Inspection on 12/07/05 for Norfolk Villa

This inspection was carried out on 12th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Norfolk Villa 05/10/06

Norfolk Villa 12/01/06

Norfolk Villa 15/12/04

Norfolk Villa 29/06/04

Norfolk Villa 21/01/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Norfolk Villa 45 Alma Road Pennycomequick Plymouth PL3 4HE Lead Inspector Brendan Hannon Announced 12 July 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Norfolk Villa Address 45 Alma Road, Pennycomequick, Plymouth, PL3 4HE 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) 01752 661979 01752 668072 Mr Robert Timothy Teasdale Mr Robert Timothy Teasdale Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No more than 19 residents are accommodated in the home at anyone time 1 named Service User over 65 with a learning disability Number to be increased to 20 for only one service user named elsewhere Date of last inspection 15/12/04 Brief Description of the Service: The home is a large detached building,160 years of age. Over time the home has been extended to the rear of the property. The home is located in the Pennycomequick area of central Plymouth. A full range of amenities and facilities are within walking distance of the home. The home can normally accomodate up to nineteen residents over two floors. There are three communal bathrooms in the home. Two of the bedrooms have ensuite bathrooms. The main lounge is in the ground floor of the extension at the rear of the building. There are two dining areas one in the older part of the building and the other in the ground floor extension. There are small gardens to the front of the building and to the side of the extension.There are nineteen single bedrooms. Eleven of these have ensuite toilet facilities. The bedrooms are both on the ground and first floors of the building. Due to the age of the original building most the rooms have high ceilings which help the rooms, and the home in general, to feel more spacious. The service offered by the home is primarily for older people with moderate needs of various types. The home does not have the categories for dementia care or severe physical disability. Some of the residents have some mobility difficulties but mostly the residents are fully mobile. The residents have a mixed range of abilities. Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced. Preparation for the inspection included, analysis of the pre inspection questionnaire, the previous inspection reports and comment cards received from relatives of the residents. An inspection plan was developed from this information. The inspector was in the home for 6.5 hours from 9.45am till 4.15pm. The inspector spoke to five of the nineteen residents with particular attention given to two residents whose care was looked at closely. The whole of the building was inspected. The owner and registered manager of the home, Mr Tim Teasdale, Mrs Teasdale and the senior deputy were all spoken with at length. Care plans and various records, including medication administration records, staff/employment records, and health and safety records, were inspected. Some policies and procedures were also inspected. What the service does well: The home provides good information about the service to all potential new residents and their representatives. This enables potential residents to make an informed choice whether to use the service. The home ensures that residents receive appropriate healthcare. Personal care is well delivered to all the residents and there was a good standard of cleanliness in the home. The residents’ quality of life is maintained through support for residents’ varied leisure activities. The residents’ nutritional needs are met, and the quality and variety of food provided to the residents is of a high standard. The service was commended in this report for the quality of food provision in the home. The quality of the décor generally throughout the communal areas and bedrooms was good. Resident’s needs are met by an adequate number of competent, qualified, properly vetted and trained staff. There is an effective, open and inclusive style of management in the home creating a stable staff team. The Registered Provider values his staff and in return they provide consistent good quality care for the residents. The service was commended in this report for the inclusive, supportive style of management used in the home. The parts of the health and safety system, that were sampled during this inspection, were appropriately managed by the Registered Provider. The home has installed valves at the point of use to manage the temperature of hot water available to residents and has covered many of the radiators in the home to reduce the risk of accidents to residents. Good management of health and safety provides the residents and staff with a safer environment to live and work in. Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 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 Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 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) 1,3,4,5 The home provides good information about the service to all potential new residents and their representatives. This enables potential residents to make an informed choice to use the service. EVIDENCE: Both the Service Users Guide and the homes Statement of Purpose were available. The information in these documents enables potential residents to make an informed decision about whether to use this service. The home will only accept a new resident, who is supported by the local authority, after a full care management care plan has been received by the home. The home also has its own pre admission form. This is not always being used to collect further information about the potential resident. The senior deputy was advised to use this form routinely to demonstrate the assessment carried out by the home before the new resident’s admission. Residents and care staff were observed and were spoken to during the inspection. Through this observation, looking at care plans, and looking at records, there was good evidence to show that the residents’ needs are being met. Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 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) 7,8,9,10 The delivery of resident’s care is good but is hampered by limited care planning and resident risk assessment. Improvements in these areas will further support the delivery of consistent, high quality care to the residents. Healthcare support and medication administration within the home are good, which helps to maintain the health of the residents. EVIDENCE: Resident’s care plans were sampled. All the residents had a care plan and individual risk assessment in place. The care planning system is clear, practical and easy to understand. The information held in the care plan document was too brief and did not cover all of the resident’s needs. There was not enough detailed information on either the resident’s assessed needs or the directions given to staff to meet these needs. Similarly there needed to be more detailed information on the risks affecting the resident and how these are being reduced to an acceptable level. The registered manager stated that all care plans are reviewed monthly. A record of each monthly review should be kept, where no change has been made to the care plan information. When a more detailed care plan has been developed for each resident the quality of care support will be further improved. Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 Stage 4.doc Version 1.40 Page 10 There was good evidence of the involvement of healthcare professionals, such as the GPs and district nurses, in the support of the health of the residents. The healthcare support facilitated by the home helps to maintain the residents in good health. Medication is adequately managed in the home. The home uses a system of secondary dispensing from the original containers in which the medication arrives. This system was inspected in detail and is safe. However secondary dispensing is against the Royal Pharmaceutical Society (RPS) Guidelines and therefore the present system should be kept under review to potentially be replaced by another system, which is compliant with the RPS guidelines at some point in the future. Only senior staff administer medication. These staff have received training from the service but should receive more thorough external training in order to gain a thorough understanding of the medication itself, as well as the administration system. Both the quality of storage and recording for medication was adequate. The senior deputy was advised to place a photograph of each resident inside their Medication Administration Record (MAR) folder to ensure correct identification of the resident. She was also advised and to keep a list of the staffs sample signatures in order to track administration within the MAR. Well managed medication administration will support the health of the residents. Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 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) 12,14,15 The home supports residents’ leisure and social activity both in and outside the home. The residents’ nutritional needs are met and residents receive enough good food. EVIDENCE: Evidence of the activity being participated in by residents is provided through adequate individual records. The residents’ daily records describe the quality of the resident’s day and any contact with friends and family from outside the home. Indoor activities include films, armchair activity group and Bingo. Some residents are able to go out unaccompanied. Others go out with members of staff on car trips and to church. This activity maintains the residents quality of life. The food provided on the day of the inspection was sampled and was tasty and well presented. Resident’s food likes and dislikes are found out by the service. A four-week menu plan is in place but the food actually prepared is not rigidly dictated by this plan. There is a comprehensive record kept of the food actually provided. This record helps to ensure that the food provided is nutritionally balanced and wholesome, and will therefore help to maintain the health and quality of life of the residents. Standard 15 was previously recognised as exceeded and this standard continues to be commended in this report. Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 Stage 4.doc Version 1.40 Page 12 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) 18 The residents are protected from abuse through the home’s policy, procedure and training. EVIDENCE: The home has all the required adult protection policies in place and the homes management has attended adult protection training. It is hoped that further members of staff will soon be able to attend Adult Protection training. Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 Stage 4.doc Version 1.40 Page 13 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) 19,20,21,22,23,24,25,26 The quality of the environment in the building is maintained to a good standard helping to give the residents a good quality of life within the home. EVIDENCE: A complete tour of the building was made during the inspection. There is an original older building that has been extended to the rear of the property. A new kitchen with new flooring has been fitted. The larder has had new flooring and shelving installed. No significant maintenance faults were seen in the building during the inspection. The laundry area was clean and tidy. The laundry walls have been covered to give a washable surface. The COSHH chemicals were locked away. In general the decoration in communal areas was good. The bedrooms have been personalised by the residents and generally facilities in the bedrooms are good. The residents enjoy a well decorated environment to live in. Considerable investment has been made in creating a safer environment in the home. The Registered Provider stated that almost all the radiators have been covered to eliminate the risk of pressure burns. The few remaining radiators are being monitored for risk through written risk assessments. However all the Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 Stage 4.doc Version 1.40 Page 14 radiators in the home should eventually be covered. It was also stated by the Registered Provider that all the window openings above the ground floor have been limited to eliminate any risks of falls from windows. The Registered Provider stated that all the hot water outlets at baths and sinks have had hot water temperature control valves fitted reducing the temperature of the hotwater to a safe level. This investment helps the residents benefit from a safer environment. Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 Stage 4.doc Version 1.40 Page 15 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) 27,28,29,30 Resident’s needs are met by enough competent, qualified, properly vetted and trained staff. EVIDENCE: The pre inspection questionnaire and staff records showed that 44 of the care staff have achieved an NVQ2 care qualification. The Registered Provider is confident that there will soon be 50 of care staff qualified to NVQ2. The residents are better cared for because the staff team is trained and competent to deliver care. The Registered Provider stated that there is always an adequate number of staff to meet the needs of the residents. The staff were seen throughout the inspection to be relaxed, patient and helpful when assisting the residents. The Registered Provider stated that the listing of Criminal Records Bureau (CRB) clearances given in the Pre Inspection Questionnaire was correct. This showed that all the staff have received an enhanced CRB clearance. Appropriate references are in place for the staff. The residents can be assured that they are secure and safe when left in the care of the staff. A simple induction system is in place for new members of staff. This system does not comply with the National Training Organisation (NTO) specification for induction. The home should develop a new structured induction format in light of the NTO specification that is practical for the home to manage, and ensures that new staff can meet the needs of the residents early in their work at the home. Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 Stage 4.doc Version 1.40 Page 16 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) 32,33,36,37,38 The management of the home is effective and continues to ensure that the needs of the residents are met. EVIDENCE: The Registered Provider and Registered Manager is Mr Tim Teasdale. He ensures that there is an open, positive and welcoming atmosphere within the home. The interaction between the residents and staff throughout the inspection showed that meeting the needs of the residents is paramount. The management and staff were seen to be working well together. Well managed and motivated staff provide better quality support for the residents. The requirements of standard 32 have been exceeded and the quality of management in the home is commended in this report. Though informal feedback is continuously received by the provider from residents, relatives and staff, there is no formalised quality assurance system at the moment. An effective Quality Assurance (QA) system based on the views of the residents and other interested parties, and supported by a policy Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 Stage 4.doc Version 1.40 Page 17 and procedure stating how QA is carried out at Norfolk Villas, should be developed. Various positive physical Health and Safety measures that have been put in place in the home are discussed within the environment section of this report. The fire protection system was generally well maintained. Maintenance checks are being carried out. A number of appropriate hold open devices are fitted to self closing fire doors. Staff are receiving appropriate fire protection training. Gas and electrical appliances were being routinely serviced and checked. Good health and safety practice will reduce any unreasonable risk, affecting residents or staff, to an acceptable level. Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 Stage 4.doc Version 1.40 Page 18 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 4 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x 4 2 x x 3 3 3 Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 Stage 4.doc Version 1.40 Page 19 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 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. 2. Refer to Standard 7 9 Good Practice Recommendations All the residents should have a comprehensive and detailed care plan and individual risk assessment. A record of monthly reviews should be kept. The home should seek at some time in the future to put in place a medication administration system that complies with the Royal Pharmaceutical Society Guidance. All care staff involved in medication administration should recieve accredited level medication administration training. All radiators in the home should eventually be covered or replaced with a low surface temperature type. The induction training structure should be redeveloped to the level of the National Training Organisation specification. An effective Quality Assurance (QA) system based on the views of the residents and other interested parties, and supported by a policy and procedure stating how QA is carried out at Norfolk Villas, should be developed. 3. 4. 5. 25 30 33 Norfolk Villa D52-D04 S3485 Norfolk Villa V226781 120705 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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