Inspection on 17/11/05 for Eastbourne Villa

This inspection was carried out on 17th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eastbourne Villa 17/01/08

Eastbourne Villa 20/06/06

Eastbourne Villa 30/06/05

Eastbourne Villa 14/01/05

Eastbourne Villa 01/09/04

Eastbourne Villa 11/03/04

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Larchfield Manor

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The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Eastbourne Villa 21 Eastbourne Road Hornsea East Riding Of Yorks HU18 1QS Lead Inspector Diane Wilkinson Unannounced Inspection 17th November 2005 1.00 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 Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Eastbourne Villa Address 21 Eastbourne Road Hornsea East Riding Of Yorks HU18 1QS 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) 01964 533253 Mr George Trevor Hart & Mrs Susan Lynn Martindale Kathleen Ann Roberts Care Home 15 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (15) of places Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th February 2003 Brief Description of the Service: Eastbourne Villa is a privately owned care home that is registered to provide accommodation and care for 15 older people, including those with dementia. The home is in the seaside town of Hornsea in the East Riding of Yorkshire, and is close to local amenities and to the sea front. Two single bedrooms have recently been provided on the second floor of the property, in accommodation that was previously lived in by the providers. Individual accommodation is now provided in two shared rooms and 11 single rooms. All areas of the home, including the garden, are accessible to service users via the provision of a passenger lift, a stair lift and ramps. The garden is well stocked with plants and flowers and provides a seating area for service users. A new conservatory has recently been built at the rear of the property and it is expected to be decorated and in use by Christmas 2005. There is on street parking for visitors and staff. Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 5 hours, including preparation time for the inspector prior to the inspection. The inspection included examination of documentation, including care plans and a tour of the premises. The inspector spoke to the deputy manager, several members of staff, two service users (one to one) and a relative. What the service does well: What has improved since the last inspection? What they could do better: Lockable storage should be provided in service user bedrooms and bedroom doors should be fitted with locks so that new service users can be offered a key on admission. Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 6 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. Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 10 There are systems in place to ensure that a service user’s individual care plan is reviewed regularly, ensuring that current care needs are recorded and met. The systems for the administration of medication are good and ensure that a service user’s medication needs are met in a safe way. Service users report that they are treated with respect at all times and that their right to privacy is upheld. EVIDENCE: Care plans examined by the inspector included an initial assessment, risk assessments (including those for the risk of falls and moving and handling) and a care programme. A service user’s life history, a record of activities undertaken and a personal care record are also included. The care plan is monitored weekly and reviewed monthly, in addition to an annual review of the care plan at is undertaken by the local authority. Service users sign a ‘care plan agreement’ that records that they are aware of the content of their care plan. Risk assessments are reviewed on a regular basis. Medication records were examined by the inspector and these were found to be satisfactory. Staff that administer medication have completed accredited Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 10 medications training, and there is a list of their names and sample signatures in medication records. Medication is stored securely; the inspector recommended at the last inspection that the lockable box used for the storage of controlled drugs should be fixed to the medication cabinet to ensure its security, and this has not yet been actioned. None of the current service users have chosen to self-medicate but there is an appropriate policy in place to support service users in this. Any changes in medication are recorded in care plans. There is no lockable storage in service users’ bedrooms to enable medication (or money or valuables) to be stored securely but this is being addressed by the registered manager. Service users are asked if their photograph can be used for their bedroom door, medication records and care plan records. Some service users said ‘no’ to having a photograph on their bedroom door, and these decisions have been respected. Most service users have a single room so can spend time alone if they wish to do so, and have somewhere to take visitors. The new conservatory is almost completed and this can be used as a private area to meet visitors. Service users are asked to sign to evidence their agreement or disagreement to their care plan. Service users report that they are treated with dignity and respect by staff. Service users are asked to sign a form that consents to the sharing of information on a ‘need to know’ basis. Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 14 Services users are encouraged and supported to maintain contact with family and friends and to take part in the local community. Service users are supported to make decisions about their lives and about life in the home. EVIDENCE: There is evidence that service users are supported and encouraged to maintain contact with relatives and friends. Relatives and friends report that they are made very welcome by staff, and are kept informed appropriately about the care of their relative. Care plans record the visits of family and friends. One service users goes to the local shop for a newspaper every morning and gets small items for other service users. The same service user goes to the supermarket to assist the registered provider with the weekly shop. Service users take part in a craft afternoon every Thursday. Service user meetings and relative meetings are held and minutes of these evidence that service users are consulted about various aspects of home life. Service users are consulted about alterations to the home and about the decoration of their bedroom. On the day of the unannounced inspection, several service users were being assisted by staff to leave the home to go to the theatre – they were being accompanied by the registered providers. One service user told the inspector that she had been to the theatre on another two Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 12 occasions during November, and was going again in December. The inspector observed that service users were given a choice of going to the theatre or not, and that poor mobility was not a barrier to taking part in the outing. Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 The home is well maintained and provides a safe environment for service users. Bedrooms have been personalised by service users to an extent chosen by them. The provision of locks and keys for bedroom doors and a lockable storage facility would enhance privacy for service users. EVIDENCE: There is a programme of routine maintenance and renewal of the fabric and decoration of the premises in place. One of the bathrooms has been converted into a ‘walk in’ shower room and this now gives service users the choice of using a bath or a shower. Some areas of the home have been redecorated and the decorator was present on the day of the inspection working on the stairs, hallway and landing. A new bath seat has been installed in the bathroom. The maintenance programme includes plans for a lock to be fitted to bedroom doors when rooms become vacant, so that new service users can be offered a key to their room. The provision of lockable storage is also planned as part of the maintenance programme. A washbasin has now been fitted in the second Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 15 floor bedroom. Bedrooms have been personalised appropriately by service users. Laundry facilities meet the requirements of the National Minimum Standards. There are policies and procedures in place for the control of infection that include all of the information that is required by the National Minimum Standards. The washing machine has a sluice facility and there are separate hand washing facilities for staff. The washing machine has the specified programming ability to meet disinfection standards. The staff rota evidences that there are domestic staff on duty seven days per week and this assists in keeping the home in a clean and hygienic state. Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The staff group is now more settled and staff are employed in sufficient numbers to ensure that the personal care needs of service users can be met. The home’s recruitment and selection policy and practices fully ensure the safety of service users. Training records evidence that staff have the skills and knowledge to enable them to meet the needs of service users. EVIDENCE: The staff rota records the role of all staff, including ancillary staff. Domestic staff and a cook are employed on seven days per week, and this enables care staff to concentrate on personal care tasks. The deputy manager informed the inspector that they now have a more stable staff group. There are ten care staff employed at the home and three have completed NVQ Level 2 in Care. A further six members of care staff are working towards this award. It is anticipated that the requirement for 50 of care staff to achieve this award will be met by mid 2006. The registered manager and the deputy manager are working towards NVQ Level 4 in Care. Recruitment and selection records were not examined on the day of the inspection – the inspector contacted the registered manager after the day of the inspection and was informed that a POVA first check and two written references had been obtained for the two most recently recruited staff at the home, prior to them commencing work. Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 17 All new staff undertake Induction training that meets Skills for Care specifications – this was confirmed by staff spoken to by the inspector. Five staff are currently undertaking Dementia care training and six staff have undertaken health and safety training. Three staff (including the registered manager) did the protection of vulnerable adults (managers) training on the 12th May 2005. This is to be ‘cascaded’ to the staff group via two training sessions, one in December and one in January. Certificates will be issued for this in-house training. Individual training records and a collated training record for the full staff group are in place. Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The home is well managed. Quality assurance systems need to improve to give relatives and other stakeholders the opportunity to express their views and to affect the way in which the service runs. The systems in place to record the management of a service user’s finances need to be more robust to ensure accuracy of records and monies held. Safe working practices ensure that the health, safety and welfare of service users is promoted. EVIDENCE: The manager has had a fit person interview with the Commission for Social Care Inspection and, as a result, has been approved as the registered manager for Eastbourne Villa. She is continuing with training towards NVQ Level 4 in Care and Management, and has recently attended the protection vulnerable adults training course for managers. Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 19 Service users completed a questionnaire in December 2004 and these are stored in service user records. The registered manager informed the inspector that surveys have recently been sent out again to service users and relatives the inspector recommends that these are analysed and published. Staff meetings are held every eight weeks – a notice is displayed and staff are able to raise issues prior to the meeting via the use of a specific form - minutes are circulated. The home has achieved QDS Parts 1 and 11 (the local authorities quality assurance scheme) and has applied for the Investors in People award. Residents meetings are held – the minutes of a meeting held on the 11th September were seen by the inspector. These evidence that service users were consulted about the menu, outings and the new conservatory. There are currently no systems in place for other stakeholders to affect the way in which the service is run. The records and monies held on behalf of service users were checked by the inspector. There were some minor discrepancies and as a result, the inspector recommends that receipts are given to relatives when they hand money over to the manager to be held for service users, and that all items purchased for service users should have a corresponding receipt. There are appropriate policies in place. There is documentation in place that records safe working practices and associated risks. Water temperatures in bedrooms and bathrooms are tested and recorded on a regular basis, and a test to detect the presence of Legionella in the water system has been undertaken and was negative. In-house weekly tests of the fire alarm system and equipment take place. There is a satisfactory fire risk assessment in place. Health and safety training at the home is ongoing – it takes place at the time of induction training and then regular updates are arranged. Accidents are recorded appropriately. The stair lift is due to be serviced in January 2006, as the contractor has to remove it so that a new carpet can be fitted on the stairs, and then refit it. The bath hoist is new and is not yet due for servicing. There is a current gas safety certificate in place and the electrical installation has been tested. There has been an annual fire test, including emergency lighting, by a recognised contractor. The passenger lift and the mobility hoist have been serviced. Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 3 Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP9 Good Practice Recommendations The box used for the storage of controlled drugs should be fixed to one of the shelves in the medications cabinet. None of the current service users self-medicate but there should be lockable storage available in all rooms to facilitate this. Bedrooms doors should be fitted with locks so that service users can be offered their own key, and lockable storage should be provided in every bedroom. The registered manager should continue with training to ensure that NVQ Level 4 in Care and Management is achieved. The home should develop a quality assurance system that fully complies with the requirements of this standard. The systems in place for the handling of service user monies need to be more robust to ensure the accuracy of records and monies held. 2. 3. 4. 5. OP24 OP31 OP33 OP35 Eastbourne Villa DS0000019664.V265895.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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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