Inspection on 13/07/05 for Derwentside Dementia Care Centre

This inspection was carried out on 13th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Derwentside Dementia Care Centre 01/07/09

Derwentside Dementia Care Centre 23/01/09

Derwentside Dementia Care Centre 25/01/07

Derwentside Dementia Care Centre 05/12/05

Derwentside Dementia Care Centre 15/12/04

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Benfield Villa Care Home 157 Durham Road Blackhill Consett, Durham DH8 5TH Lead Inspector Patricia English Unannounced Inspection 13 July 2005 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. Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Benfield Villa Care Home Address 157 Durham Road Blackhill Consett Co. Durham DH8 5TH 01207 581596 01207 588596 lk@mentalhealthcare.co.uk Mental Health C.A.R.E 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) Lynne Kelly CRH 30 Category(ies) of DE(E) Dementia - over 65 (16) registration, with number OP Old age (14) of places Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15 December 2004 Brief Description of the Service: Benfield Villa is a care home providing personal care and accommodation for 14 older people and 16 older people with dementia. The registered provider is Mental Health Care. The home is located on the main street in Blackhill which is an area on the outskirts of Consett and is close to houses, shops, a pub and other amenities. It was first opened in 1990 and consists of a two-storey building from the victorian period. There are gardens to the front and rear, an indoor courtyard and car parking facilities. The accommodation is split into two units with the first floor accommodating older people with dementia. There is a passenger lift for access. There are no en-suites facilities but an adequate number of bathrooms and toilets are provided. Each unit has spacious lounge and dining areas including a conservatory leading from the ground floor lounge. A hairdressing salon is located on the first floor. Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over approximately seven and a half hours and the manager, deputy manager, four care staff, three relatives and three residents were spoken to and gave their views. On this occasion the inspector looked at a total of 12 standards under Choice of Home, Health and Personal Care, Environment, Complaints and Protection, Staffing and Management and Administration. What the service does well: What has improved since the last inspection? The new owners have carried out a considerable amount of work to update the building and are now concentrating on a programme of redecoration and refurbishment and this has already made a significant impact in a number of areas in the home. The manager has made a number of positive changes in the staffing arrangements which have benefited both staff and residents. The staff supervision programme has much improved and is progressing well. The staff training and development programme is also developing well and staff comments indicated that they had plenty of opportunity to progress and develop their knowledge and skills. Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 Page 6 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. Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 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 Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 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) 1 and 3 The home’s admission procedures are being strictly followed and prospective residents have their needs assessed by a qualified person prior to entering the home to ensure that the home can adequately meet their needs. Assessments are comprehensive and recorded in good detail to ensure that staff in the home have all the relevant information they need. EVIDENCE: The Statement of Purpose and Service User’s Guide were in the process of being revised and amended to reflect changes since the new owners took over the home last year. The records of three residents were inspected and these showed that the home’s admission procedures were being followed correctly and in all cases the admissions were planned. All of the residents had been appropriately assessed by a qualified person prior to their admission to the home and had a full assessment of their needs recorded including risk assessments. There has been a big improvement in the assessment procedures and supporting documentation which was very comprehensive and covered all aspects of health, mental health, personal and social care needs. The information recorded was generally in good detail and dated and signed appropriately. Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 Page 9 Where applicable the assessments included details of residents’ behavioural problems and mental health needs and their relatives were included in the assessment process wherever possible. Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 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) 7and 8 There is a clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet residents’ needs. The health needs of residents are well met with evidence of good multi disciplinary working taking place on a regular basis. EVIDENCE: Each resident’s care plan was generated from their needs assessment and identified all aspects of their health, mental health, personal and social care needs including areas of risk and clearly specified the action to be taken to meet the assessed needs. These care plans showed a marked improvement both in the quality of the documentation and the detail of the information recorded. Records showed detailed evidence of daily progress reports and monthly evaluations of each resident’s care plan and were updated to reflect changing needs. Each resident’s personal file held records of reviews and visits carried out by social workers and in two of the records it was clear that specific intervention Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 Page 11 from a Social Worker and a Community Psychiatric Nurse had been sought when needed and appropriate action had been taken. Specific records were kept of any involvement or intervention from health care professionals e.g. GP, District Nurse, Dentist, Optician, Chiropodist etc. and these showed that the home was taking the necessary measures to promote and maintain residents’ health care needs. People visiting the home had written a number of comments in the home’s comments book, all of them praiseworthy, such as “the level of care and commitment is excellent”, “residents are happy, content and well looked after”. Comments received from residents and relatives during the inspection were also complimentary of the standard of care provided and staff were said to be “efficient and friendly”. Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 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 and 13 Social activities are well organised, creative and provide stimulation and interest for residents in the home. The manager ensures that the residents’ individual abilities, expectations and preferences are taken into account when planning activities and social events. EVIDENCE: The home has a dedicated member of staff to organise and plan a programme of activities on a weekly basis. This programme includes a variety of indoor and outdoor recreational and social activities such as board games, crafts, quizzes, aromatherapy, chair exercises music and videos and social events such as “sherry nights”, entertainment from local singers and visits to the park. A poster in the home was inviting people to the home’s Summer Fete and raffles were being held to raise funds. Positive action had been taken in response to a recommendation from the last inspection to provide more detailed information of each resident’s social, religious and recreational interests. More information was recorded in the care plans together with a brief life history (where possible) and records are kept of any activities residents have engaged in. It was noted that residents’ abilities were taken into consideration when organising activities to suit their individual needs and this included residents with dementia and those who have sight, hearing or physical disabilities. Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 Page 13 The manager has started a programme of meetings for residents and relatives which have proved popular and there are occasions when local schools or other groups have visited the home. Staff commented that activities within the home had much improved since the activities organiser had been in place and that there is “always something going on” for residents. Among the numerous comments made by relatives and visitors to the home were remarks such as “ given a warm welcome”, “staff are polite to visitors” and “there is a lovely, relaxed atmosphere” which indicates that the home provides a homely and caring environment for residents. Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 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 There are satisfactory systems in place for seeking the views of residents, relatives and people visiting the home and from the numerous comments recorded it was evident that all feel encouraged to express their views and concerns freely and openly and that they will be listened to. EVIDENCE: There were no recent entries in the formal complaints record. The home’s “Comments and Suggestion” book had numerous comments recorded, the majority of which came from visitors to the home and all were very positive apart from one or two minor concerns which had been immediately dealt with satisfactorily. It was evident from the entries in the book that people visiting the home were taking the opportunity to record their views and this confirmed that they felt able to express their views freely. During the inspection visitors commented that they “had confidence in the home” and they stated that the manager and staff were approachable and would always listen to their comments or queries. Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 Page 15 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) 19 Although the home’s refurbishment and redecoration programme has still some way to go to be fully completed, recent investment has significantly improved the appearance of this home creating a comfortable and safe environment for the people who live there. EVIDENCE: Since the new Registered Providers have purchased the home, good progress has been made with the home’s maintenance and refurbishment programme and a number of areas have been redecorated and new carpets have been fitted. Also, staff had been provided with a new rest room and the laundry room has been improved. On the day of inspection the home was generally clean and tidy and there were no unpleasant odours. However, some signs of wear and tear were identified during a brief tour of the premises and these concerned chipped paintwork on bedroom doors, stained and worn carpets (particular in one doorway where the carpet was fraying) and some worn and shabby bedroom furniture. Three of the bathrooms were being used as storage areas for hoists, obsolete furniture and other articles and staff explained that this was only because these particular bathrooms were not Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 Page 16 being used by residents. The manager confirmed that the bathrooms should not be used in this way and that the articles would be removed and stored in an appropriate storage area. Despite these issues, the remarks made by service users, visitors, relatives and staff confirmed that they were all very pleased with the investment being put into the home and the improvements being made. Although it was recognised that some of the bedrooms still needed refurbishment, all felt that the environment within the home was “homely, clean and comfortable”. Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 Page 17 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 to 30 Staff morale is high resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. Recruitment procedures have not been strictly followed and this could pose a potential risk to service users. EVIDENCE: The manager has made a number of changes which have significantly improved staffing arrangements within the home. Changes in staff rotas and the ratios of care staff to service users (particularly at busy times of the day) have proved to be successful and have also allowed for the manager to have a suitable number of hours in which to carry out her management duties. Staff commented that there has been a “big improvement” and they now feel the benefit of the changes particularly the extra time allowed for handovers between 2:00 p.m. and 3:00 p.m. when they can catch up on some of their tasks such as writing up care plans. There has also been a positive development in the employment of sufficient catering staff and a change in their shift pattern ensures that care staff do not have to undertake any extra catering duties at mealtimes. The rotas showed that domestic staff were not always covered when they were off sick or on holiday and this sometimes meant that there were times when there was no domestic on duty or that the domestic hours were reduced. This resulted in care staff sometimes having to carry out domestic duties in addition Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 Page 18 to their care duties. The manager agreed to review domestic staffing arrangements to address these issues. The home’s staff training and development programme including induction training is satisfactory. Training for NVQ level 2 is ongoing and five staff have also achieved their level 3. The NVQ training now includes one for “housekeeping” which a member of staff has enrolled for. Mandatory training is updated and other courses includes a number of subjects relevant to the needs of residents e.g. Dementia Awareness, Nutrition, Challenging Behaviour. Positive comments received from staff indicated that they were encouraged to attend training courses and develop their skills and in particular they were enthusiastic about attending courses in how to use a computer (IT) now that the home was planning for all records to be computerised. Recruitment procedures were not being strictly followed. Records of two staff showed that they were not asked to sign a declaration that they were physically and mentally fit for the purposes of the work they had to perform at the care home; also, checks were not being carried out on any previous employment where the person had been working with vulnerable adults. Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 Page 19 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 being appropriately supervised to ensure that they carry out their duties competently. EVIDENCE: The manager has taken positive action to address a requirement from the previous inspection regarding staff supervision. A formal programme has now been introduced and all but five staff have had their first supervision under the new process. Supervisions are carried out by the manager, deputy manager and senior care workers and formerly recorded. Staff commented positively on the process and said it was a good opportunity to “air their problems”. Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 4 x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x 3 x x Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 Page 21 no 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 19 Regulation 13/23 Requirement Carpets and furniture showing signs of wear and tear must be repaired or replaced as necessary. Where applicants have previously worked in a position which involved work with children or vulnerable adults, verification of the reason why they ceased to work in that position must be obtained, so far as reasonably practicable Applicants must sign a declaration that they are physically and mentally fit for the pruposes of the work they have to perform Timescale for action 30 September 2005 31 August 2005 2. 29 19 Schedule2 3. 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 22 Good Practice Recommendations Aids and equipment should be stored in designated storage areas B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 Page 22 Benfield Villa Care Home Commission for Social Care Inspection No 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Benfield Villa Care Home B54 S61959 Benfield Villa V227155 280605 Stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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