Inspection on 30/06/05 for Eastbourne Villa

This inspection was carried out on 30th June 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 17/11/05

Eastbourne Villa 14/01/05

Eastbourne Villa 01/09/04

Eastbourne Villa 11/03/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

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 Yorkshire HU18 1QS Lead Inspector Diane Wilkinson Unannounced 30 June 2005 10:00 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. Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Eastbourne Villa Address 21 Eastbourne Road Hornsea East Yorkshire HU18 1QS 01964 533253 01964 533449 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) Mr George Trevor Hart & Mrs Susan Lynn Martindale Susan Martindale Care Home 15 Category(ies) of OP Old Age (15) registration, with number DE(E) Dementia - over 65 (15) of places Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 14th January 2005 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. 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. There are plans in place to build a conservatory at the rear of the property to extend living space at the home. There is on street parking for visitors and staff. Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 7 hours, including preparation time prior to the inspection. The inspection included a tour of the premises and examination of documentation, including care plans. The inspector spoke to the acting registered manager, the deputy manager, the registered provider and several service users (including two service users in their own rooms). What the service does well: What has improved since the last inspection? What they could do better: The recruitment and selection of staff needs to be improved to ensure the safety of service users. Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 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 J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 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 Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 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) 3 Service users have their needs assessed prior to their admission to the home and admission only proceeds if their needs can be met. EVIDENCE: Four service users were recently admitted to Eastbourne Villa from another care home in Hornsea. The acting registered manager visited these service users in their previous home to commence a needs assessment and to begin the care planning process. Relatives and friends of service users were appropriately involved in this process. Staff were also recruited from the same care home and this eased the transition from one care home to another for the service users concerned. The acting registered manager informed the inspector that service users are always visited at home or in hospital prior to their admission to the home, and that they would refuse admission for a service user if it was felt that their needs could not be met by staff at the home. Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 & 11 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. There is evidence that deteriorating illness and death are dealt with sensitivity and that changing needs are met. EVIDENCE: Care plans are developed from an assessment of needs completed by care management and the home’s own assessment. Service users sign a ‘care plan agreement’ that records that they are aware of the content of their care plan. Monthly reviews of the care plan take place, as well as formal annual reviews by care management. The inspector observed that formal reviews are also arranged for privately funded service users. There are thorough risk assessments in place that include the risk of falls, pressure care needs and the use of bed rails. Weekly monitoring sheets include a record personal care, mobility, diet and medication. Nutritional screening takes place and there is a record of all visits and communications from GPs and hospital appointments, and the outcome of Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 Page 10 these visits. On one occasion a record of a GP’s visit indicated a change to a service users care needs – this was not reflected in the care plan. On other occasions, the care plan had been altered accordingly. The need for pressure care is recorded in a satisfactory manner and the inspector observed that appropriate equipment is provided for service users. Medication records were examined by the inspector and these were found to be satisfactory. Staff that administer medication have now completed accredited medications training, and there is a list of their names and sample signatures in medication records. Medication is stored securely, but the inspector recommends that the lockable box used for the storage of controlled drugs be fixed to the medication cabinet to ensure its security. 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. There is an appropriate policy in place on death, dying and deteriorating illness – this includes details about palliative care. There is evidence in records that staff have read and understood the policy that is in place. Discussions have taken place with service users and relatives in an effort to ensure that deteriorating illness is dealt with appropriately and sensitively. Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 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 standard(s) 12 & 15 Service users are supported and encouraged to maintain their chosen lifestyle following admission to the home. The meals in the home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: Care plans include a record of a service users social interests and hobbies. One service user goes out daily for a newspaper and also goes to the supermarket with the provider to assist with the weekly shop. The inspector observed that some service users are assisted to take part in individual activities such as knitting and reading, and other service users are encouraged to take part in group activities (such as a ball game designed to improve mobility and coordination). Care plans include a record of all activities undertaken by service users as well as any contact with family and friends. A new fish tank with gold fish has been purchased and some of the service users take an interest in this. New tables and chairs have been purchased for the dining room. The television was turned off and music played instead over the lunchtime period. The inspector observed that the meal was unhurried and some service users remained at the dining table chatting to each other after the meal was over. Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 Page 12 There was a menu on display and this recorded two choices of meal at lunchtime and teatime. Care plans include a record of likes/dislikes re: food and any special dietary needs. The only special dietary needs catered for at present are for diabetics. Appropriate assistance was offered to service users. Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 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 standard(s) 16 & 18 Service users know how to make a complaint to the home, and are confident that their complaints will be listened to and dealt with appropriately. Service users are protected from all forms of abuse by the provision of policies and procedures that have been read by staff, and by staff undertaking appropriate training. EVIDENCE: There is an appropriate complaints policy and procedure in place at the home. There has been a recent complaint made to the Commission for Social Care Inspection and this is currently being investigated by the Commission. This had been appropriately recorded by the acting registered manager. The complaints procedure is on display at the home and is included in the statement of purpose and service user guide. Service users spoken to said that they knew how to make a complaint but that there had never been any need for them to do so. Any concerns are usually dealt with informally and to everyone’s satisfaction. There are appropriate policies and procedures in place to protect service users from abuse, i.e. Abuse (No Secrets), management of violence, anti-racism, whistle blowing, best practice for caring for service users with Alzheimer’s and handling service user’s property and finances. Staff have signed a document to evidence that they have read these policies and procedures, and staff training on the protection of vulnerable adults from abuse has taken place. Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 Page 14 The same complaint referred to above was also investigated by the Social Services Department of the local authority under their vulnerable adults procedure. The investigation concluded that no abuse had taken place and the home was not required to take any further action. Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 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, 22, 24 & 25 Specialist equipment has been provided to enable service users to retain as much independence as possible. 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 now a programme of routine maintenance and renewal of the fabric and decoration of the premises in place. New dining room furniture has been purchased and the electrical system at the home is in the process of being updated – this includes the provision of two double electric sockets in bedrooms. The outside of the home has been redecorated. The accommodation on the second floor of the home has been converted into two single bedrooms for Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 Page 16 service users – the Fire Officer was consulted and all necessary work recommended by the Fire Officer has been carried out. A stair lift has been provided to the second floor to enable access for service users. The acting registered manager and the registered provider were advised that they should have consulted with the Commission for Social Care Inspection before the work was carried out. One of the new bedrooms does not have a washbasin and the home have agreed to have one installed by the 31st August 2005. The premises have now been assessed by a suitably qualified person – positive comments were made about equipment provided by the home by the occupational therapist who undertook the assessment. The inspector recommends that the unused toilet be made into a shower room to provide additional facilities for service users. Service user’s bedrooms have been personalised to meet their wishes – a list is kept of all possessions brought into the home by service users. All service users have been asked if they would like a key to their bedroom door and all have refused. The inspector recommends that this should become part of the maintenance programme, as there should be locks on all bedroom doors so that service users can be offered their own key. There should also be lockable storage available in each bedroom. All radiators have now been fitted with guards to protect service users from burning. Water temperatures are tested on a regular basis to control the risk of scalding and these tests are recorded. A test to detect the presence of Legionella in the water supply has taken place and this was negative. Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 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) 29 The home’s recruitment and selection policy and practices do not fully ensure the safety of service users. EVIDENCE: All new applicants for employment complete an application form that includes details of their employment history and any appropriate training undertaken. A new staff member commenced work at the home prior to a satisfactory CRB check and two written references being obtained (one written reference and one verbal reference had been received). A POVA first check was requested for this staff member, but this was after they had commenced work at the home. A risk assessment does take place, for example, existing CRB checks are examined and relevant documentation (such as birth certificates, passports and medical cards) are checked. Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 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 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) 33 & 38 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. Safe working practices need to improve to ensure that the health, safety and welfare of service users is promoted. EVIDENCE: An annual service review was recorded for 2004 and this includes ‘target setting’ for 2005. Service users completed a questionnaire in December 2004 and these are stored in service user records. The inspector recommends that these are analysed and published. Staff meetings are held and minutes are circulated. The home has achieved QDS Parts 1 and 11 (the local authorities quality assurance scheme). No evidence was seen of meetings with service users or relatives, and there are currently no systems in place for other stakeholders to affect the way in which the service is run. Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 Page 19 New staff are required to read the home’s policies and procedures and sign to say that they have done so. There is documentation in placed to record safe working practices. Health and safety audits are undertaken as part of the quality assurance system. The electrical installation is currently being updated – two double electric sockets are being provided in bedrooms and a new fuse box (including trip switches) is being installed. There is a current gas safety certificate in place. Accidents are recorded appropriately and accidents and incidents are notified to the Commission for Social Care Inspection under Regulation 37 of the Care Homes Regulations 2001. Fire safety audits are undertaken every month – these used to occur weekly and the inspector recommends that this is reinstated. There has been no fire drill for several months and the acting registered manager agreed that one will take place as soon as possible, and then these will continue on a regular basis. The Fire Officer has recently visited the home to advise about the use of the second floor as bedroom accommodation and all work recommended by the fire department has been carried out. There is a fire risk assessment in place. The bath hoist and the mobility hoist were serviced in September 2004. There of a maintenance contract in place for the passenger lift, but no record was seen of when the lift was last serviced. Health and safety training at the home is ongoing. Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x 3 x 2 3 x STAFFING Standard No Score 27 x 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x x x x 2 Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 Page 21 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. 2. Standard 19 29 Regulation 16 & 23 18 & 19 Requirement Timescale for action 31.8.05 A hand washbasin must be installed in the new bedroom by the date stated. There must be a satisfactory CRB Immediate check and two written references in place before staff commence work at the home. 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 9 Good Practice Recommendations Every effort must be made to transfer information from the record of visits from health professionals into care plans. 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 home should develop a quality assurance system that fully complies with the requirements of this standard. There must be evidence that the passenger lift is serviced J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 Page 22 3. 4. 5. 24 33 38 Eastbourne Villa on a regular basis. The inspector recommends that weekly fire tests are reinstated and that regular fire drills take place. Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Eastbourne Villa J53_s19664_Eastbourne Villa_v235477_300605_Stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!