CARE HOMES FOR OLDER PEOPLE
Holwell Villa Holwell Villa 119 New Road Brixham Devon TQ5 8BY Lead Inspector
Judy Cooper Announced Inspection 20th September 2005 10:00 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 Holwell Villa DS0000018373.V250381.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. Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Holwell Villa Address Holwell Villa 119 New Road Brixham Devon TQ5 8BY 01803 854103 01803 859669 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) Mr Ronald Frank Marlow Mrs Barbara June Marlow Christina Marie Thomas Burridge Care Home 17 Category(ies) of Dementia - over 65 years of age (17), Old age, registration, with number not falling within any other category (17), of places Physical disability over 65 years of age (17) Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Females may be admitted from the age of 60 Mrs Burridge to complete her Registered Manager`s Award within the next twelve months 08/11/04 Date of last inspection Brief Description of the Service: Holwell Villa offers accommodation with personal care to older people (60/65 ), older people with physical disability and older people with dementia. It is registered to provide a service for up to 17 service users both male and female. The manager also accepts day care service users (maximum of two, when the home has the capacity to do this i.e. if there is a resident vacancy etc). The home is laid out over 3 levels and has a passenger lift connecting the ground, first and second floors. With regard to private accommodation, there are 11 single bedrooms (2 of which have en suite facilities) and 3 double bedrooms (2 of which also have en suite facilities). In terms of communal space, Holwell Villa has a lounge and a dining room as well as a front garden and rear patio with seating. There are also communal bathrooms and toilets throughout the home. The building itself is a large detached property located within walking distance of Brixham town centre with its range of shops and amenities. Holwell Villa DS0000018373.V250381.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 one day. Several residents, as well as their relatives and other interested parties returned the standard written feedback form prior to the inspection. Opportunity was taken, at the inspection to tour the premises, examine records and policies, briefly meet with the owners, as well as the home’s manager and deputy manager (who were both present throughout the inspection). Several of the residents were spoken with during the inspection as well as two visitors to the home, and staff on duty were also observed and spoken with, whilst in the course of undertaking their daily duties. What the service does well:
The manager ensures that an “open door” policy is in place which allows residents, staff and residents families/carers the ability to speak openly and easily, which helps all concerned deliver the appropriate care. There is also a very relaxed, family atmosphere within the home which the manager and staff should be commended on for maintaining. The manager and staff provide very individual care for the residents, some of whom are now unable to communicate their needs. The manager and staff are aware of this and ensure care matches the residents’ needs and personal preferences. The manager also undertakes a regular “hands on” role within the home to ensure she is aware of the residents’ needs and is aware of how the staff can best meet these. One of the home’s main strengths is the way that the staff maintain residents’ dignity and their rights to make personal choices. Due to the category of the resident group cared for at Holwell Villa (i.e. some residents suffer from advanced dementia), it means that staff need to take time and use good observational skills to determine what a resident may be trying to communicate, and this is an integral part of the staffs’ role within the home. Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better:
Increase staffing levels, particularly during the weekend afternoons, to ensure that residents’ needs and welfare can be met and upheld. To ensure that residents are fully protected by the appointment of suitable staff, the registered manager must have sight of the returned Criminal Record Bureau enhanced disclosure for all members of staff, before staff are left to work in an unsupervised capacity with residents. The registered provider must ensure that residents are protected from the risk of fire within the home by carrying out the recommendations contained within the home’s fire risk assessment and by maintaining fire precautions in line with those recommended by the local fire and rescue service. Any radiator not yet guarded must be, to ensure that residents are protected form the risk of sustaining a burn from a hot surface.
Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 7 To protect residents from risks associated with window openings, the registered provider must undertake a risk assessment of all of the homes’ windows and install window restrictors where any risk is identified. Written details of these risk assessments must be included within the other documentation appertaining to minimising risks within the home. Suitable privacy locks must be installed to the home’s communal toilet and bathing facilities. The two installed on the second floor must be replaced, as they do not enable staff to have access in the event of an emergency. Consideration should be given to providing a more easily accessible bathing area i.e. a walk-in shower, for those residents who are physically less able. . 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. Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 8 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 Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 9 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): 1 (Standard 6 is not applicable). The admission process is appropriately managed with residents’ needs explored and known prior to admission to the home. EVIDENCE: By looking at the records for two residents, who have recently been admitted to the home, (under a planned emergency admission) it was noted that a full and detailed admission procedure was undertaken, even when time was of the essence, which had ensured that Holwell Villa was an appropriate home for the residents. The manager has created a pre-admission document that considers all aspects of the proposed residents’ needs. The manager uses this document to full effect with prospective residents and/or their families, care managers etc. Both of the residents, for whom records were inspected, were able to confirm that they had been made to feel comfortable, both on admission and since, and that all their needs were being well met. The home does not provide for intermediate care. Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 10 Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 11 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): 7,8,9,10. Residents’ heath and personal care needs are well known, documented and met. Residents are treated with dignity and respect and their individuality and independence maintained as much as is possible. EVIDENCE: Care plans contained all relevant details appertaining to providing for individual residents’ care. The care plans had been regularly reviewed with the resident and/or the resident’s relative/next of kin where possible. Feedback from a District Nurse stated the following “I am a District Nurse and visit the home on many occasions and have no complaints”. The home’s policies and procedures, regarding the administration of medication, were in order and the medication cupboard and medication records were inspected and found to be satisfactory. No resident self administers and the manager has recently amended the home’s medication policy to ensure that it is pertinent to the way the homes’ staff actually administer medication within Holwell Villa. All staff that do administer medication have received training in the same and it is to the manager’s credit that other staff have also
Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 12 been afforded the opportunity to receive the same training so that they can be aware of how medications work and what effect the medication may have on individual residents. It was noted during the inspection that residents were always treated with respect and that their dignity was upheld. Such evidence that supported this was noting the gentle way that staff spoke to residents, taking into account their individual levels of ability, all residents were nicely dressed, clean and well presented. A feedback card from a visiting hairdresser stated the following “I have been hairdressing at Holwell Villa for many years and always found a nice welcome with the residents being very well cared for.” Choice was offered at lunchtime and time was given for those able to, to choose what they wanted. For others unable to do this, staff made the best choice they could on the resident’s behalf, taking into account personal knowledge and understanding of the resident concerned A comment contained in a feedback card from a relative stated the following “Excellent, couldn’t be more efficient, friendly. Nothing too much trouble. Feel welcome. Good to residents.” Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 13 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): 12,13,14,15 Residents enjoy a pleasant and supported lifestyle at the home, which helps them maintain a good quality of life, with visitors welcomed and encouraged. Various informal activities, such as cooking are made available and excellent meals are provided. EVIDENCE: Staff undertake activities with residents both individually and as a group on a daily basis. This can involve in house activities or residents benefit from being taken out on an individual basis to the local town or places of interest. The home operates an open visiting policy and during the day it was noted that two visitors were welcomed into the home and were obviously comfortable within the home’s environment, whilst the visitor’s book clearly showed that the residents had many visitors at varying times throughout the day. Residents are encouraged to express their individuality as far as possible and to this end one resident is able to have her pet cat with her and anther married couple their two cats and pet bird. One resident has recently chosen the colour scheme for his room himself, which staff have followed when redecorating the room. Those residents that smoke are able to do this in a designated area of the home under staff supervision (if assessed as necessary).
Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 14 The home’s cook has been at the home for a number of years and is very familiar with the residents’ individual needs, likes and dislikes. It was noted that the meal served on the day of inspection was to a high standard, presented well, being both appetising and hot and was enjoyed by residents. It was also particularly pleasing to hear how those residents who have difficulty feeding themselves are enabled and encouraged to maintain these life skills as long as possible by being helped by staff when necessary but allowed the time to “try themselves”. This support is provided in a discreet manner and with due regard for other residents feelings. Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 15 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): 16,18. Arrangements for protecting residents and responding to their concerns are satisfactory EVIDENCE: The home’s complaint policy remains in order with all residents and/or their families having received a copy of the complaints procedure, which is contained in the home’s service user guide. There have not been any complaints within the past twelve months either received by the home or by this Commission. The home continues to maintain appropriate, updated adult protection policies which staff have easy access to, including the Local Authority guidance and the “No Secrets” video. All staff have either attended, or are attending, the vulnerable adults training made available from the Local Authority. New members of staff are taken through adult protection issues by an outside trainer. Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 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 the following standard(s): 19,21,26 Recent improvements/upgrading measures have helped ensure that Holwell Villa provides a comfortable, clean and warm environment. The responsible person is not fully maintaining some areas of health and safety within the home which is compromising residents’ safety. EVIDENCE: Overall the home presented as comfortable, clean and welcoming. The tour of the building evidenced that the home has recently commenced an upgrading programme (including redecoration of the homes’ communal areas and one resident’s bedroom), that is aimed at providing a good standard of accommodation throughout. Bedrooms have been personalised as desired and residents can bring in personal items with them if they wish to. The manager stated that the home would provide a suitable lock if requested by a resident, but they are not provided as standard on admission.
Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 17 The lounge and dining areas provide adequate space and are well appointed. Plans are in hand to create further lounge and dining areas by the erection of large conservatory at the front of the house. The management maintains the day to day home’s fire precautions in line with the requirements of the local fire department, however it was noted during the inspection that the home’s recent fire risk assessment had highlighted the need for all fire extinguishers to be lifted off the floor by using a wall bracket or other means. Fire extinguishers should also be checked monthly by a member of the homes’ staff, to ensure that they are in order. This is to comply with the local Fire and Rescue Services recommendations and ensure that residents are fully protected from the risk of fire within the home. Two privacy locks, accessing a toilet and a toilet and bathroom on the second floor were seen to be of an inappropriate type, in so far as they would not allow staff to have access from outside in the event of an emergency. It was also noted that the bathing facility on the second floor is not used regularly by residents. The recent Occupational Therapist’s report on the home stated that a walk-in shower might be of more benefit to the more physically frail residents at the home. It was further noted that three radiators within the home had not yet been protected. (two being on the landing of each floor and one in bedroom eighteen’s en-suite facility). It was also noted that window locks had not been put in place on any windows on the second floor (rooms 1-7) or to the first floor landing window, and there were no risk assessments in relation to this. This could place residents at risk. The home was clean, and there were infection control measures in place, which protects residents from the spread of any infections. Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 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 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): 27,28,29,30 Staff are not always employed in sufficient numbers to meet the current resident groups’ needs. Residents are currently not fully protected by the home’s recruitment polices. Increased staff training has allowed the staff the opportunity for further personal development and to increase their skills and awareness in caring for this resident group. EVIDENCE: Staffing levels at weekend were not seen to be in sufficient numbers to ensure that residents’ needs could always be met. This is because there are periods of time (particularly during weekend afternoons) when there are only two members of staff on duty for sixteen residents and should one staff member be called away it would leave one carer to provide care for fifteen residents on their own. Residents spoken to did state that they felt well looked after and that staff were “very kind”. The staff recruitment programme had not been completed to the required standard. Enhanced C.R.B checks, although applied for, had not been received back, prior to two staff members working with residents in an unsupervised capacity, which could put residents at risk. It was pleasing to note, that the staff mix included two male carers, which helps keep a balance of a mixed gender staff group working within the home.
Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 19 Training was well planned and supports the staff in providing for the varied needs of the residents with statutory training and other work related courses being made available including NVQ training. Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 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 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): 31,33,35,38 The home is managed efficiently and well with residents best interests upheld. Although every day routine health and safety matters are well managed, some environmental safety precautions have not been provided for/completed, which means that residents’ health and safety is being compromised. EVIDENCE: The home is well managed and was seen to be the case on the day of inspection, and the manager has now nearly completed her registered manager’s award. Since the last inspection in November last year, the registered manager has improved the overall management of the home by compiling a more “steam lined” recording system and has increased her awareness of the day to day skills required in managing a residential care home. This has resulted in an effectively run home, which ultimately benefits residents and staff.
Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 21 The registered provider and manager have undertaken the work required to allow the home to be assessed for the “Investors in People” award, which is to take place in November this year. The manager undertakes quality auditing within the home and residents and staff etc are invited to have a say in how they feel the home is being run and to make any suggestions for change known. Feedback questionnaires are sent out and there are regular meetings within the home. The home’s business plan was made available at the inspection, which evidenced that the home is looking to the future and to undertaking improvements, which would be of most benefit to residents. Resident’s’ finances were protected, with the home holding monies as required in a secured area and with records clearly identifying any expenditure made on behalf of the resident. The owner is an appointee for on resident and there were records held regarding this resident’s monies. Records that were inspected included the home’s fire logbook, the home’s accident book, and room risk assessments. It was noted that the room risk assessments did not cover the bedroom windows in those rooms where restrictors have not been provided (as detailed previously under Standard 19). Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x 2 x x x x 2 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x x x x 2 Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 23 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. 1 Standard 19 Regulation 23 Requirement The registered provider must ensure that the homes’ fire precautions are maintained in accordance with the requirements of the local fire and rescue service. The registered provider must ensure that any type of privacy lock provided is such that staff can override it in an emergency. The registered provider must undertake risk assessments in relation to the provision of window restrictors to all windows within the home, and provide as required. The register person must ensure that all hot surfaces within the home are protected or have a low surface temperature. The registered provider must ensure that at all times suitably qualified, competent and experienced persons are working at the home in such numbers as are appropriate for the health and welfare of the service users.(Previous requirement with timescale of 08/12/04).
DS0000018373.V250381.R01.S.doc Timescale for action 20/10/05 2 21 13 20/10/05 3 19 13 20/10/05 4 19 13 20/11/05 5 27 18 20/11/05 Holwell Villa Version 5.0 Page 24 6 29 18 The registered manager must ensure that an enhanced disclosure from the Criminal Records Bureau is received, and seen, before a staff member is allowed to work with residents in an unsupervised capacity. 20/11/05 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 21 Good Practice Recommendations The registered provider should consider ways of making bathing more accessible to those residents with physical disabilities. Holwell Villa DS0000018373.V250381.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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