Inspection on 18/04/05 for Alpine Villa

This inspection was carried out on 18th April 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

Alpine Villa 13/05/08

Alpine Villa 25/06/07

Alpine Villa 27/06/06

Alpine Villa 11/10/05

Alpine Villa 22/09/04

Alpine Villa 17/07/04

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

CARE HOMES FOR OLDER PEOPLE Alpine Villa 70 Lowbourne Melksham Wiltshire SN12 7ED Lead Inspector Thomas Webber Announced 18 April 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Alpine Villa Address 70 Lowbourne Melksham Wiltshire SN12 7ED 01225 706073 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Luzuisminda Mercer Mrs Luzuisminda Mercer Care Home Only 15 Category(ies) of DE(E) Dementia - over 65 (15) registration, with number MD(E) Mental Disorder - over 65 (15) of places Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: The maximum number of service users who may be accommodated in the home at any one time is 15 Date of last inspection 22nd September 2004 Brief Description of the Service: The home is a private residential care home offering accommodation and personal care to a maximum of 15 residents who are over the age of 65 with either dementia and/or mental disorder. The home is a large Victorian house which is located in the market town of Melksham close to all local amenities. The accommodation provides a sitting room/dining room together with a conservatory and a separate dining room and lounge. There are three double bedrooms and nine single bedrooms, one of which has en-suite facilities. Residents bedrooms are located on the ground and first floor levels and are accessed by a stair case. Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, undertaken during the course of one and a half days from 09:00 to 17:30 and 09:00 to 12:10 respectively. The inspection’s primarily focus was influenced by a number of complaints received by the Commission just prior to the inspection date. A series of further visits to the home were also made after the announced inspection and were not completed until 9th June 2005. These were made at a variety of times in order to observe the serving of lunch, waking and night routines and to formally interview all staff. A range of records were examined as part of the inspection and the investigation into the complaints. The Vulnerable Adults procedure was instigated in relation to the complaints but with particular reference to the allegation of physical abuse. A follow up visit was also made to the home on 26th July 2005 primarily to evidence the home’s response in relation to the requirements and recommendations regarding the complaint investigation. The outcomes are reflected under the requirements and recommendations section of this report. Full details of the findings and outcomes are recorded in the additional visit letter, which is due to follow this report. A tour of the premises was undertaken and all fourteen residents in situ were seen. The views of some of the residents were sought on an individual and group basis, regarding the care and services provided by the home and the views of one relative was also obtained during the inspection. Four comment cards from relatives and eight from residents were received prior to the announced inspection. The views of all staff were sought in relation to the complaints made. What the service does well: The comments received from the residents and their relatives about the care and services provided are of a positive nature and specific comments are reflected within the body of this report. Residents are provided with a written contract and they are assessed either prior to, or soon after admission. Opportunities exist for prospective residents and their families to visit prior to admission. Residents’ health care needs are being appropriately met. The home provides opportunities to meet the residents’ social and religious and recreational interests, both within the home and in the wider community. Residents are assisted to exercise choice and control over their lives within their capabilities and a flexible and reasonable diet is provided for the residents. Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 6 Residents have access to safe and comfortable indoor and outdoor communal facilities. There are sufficient toilets and bathing facilities, Residents’ bedrooms meet their needs and are personalised to their individual wishes. The home is maintained to a reasonable standard being clean and tidy. The laundry facilities meet the needs of the residents. Residents, within their capabilities, and their relatives know how to complain, although no concerns have been raised by them. 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3, 5 and 6 Residents are provided with a written contract, although there are some deficiencies within the home’s contract. Residents receive an assessment either prior to, or soon after admission, depending on the nature of the admission. Opportunities exist for prospective residents and their families to visit prior to admission. EVIDENCE: Evidence was available to confirm that both residents case tracked had received a copy of the home’ contract or where funded by social services, a copy of the placing authority’s terms and conditions. However, the home’s contract needs updating to ensure it complies with Standard 2.2 which includes the name of the resident, number of room occupied, fees payable by whom and rights and obligations of the resident and registered provider and who is liable if there is a breach of contract. Evidence was available to confirm that the home’s assessment tool had been completed in respect to one resident case tracked. A full assessment had also been received from the ward where the resident had resided prior to admission to the home. Evidence was available to confirm that the home had sent a letter to confirm that it could meet the resident’s needs. With regard to the Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 9 second resident, who was admitted from outside of Wiltshire, evidence was available to confirm that the home had completed its own assessment two days after the resident had been admitted to the home. However, a copy of the community care assessment had not been received by the home from the placing authority. The proprietor was advised of the need to obtain a copy of all prospective residents’ community care assessments or the equivalent prior to admission for those residents who are funded by social services. Opportunities are available for all prospective residents and their families to visit the home prior to admission to meet with staff, other residents, tour the premises and ask any questions relating to the running of the home. However, in respect to the two residents case tracked, only one of them visited with her family. The other resident was referred to the home by her family. The home does not provide intermediate care therefore Standard 6 is not applicable. Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 8, 9 and 10 Residents’ health care needs are being appropriately met. Residents are unable to self medicate as they are deemed not capable. There are serious deficiencies within all aspects relating to medication which do not protect the residents. Residents’ right to privacy is not always maintained. EVIDENCE: Residents admitted to the home are registered with one of two surgeries. Residents who are able attend the surgeries for any appointments with the assistance of staff or their families and this was confirmed within the residents’ records. Where visits are made to the home by GPs the district nurse and physiotherapists, these would be undertaken in the privacy of the residents’ bedrooms. Residents can and do access other health care services such as dental, opticians and chiropody as and when required. Appropriate aids for incontinence are provided for those residents who require them. The home has established a medication policy. However, none of the residents are deemed capable of being responsible for the administration their own medication. Therefore, the more experienced staff and those who have completed the ‘Safe Handling of Medicines’ course administer medication to residents. However, examination of the system for the receipt, storage and Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 11 administration of medication showed that there were a number of areas of deficiency, which were a cause for serious concern, and needed immediate attention. These included the need to establish a system for the receipt of medication, unwanted medicines, in particular, those refused and left within their cassettes need to be recorded in the returns book and staff must be more vigilant to ensure that they consistently and accurately sign the medication sheets for medication administered. It was also noted that there were occasions where staff had signed for the medication given although the medication was still within the cassettes. Staff must also ensure that medication is never left unattended. The eight residents’ comment cards, which were completed on their behalf with staff assistance, referred to residents feeling that their privacy is respected. However, there have been concerns/complaints raised at previous inspections and again by the anonymous complainant. Privacy is not aided by the design of some of the toilets and the inappropriate behaviour of a particular resident and the home’s practice of dealing with this. Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14 and 15 The home attempts to provide opportunities to meet the residents’ social and religious and recreational interests and needs. Residents are assisted to exercise choice and control over their lives within their capabilities, although there are areas of practice which need addressing for the benefit of the residents. A flexible and reasonable diet is provided for the residents, although the timing of some meals needs reviewing. There are also deficiencies in the recording of meals taken. EVIDENCE: From discussions with management, staff and residents it is apparent that residents, within their capacity, can choose where and how to spend their time. Residents have the opportunity to pursue their own individual interests, which include attending various community based activities, as well as being able to participate in the various organised activities arranged by the home. The vast majority of residents require accompanying by their families, proprietor or staff when out and residents are taken out to the shops or for a walk in the local park. A church service is held within the home on a monthly basis and one resident attends the catholic service with the proprietor. From recent complaints investigated, there were areas within the practice of the home relating to getting up and getting ready for bed early and around the choice of bathing and showering. These have been referred to the proprietor Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 13 to review such practices and to ensure that there is a consistent approach where residents have a choice in these areas. Observations and discussions with residents, management and staff indicated that residents, depending on their capabilities, can exercise personal autonomy and choice in a number of ways. Residents can bring items of furniture and personal possessions to make their bedrooms more homely, they can make their own drinks, choose where to spend their time, where to eat, and what activities to participate in. Residents are provided with a choice for breakfast, although a number of them choose to have the same meal each day. Set meals tend to be provided for lunch and teatime, although sometimes there is a clear choice on the menu at lunchtime. However, there are other occasions where alternatives have been provided and this is evidenced within residents’ case notes. Residents’ case notes also confirm that there is some flexibility with regard to mealtimes and in providing refreshments with residents being provided with food and drinks at other times of the day and night. Special diets are also catered for. Residents tend to use the dining rooms for their meals although they could choose where to eat their meals and evidence was available to confirm that some residents have some or all of their meals in their bedrooms. The menu does not always reflect the meals provided and the management of the home was advised of the need to ensure that where changes are made to the menu these are suitably recorded. Some concern was raised about the timing of the main meal of the day and management has been advised to review this. Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Residents, within their capabilities, and their relatives know how to complain, although there are deficiencies within the procedure. There are areas within the procedures for protecting residents from abuse which are also deficient. EVIDENCE: The home has established a complaints procedure and a copy of this is displayed on the notice board in the hallway by the kitchen. The proprietor reported that residents who have dementia are not provided with a copy of this procedure but she has agreed to provide a copy to their relatives with a copy also being made available within the home’s service users’ guide. The proprietor has also agreed to give a copy of the procedure to those residents with mental health problems. The four comment cards received from residents’ relatives confirmed that they are aware of the complaints procedure and none of them have ever made a complaint. However, the proprietor was also advised of the need to update the complaints procedure to include the address for the Commission for Social Care Inspection and to inform complainants that they can contact the Commission at any stage, should they wish to do so. The proprietor reported that she has received no complaints since the last inspection. However, the Commission had received a total of twenty-one complaints from a person who has wished to remain anonymous. The nature of the complaints related to food, refreshments, routines of the home, care practices, staffing, medication, the recording of activities, the wedging open of fire doors and physical abuse. Investigation of the complaints by the Commission in conjunction with the Vulnerable Adults Unit showed that fourteen of these were not upheld and six were upheld. Those upheld related Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 15 to care practices, staffing, medication and the wedging open of fire doors. The complaint relating to physical abuse was unresolved as there was no evidence to support the complaint. The home has established its own policy and procedure in relation to responding to suspicion or evidence of abuse and the home has a copy of the shortened version of the Wiltshire and Swindon Vulnerable Adults procedures. The proprietor was advised of the need to obtain a copy of the full version of the Wiltshire and Swindon Vulnerable Adults procedures and ensure that the home’s policy and procedure reflects that procedure. She was also advised of the need to obtain further copies of the shortened version of the Wiltshire and Swindon Vulnerable Adults procedures and ensure that these are distributed to all staff and ensure that staff are familiar with these. Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20, 21, 23, 24 and 26 Residents have access to safe and comfortable indoor and outdoor communal facilities. There are sufficient toilets and bathing facilities, although not all of the toilets are of a suitable design to aid privacy and dignity of the residents. Residents’ bedrooms meet their needs and are personalised to their individual wishes. The home is maintained to a reasonable standard being clean and tidy. The laundry facilities meet the needs of the residents. EVIDENCE: The home provides a sufficient number of bath, shower and toilet facilities, which are located within close proximity to residents’ bedrooms and the communal rooms. However, some of the individual toilets are very small in size, particularly those located on the ground floor that are strategically located close to the main lounge/dining room. Some residents who tend to leave the doors open or hold them open with their feet see these toilets as being somewhat claustrophobic. These toilets are also too small for staff to assist residents who require it, therefore not providing privacy and dignity when being used. Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 17 The home provides sufficient communal space that consists of a lounge/dining room together with a conservatory, a separate dining room and an additional lounge to the front of the property. These areas are furnished and decorated to an adequate standard. The home also provides a small, enclosed rear garden which was observed to be used by some residents, particularly those who smoke. The home provides nine single and three shared bedrooms, two of which are provided with en-suite facilities. Residents’ bedrooms are located on the ground and first floor levels which are accessed by a stair case. All rooms are fitted with a call bell system which residents can use to summon staff assistance if required. Residents’ bedrooms are adequately furnished and decorated to varying degrees and the proprietor reported that residents’ bedrooms are normally redecorated and re-carpeted when there is a change of occupation. Residents can and have brought items of personal possessions to make them more homely with residents having personalised their bedrooms to their individual wishes. Residents, who commented, spoke favourably about the standard and cleanliness of their accommodation. The home continues to be maintained to a reasonable standard, being clean and tidy and, in the main, free from offensive odours. The laundry room is located on the ground floor and provides adequate facilities to meet the needs of the home. Residents’ clothing is labelled to ensure that garments are appropriately returned and care staff, with some input from the waking night staff, undertake this task. Residents, who commented, spoke favourably about the laundry arrangements in place. Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 The home does not provide sufficient staff on duty to meet the needs of the residents. The recruitment practice for the protection of residents must be far more robust. Training appears to be undertaken by staff, although there are areas of deficiency within this. EVIDENCE: The deployment of staff ensures that there are a minimum of two members of care staff on duty throughout the waking day with one member of waking night staff on duty and another member of staff sleeping in each night. However, the staff rotas showed that there were the odd occasions when these staffing levels were not being achieved. The other deficiency was the apparent lack of ancillary staff being on duty. The staffing levels do not include those hours worked by the manager and ancillary staff employed. The deputy manager was advised of the need to ensure that the minimum staffing levels of the previous registration authority are maintained at all times and this includes appropriate numbers of ancillary staff, even if it means the employment of agency staff. This is particularly important due to the high dependency needs of residents accommodated and the type of category of registration i.e. mental health and dementia. The written staff rotas must always reflect and be a true account of all staff on duty and demonstrate the member of staff sleeping in each night. The home must also send copies of the staff rotas on a weekly basis to the Commission who will monitor staffing levels to ensure compliance. Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 19 The Commission received eight residents’ comment cards, which were completed by them with the support of staff. The comments referred to residents feeling well cared for, they like living at the home, feel safe, their privacy is respected and the staff treat them well. Four comment cards were also received from residents’ relatives who stated that they feel welcome when they visit, are kept informed of important matters, are consulted about their relatives’ care, are of the opinion that there are always sufficient numbers of staff on duty and are satisfied with the overall care provided. Specific comments made by the residents’ relatives include: residents are all like one big family and the relative is very pleased with the way her mother is cared for, residents are always clean, bathed or showered daily, staff are kind and caring and she has complete trust in Mrs Mercer – her mother has been in her care for almost seven years. Another relative stated that her mother has been a resident for more than six years and she has been satisfied with the care her mother has received. Staff are kind and there is a friendly atmosphere. She is well looked after and bathed every day. One relative met and spoken to during the inspection also stated that he was very happy with the care provided to his mother, she appears relaxed within the company of staff, although she wasn’t too keen on one member of staff who has since left. He is kept informed and consulted about all decisions made. Residents spoken to commented positively about the care provided by the staff. Two of the most recent staff files were checked to ascertain whether the home was following appropriate recruitment practices as part of the protection for the residents. Although the most recent staff member recruited showed improvement in this area, the home must ensure that the issues identified are addressed. The home needs to amend its application form to include a section for applicants to record whether they are physically and mentally fit, a full employment history must be obtained and any gaps need to be explored and recorded. The proprietor was advised of the need to obtain appropriate written references which she has applied for before the appointment of staff, rather than accepting “to whom it may concern” letters. Staff have a variety of experience in the caring profession with some having considerable experience. Two members of staff have completed the NVQ 2 course with three completing NVQ 3 and another four completing NVQ 2. Staff training records also showed that four members of care staff have completed training in Dementia Awareness and information is available regarding Mental Health and Dementia, which is reported to be covered during staff meetings. However, the home must also ensure that all staff have completed the various mandatory training courses. Courses completed by staff must be certificated. Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 Staff are not being monitored and supervised on a consistent basis to ensure continuity of practice. EVIDENCE: Evidence was available to show that formal and recorded supervision is being provided on an inconsistent basis. Some staff are receiving supervision on a monthly basis, which exceeds the minimum requirements of the national minimum standards of six times a year, whereas other staff are not meeting this standard. This deficiency was brought to the attention of management. In addition, the method used for recording of supervision does not meet best practice by both parties signing and dating thus confirming that the minutes are an accurate account of what was discussed and a copy being maintained by both parties. Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 2 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION x 3 2 x 3 3 x 3 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x x 2 x x Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4(1)&(2) & Schedule 1 Requirement The registered individual must ensure that the homes statement of purpose includes all the information detailed in Regulation 4 and Schedule 1 with a copy being provided to the Commission for Social Care Inspection. (Previous timescale of 01/02/04 - Not checked on this occasion) The registered individual must ensure that the homes service users guide fully complies with Regualtion 5 and Standard 1 .2. Copies of this document must be provided to all residents and prospective residents as well as a copy being provided to the Commission for Social Care Inspection. (Previous timescale of 01/02/04 - Not checked on this occasion) The registered individual must update the homes contract to ensure that it complies fully with Regulation 5 and Standard 2.2 and provide residents with the revised copy, where appropriate. The registered individual must ensure that all service users’ needs and any risks identified by Timescale for action 31/10/05 2. 1 5 31/10/05 3. 2 5(1)(c) 31/10/05 4. 3 14 & 15 31/10/05 Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 23 5. 3 14(1)(b) 6. 7 15 7. 7 12(1)(a) pre-admission assessment are incorporated into their care plan with details of how those needs are to be met. (Previous timescale of 22/09/04 - not met) The registered individual must obtain a copy of all prospective residents’ community care assessments or the equivalent prior to admission for those residents who are funded by social services. The registered individual must ensure that residents’ care plans are reviewed at least once a month and revised to reflect any changes in care need. It is also essential that all care needs are fully documented with clear guidance to staff on what actions they should take. (Previous timescale of 22/09/04 - not fully checked on this occasion) The registered individual must ensure that the care of the identified resident is reviewed with strategies developed to minimise the incidents of inappropriate behaviour within the lounge. A strategy to manage such behaviour must be developed in consultation with the Community Psychiatric Nurse. This must be evidenced and recorded within the resident’s care plan. A follow up visit carried out on 26/07/05 confirmed that this requirement is no longer applicable. The registered individual must gain professional advice in the event of a resident being unable to take their medication. Staff must not undertake any practice such as the crushing of medication without such 31/10/05 31/10/05 31/10/05 8. 9 12(1)(a) 01/08/05 Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 24 9. 9 13(2) discussion and the receipt of a written, signed agreement from appropriate professionals. The registered individual must gain clarity regarding the disposal of medication, which has become moist from a resident having had the tablet in their mouth. This must be recorded within the medication policy. A follow up visit carried out on 26/07/05 confirmed that this requirement has been complied with. The registered individual must ensure that medication is not left unattended at any time. A follow up visit carried out on 26/07/05 confirmed that this requirement has been complied with. The registered individual must ensure that a record demonstrating the receipt of all medication is maintained. A follow up visit carried out on 26/07/05 confirmed that this requirement has been complied with apart from the need to record the date medication is checked. The registered individual must ensure a record is maintained of all unused medication returned to the pharmacy. This must include unused medication in cassettes. A follow up visit carried out on 26/07/05 confirmed that this requirement has been complied with. The registered individual must ensure that the medication 01/08/05 10. 9 13(2) From 26/05/05 11. 9 13(2) 01/08/05 12. 9 13(2) 01/08/05 13. 9 13(2) 01/08/05 Page 25 Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 14. 10 12(4)(a) 15. 12 12(1)(a) administration sheet is an accurate record of all medication given. The registered individual must 05/09/05 ensure that residents’ privacy and dignity are maintained whilst being assisted or independently using the toilet facilities. Current facilities immediately located by the main lounge do not enable this to be achieved. Therefore the Commission for Social Care Inspection requires the registered individual to submit a written proposal of how she intends to address this issue. The registered individual must From review the current practice of 18/07/05 beginning to wake residents up at 6am. This must also address the current practice of getting the majority of residents up before the day staff come on duty. This routine must reflect the preferences of residents and where this is not possible consultation must be sought from the residents’ families/care managers. A follow up visit carried out on 26/07/05 confirmed that this requirement has been complied with. The registered individual must review the expectation of residents having a bath or shower every day. If this is required, an agreement must be sought in consultation with the resident’s care manager. A follow up visit carried out on 26/07/05 confirmed that this requirement has been complied with. The registered individual must review why residents who 16. 12 12(1)(a) 05/09/05 17. 12 12(1)(a) 05/09/05 Page 26 Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 18. 15 17(2) require assistance are helped into their bedclothes after tea. This routine must reflect the preferences of residents and where this is not possible consultation must be sought from the residents’ families/care managers. The registered individual must ensure the menu is an accurate record of food served to residents. Alternatives to the main meal must also be recorded. A follow up visit carried out on 26/07/05 confirmed that this requirement has been complied with. The registered individual must identify and clarify the reasons for assisting residents to the table for lunch at 11.30am. Consideration must then be given to reviewing the time of the meal and not be based on the insufficient staffing levels currently on duty. A follow up visit carried out on 26/07/05 confirmed that this requirement has been complied with. The registered individual must update the complaints procedure to include the address for the Commission for Social Care Inspection and to inform complainants that they can contact the Commission at any stage, should they wish to do so. The registered individual must obtain copies of the full and shortened versions of the Wiltshire and Swindon Vulnerable Adults procedures and ensure that the home’s policy and procedure reflects From 26/05/05 19. 15 18(1)(a) From 18/07/05 20. 16 22 31/08/05 21. 18 18(4) 31/08/05 Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 27 that procedure. These must be distributed to all staff and ensure that staff are familiar with these procedures. A follow up visit carried out on 26/07/05 confirmed that this requirement has been complied with apart from the need to ensure that the homes policy and procedure reflects the Wiltshire and Swindon Vulnerable Adults procedures. The registered individual must that the minimum staffing levels of the previous registration authority are maintained at all times which includes appropriate numbers of ancillary staff. The registered individual must ensure that the written staff rotas always reflect and be a true account of all staff on duty and demonstrate the member of staff sleeping in each night. The home must also send copies of the staff rotas on a weekly basis to the Commission who will monitor staffing levels to ensure compliance. The registered individual must amend its application form to include a full employment history, any gaps are explored and recorded and a section for applicants to record whether they are physically and mentally fit. The registered individual must send for references rather than accept references addressed to whom it may concern. The registered individual must ensure that all staff have received the various mandatory training courses. The registered individual must develop and implement a quality 22. 27 18(1)(a) From 26/05/05 23. 27 18(1)(a) From 26/05/05 24. 29 19 31/08/05 25. 29 19 31/09/05 26. 30 18(1)(c) 31/03/06 27. 33 24 31/09/05 Page 28 Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 28. 36 18(2) assurance system. (Previous timescale of 01/03/04 - not met) The registered individual must 31/12/05 ensure that all staff receive formal and recorded supervision on a consistent basis and at least six times a year. (Previous timescale of 01/02/04 - not met) 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. Refer to Standard 7 7 Good Practice Recommendations The registered individual should ensure that the practice of residents wishing to leave the toilet door open, is recorded within their individual care plans. The registered individual should ensure that all residents have a choice of a bath or a shower. If residents are unable to make this decision, advice should be sought from the residents’ families and recorded within their individual care plan. The registered individual should regularly monitor the daily record correct reflection of actual practice. A follow up visit carried out on 26/07/05 confirmed that this recommendation is being addressed. The registered individual should ensure the home’s policy on changing residents if soiled is clear and clarified with all staff. The registered individual should ensure that any member of staff or work experience student who are under 18 years of age does not undertake any personal care of residents. A follow up visit carried out on 26/07/05 confirmed that this recommendation is no longer applicable. The registered individual should collate and organise the certificates of staff training as evidence. The registered individual should ensure that the terminology staff use in the event of incontinence is addressed within formal supervision. A follow up visit carried out on 26/07/05 confirmed that Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 29 3. 7 4. 5. 10 27 6. 7. 30 36 this recommendation is being addressed. Alpine Villa D51_D01_S28251_APLINEVILLA_V214981_180405_Stage4.doc Version 1.20 Page 30 Commission for Social Care Inspection Suite C, Avonbridge House Bath Road Chippenham Wiltshire, SN15 2BB 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. 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