertime meals is displayed daily on the notice board in the dining room. The inspector observed two meals being served. The quality of the meals was good and people appeared to enjoy them. Staff ensure that they are on hand to provide people with support throughout mealtimes. Staff provide support in a caring and sensitive manner. The kitchen is kept tidy and hygienic. Food cupboards, fridges, and freezers are all well stocked. A relative who returned a survey said ‘menus are well thought out. Provide good home cooked food that is well presented.’ Of the six people living at the home who returned surveys, all said that they ‘enjoyed’ the food served. One person commented ‘I have special needs such as soft food. This is always well prepared.’ Relatives who returned surveys said: ‘Mum is a devout Catholic and staff who hold no strong religious beliefs have even taken mum to church.’ ‘Staff who are not on duty come into work for special occasions.’ Of the six people living at the home who returned surveys, two said that there are ‘always’ enough activities provided within the home. Three said that this is ‘usually’ the case and one other person said that this only happens ‘sometimes.’ Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The arrangements for protecting people from harm or abuse are good. means that people can feel safe and protected. EVIDENCE: The home has a detailed complaints procedure, which includes the recommended information. The policy has recently been updated to reflect the Commission’s new contact details. Neither the Commission nor the home have received any complaints since the last inspection. The home’s adult protection policy complies with the relevant guidance and legislation. There have been no adult protection concerns raised with either the home, or the Commission, since the last inspection. All staff have received training in the protection of vulnerable adults with the exception of recent starters. Arrangements have been made for these staff to complete the required training. Of the six people living at the home who returned surveys, five said they would know who to talk to if they wanted to make a complaint. All said that they knew how to make a complaint. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 19 This Of the seven staff that returned surveys, all said that they had been told how to handle complaints. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The standard of the environment and overall quality of the furnishings and fittings are good. This means that people are able to live in a safe, wellmaintained, and comfortable environment that encourages independence. EVIDENCE: People’s bedrooms, the communal areas, toilets, and bathrooms are clean, well maintained, and domestic in appearance. Bedrooms are nicely decorated and have been personalised. Radiators throughout the home are guarded. The home is warm, well lit, and free from offensive odours. A range of aids and adaptations are available such as a mobile hoist and an adapted sit-down shower facility. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 21 The laundry is clean and hygienic. The washing machine and dryer are in good working order. Hazardous materials are locked away to prevent accidents occurring. The fire doors checked are in good working order and fire escapes and corridors are free of obstacles. The kitchen is clean and hygienic. The local environmental health team has recently inspected the home. The premises were generally considered satisfactory with only a few recommendations being made. Ms Hadaway said that the majority of recommendations have already been, or are being, addressed. Following the visit, the provider is in the process of seeking quotes for the replacement of the kitchen units. The home has agreed to complete the Department of Health self-assessment infection control checklist and A relative who returned a survey said ‘high standard of décor, cleanliness and maintenance throughout the property.’ Of the six people living at the home who returned surveys, all said that the home is ‘always fresh and clean.’ Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, and 30. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The arrangements for ensuring that new staff meet all of the outcomes set out in the ‘Skills for Care’ Common Induction Standards are not fully adequate. This may mean that staff do not have all of the underpinning knowledge required to commence a nationally recognised qualification in care. EVIDENCE: There are rotas showing which staff are on duty and at what times. The rotas contain the required details. The home employs nine full time and five part time staff. Six ancillary staff are also employed. Approximately 420 care staff hours are provided each week to meet people’s need for support with personal care. An additional 113 care hours are also provided. Between 8am and 8pm, three staff are rostered on duty to provide care and support to 17 people. Two care workers cover the nighttime period. There is always a senior carer on each shift. Towards the end of 2007, the home experienced difficulties recruiting a full time cook. Consequently, the hours were covered in-house and, although the required staffing levels were maintained, it was a very stressful period. A full time cook has now been Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 23 recruited. Seven staff left their employment with the home since the last inspection. Agency staff are not used at Rosewood Villa. Of the fourteen care staff employed, 50 have obtained a relevant qualification in care, and two others are in the process of doing so. Three other staff have enrolled to complete a recognised qualification in care. In addition, 50 of the home’s support services team, i.e. housekeeping, maintenance, and catering staff, have obtained a National Vocational Qualification at Level 2 in Support Services. Before staff commence working at the home: • • • • They are required to complete an application form and attend an interview; A Criminal Records Bureau Disclosure check is obtained; Two written references are obtained; Their identity is checked and verified. New staff are provided with in-house induction training. A written record of the training provided is kept. However, there are no records confirming that new staff have met all of the outcomes within the ‘Skills for Care’ Common Induction Standards. (CIS) Neither is there evidence that the home has completed the CIS Certificate of Successful Completion for staff who have successfully completed this level of training. The provider has given an undertaking to review their in-house induction processes to ensure that they are compliant with the Skills for Care Standards. Staff are provided with opportunities to complete and update their training in key areas. For example, two recently appointed staff have completed training in infection control, fire prevention, food hygiene and health and safety. Staff have received training in person centred planning as part of their dementia care training. Arrangements have been made for staff to complete training in implementing the Mental Capacity Act. Arrangements are in place for staff to receive regular supervision. For example, the manager received formal supervision on six occasions in 2007. A member of staff appointed in November 2007, had already received two supervision sessions. A member of staff who returned a survey said ‘supervisions and appraisals are held every eight weeks, but I can usually get to speak to or get support from the acting manager when I need to.’ Relatives who returned surveys said: ‘Staff are patient and genuinely want to give people a good quality of life. Staff treat them as individuals and prompt them due to forgetfulness.’ Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 24 ‘’More time for residents is always desired but often not practical if other demands on staffs’ time exist. For example, the inability to recruit a cook meant that staff had to do the cooking for a number of weeks. There were no complaints from them as I remember.’ Of the seven staff who returned surveys: • • • • • • • All said that their employer carries out pre-employment checks; Six said that their induction covered what they needed to know to do their job. One person said that this was ‘mostly’ the case; All said that the training they receive is relevant to their job, helps them to understand people’s needs and keeps them up to date with new ways of working; Five said that they met ‘regularly’ with their manager. Two said that this ‘often’ happens; Six said that the ways in which information is shared within the home ‘always’ works well. One said that this is ‘usually’ the case’; Six said that there are ‘usually’ enough staff on duty to meet people’s needs. One said that this is only ‘sometimes’ the case; Six said they have the skills and experience to meet people’s needs. One said that this is only ‘sometimes’ the case. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The arrangements for protecting people from potential harm are good. This means that people live in a home where their health, safety, and welfare are promoted and protected. EVIDENCE: The home has not had a registered manager for over 18 months. Since the last inspection, a temporary manager has been appointed to oversee the dayto-day running of the home. Ms Hadaway has worked at the home for over six years and holds a Level 3 National Vocational Qualification in Care. The provider has arranged for Ms Hadaway to update her statutory training in the Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 26 required areas. The providers are responsible for the recruitment and selection of staff, financial management, and business development. A member of staff who returned a survey said that ‘all the team are approachable and the acting manager is brilliant.’ Since the last inspection, the providers have: • • • Completed the Commission’s Annual Quality Assurance Assessment tool. The document has been satisfactorily completed providing evidence of what the service does well and what it hopes to do better in 2008; Arranged for resident meetings to take place. Meeting minutes are kept and show that people are made aware of their rights and encouraged to comment on the care they receive; Completed an audit of the quality of care and services provided at the home. The providers have designed their own in-house quality tool which focuses on how well the home meets the National Minimum Standards; Devised a form that will allow them to monitor policy and procedure updates and reviews. • Plans are underway to design surveys that will ask people living at the home, their relatives, staff, and professional visitors, to comment on the quality of care and facilities provided. The home does not handle people’s money or act as an ‘appointee’ for anyone living at Rosewood Villa. No one living at the home is subject to Power of Attorney or Guardianship Orders. All staff have been provided with a copy of the home’s health and safety policy and are required to complete an acknowledgement slip. The home is safe and hazard free. For example: • • • • • • • The provider has appointed an external consultant to advise the home on health and safety matters and ensure that it operates within the legislation; The home’s lift was last serviced in February 2008; The home has a current gas safety certificate and a Certificate of Liability Insurance; In 2007, the home’s water systems were checked for the presence of Legionella; The home has a current Periodic Electrical Installations and Wiring Certificate; The home’s electrical equipment was tested in January 2008; A record of all accidents occurring within the home has been kept. In addition, the home has a current fire risk assessment and copies of the fire evacuation procedure are displayed around the building. Regular fire Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 27 prevention checks have been carried out. The home’s fire alarm system has had an annual service within the last 12 months. Two recently appointed staff received certificated fire training in January 2008. Staff are provided with opportunities to participate in fire drills and in-house fire instruction. There is a contract to remove clinical waste from the home. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 28 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 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X N/A X X 3 Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last Yes 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 OP7 OP8 Regulation 12 & 15 Timescale for action Ensure that where people have 01/05/08 been identified as being at risk of developing pressure sores, a care plan is put in place. This will help to ensure that staff are clear about the action they must take to meet people’s needs. 2. OP31 9 Appoint and register an 01/04/08 experienced and qualified manager with the Commission. (The timescale for complying with this requirement expired on 01/06/07) Provide the Commission with monthly updates regarding progress made to appoint a registered manager. This will help to ensure that the home is managed by an experienced and qualified person who has the necessary skills to run Rosewood Villa in the best interests of the people living there. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 30 Requirement 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 OP7 Good Practice Recommendations Re-introduce a key worker system. Ensure that six monthly placement reviews involving social services take place wherever relevant. 2. OP8 Use: • • 3. 4. 5. OP12 OP30 OP30 The ‘MUST’ nutritional assessment to identify those people at risk of under-nutrition; A recognised assessment tool to assess those people at risk of falling. Ensure that people’s social needs are clearly identified in their care plan. Ensure that staff receive training in the implementation of the Mental Capacity Act. The manager should ensure that they: • Are satisfied that any new worker employed at the home has met all of the outcomes within the Skills for Care Common Induction Standards (CIS) and that there is clear recorded evidence of this; Have signed off the CIS Certificate of Successful Completion. • 6. OP33 Issue surveys to obtain the views of people living at the home, staff, and professional visitors, regarding the quality of support and facilities provided at Rosewood Villa. Rosewood Villa DS0000000453.V360642.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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