CARE HOMES FOR OLDER PEOPLE
Rose Villa Care Home (N) Limited 269 - 271 Beverley Road Kingston upon Hull East Yorkshire HU5 2ST Lead Inspector
Eileen Engelmann Unannounced 19 April 2005 at 09:30 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. Rose Villa Care Home (N) Limited J54_S50391_ Rose Villa_V221188_190405_Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Rose Villa Care Home (N) Limited Address 269 - 271 Beverley Road, Kingston upon Hull, HU5 2ST 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) 01482 472151 Dr Chanshyam Singh Chauhan Care Home with Nursing 36 Category(ies) of DE(E) Dementia over 65 - 36 places registration, with number OP Old Age 36 places of places PD(E) Physical Disability over 65 - 36 places TI(E) Terminally Ill 36 places PD Physical Disability 36 places Rose Villa Care Home (N) Limited J54_S50391_ Rose Villa_V221188_190405_Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: The registered persons must demonstrate, at all times, that they are staffing the Home to meet the needs of the service users in residence.. The registered persons should take account of the Residential Forum staffing levels within the development of the service and work towards these. Date of last inspection 28 October 2004 Brief Description of the Service: Rose Villa is a care home with nursing providing accommodation for up to 36 people who are in need of care by reason of old age, dementia, physical disability or terminal illness. Aids and adaptations are provided throughout the home to assist residents in moving around more independantly. There are 14 single and 11 double rooms located on 3 floors, accessible by a passenger lift. Some of the bedrooms have en-suite facilities. The garden area (which includes seating for residents) is accessible via a ramp. There is a car park for staff and visitors and the home is close to a bus route. Rose villa is located to the north of Hull City centre in the Pearson Park area of Beverley Road. Rose Villa Care Home (N) Limited J54_S50391_ Rose Villa_V221188_190405_Stage 4.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out with the acting manager, staff and residents of Rose Villa. The inspection took 6.5 hours and included a tour of the premises, examination of staff and resident files and records relating to the service. One additional visit has been made since the last announced inspection and was in response to a complaint received by the Commission. The investigating officer found sufficient detailed information within the home to reach the decision that the complaint could not be proven. Four of the eight staff on duty and seven of the twenty-nine residents were spoken to, their comments have been included in this report. What the service does well:
The home has an experienced and enthusiastic team of staff who work well together and enjoy taking part in training and development sessions. The staff are motivated and keen to ensure that residents receive high standards of care. Resident’s comments indicate they hold the staff in high regard, one individual said that ‘the staff were friendly, helpful and always supportive’. Two residents said that they ‘enjoy living at the home and that it has a very welcoming and pleasant atmosphere’. The home offers residents the opportunity to make decisions about their daily lives. One individual said that he ‘likes to be as independent as possible and staff respect his choices and decisions around his care and have done risk assessments with his consent and input’. . Meals are well presented and offer people at the home a choice and variety of different foods. One resident asked staff if he could have his lunch at a later time as he was going out, this was not a problem. Leisure activities and events are available in the home daily; residents have the option of joining in (or not) as they wish. Staff are happy to take individuals out to local shops and into the town. Outside entertainment is on offer with staff willing to take individuals out on a one to one basis. Three residents spoken to said they were pleased with the choice and variety of
Rose Villa Care Home (N) Limited J54_S50391_ Rose Villa_V221188_190405_Stage 4.doc Version 1.20 Page 6 activities on offer and ‘enjoyed taking part in the arts and craft sessions’. They are given information about future events in the monthly newsletter. The home is welcoming and has a relaxed atmosphere. Residents said they are happy with their bedrooms and can bring in their own possessions, making it feel more like home. 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office.
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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 Rose Villa Care Home (N) Limited J54_S50391_ Rose Villa_V221188_190405_Stage 4.doc Version 1.20 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. Progress has been made to develop the homes needs assessment to ensure that it covers all aspects of care. All residents undergo a full needs assessment and are given sufficient information about the home and its facilities prior to admission, to enable them to be confident that their needs can be met by the service. EVIDENCE: Each resident has their own individual file and all four of those looked at had a full needs assessment completed within them, including one for a privately paying individual. The information from the assessment process is used to formulate the individuals care plan. The acting manager said that he verbally tells individuals if the home can meet their needs, and this process is being developed into a written format. Two residents spoken to were able to give detailed information about their care needs and the input they required from the staff, service and outside professionals, and this was found to be accurately documented within their care plans. Staff members on duty were knowledgeable about the needs of each resident and had a good understanding of their specific problems/abilities and the care given on a daily basis.
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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 and 9. The health, personal and social care needs of the residents are clearly documented and are being met by the service and staff. Residents are encouraged to be independent within their daily lives using a risk assessment approach to care. EVIDENCE: Individual care plans are in place for all residents and clearly set out the health, personal and social care needs identified for each person. Four of the plans looked at have been evaluated on a monthly basis and any changes to the care being given is documented and implemented by the staff. One resident said that he likes to be as independent as possible and is fully aware of his diagnosis and future prognosis. His wishes and choices are clearly recorded in his care plan, as are his abilities to carry out a number of his care tasks by himself. Risks assessments are also in place. Three residents said that they have good access to their GP’s, chiropody, dentist and opticians. They all attend outpatient appointments at the hospital and records show that they have an escort from the home if wished. One resident said that he self-medicates his own pain relief and the staff monitors this and it has been risk assessed, two other individuals spoken to prefer the staff to administer their medication. Staff need to ensure they sign every time for medication received into the home and that being administered.
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The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15. Residents are provided with choice and diversity in the meals and activities provided by the home. Individual wishes and needs are catered for and people have the option of where, when and how they participate in both eating and leisure activities. EVIDENCE: Seven residents were spoken to and all said how much they enjoyed the food provided at the home. One individual said that there was a new chef and the meals were much improved as a result of this. The cook said that she was saving the midday meal for one individual who had gone out that morning and who had requested his meal later in the day. One member of staff who works in the administration office has one afternoon a week to carry out activities with the residents and the care staff do events on a daily basis. Three individuals said that they enjoy the painting and craftwork completed during the afternoon session. The residents and staff spoken to enjoyed the choir who had visited the home the previous week, as the choir members had moved around the room encouraging individuals to join in with the singing and had worn old-time costumes to complement the type of songs being performed. Two residents were happy that the staff respected their need for personal time alone in their rooms and appreciated the fact that they could dip into and out of the activities at will.
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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 and 18. The home has a satisfactory complaints system with some evidence that residents feel that their views are listened to and acted upon. Staff and residents are confident about reporting any concerns and the acting manager acts quickly on any issues raised. EVIDENCE: The home has a complaints policy and procedure that is simple, clear and easy to understand. Copies of the policy are in each resident’s bedroom and the individuals spoken to are aware of the procedure to follow and said that the staff or acting manager listens to their concerns and takes action if necessary. The complaints record shows that there has only been one complaint since the last announced inspection and the Commission investigated this. The complaint was not up held. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of service users money and financial affairs. The acting manager said that he has attended the local Protection Of Vulnerable Adults (POVA) training organised by the East Riding of Yorkshire POVA co-ordinator, this information has been cascaded down to other members of staff. The staff on duty displayed a good understanding of the vulnerable adults procedure. They are confident about reporting any concerns and certain that any allegations would be followed up promptly and the correct action taken. Rose Villa Care Home (N) Limited J54_S50391_ Rose Villa_V221188_190405_Stage 4.doc Version 1.20 Page 12 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, 24 and 26. Residents are provided with a safe, comfortable and clean environment. They are able to personalise their own rooms, however their belongings cannot be kept safe as no progress has been made on the provision of door locks. EVIDENCE: Three of the residents spoken to were in their own bedrooms and expressed their satisfaction with their private accommodation and the facilities provided. Painting and decorating is ongoing with a number of bedrooms undergoing refurbishment. Some areas in the corridors require repairs to the décor as wheelchairs and trolleys have damaged them. A number of bedroom carpets have stains on them and need deep cleaning. All other areas remain clean and odour free. The provision of bedroom door locks and keys remain outstanding requirements from the previous inspections. One person said that she did not want one fitting as she would feel shut in, but others felt they would benefit from the additional privacy. Residents are able to personalise their own rooms as wished and have input into what furnishings are provided or not depending on the individual’s choice.
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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 and 30. Since the last inspection the standard of vetting and recruitment practices has declined with appropriate checks not being carried out and potentially leaving residents at risk. Staffing numbers are sufficient to meet the needs of the residents and carry out activities. EVIDENCE: The staff file of one new member of staff showed that she is under the age of eighteen and has been employed before the results of her CRB have been received. Three other staff files showed that this check has been carried out. None of the staff files looked at had any evidence of interview notes being completed in line with the recruitment policy/procedure. The manager said that this had been done verbally. There is an induction procedure in place for all new staff, but there was no sign that this had been carried out for the new staff member. The manager said that he had not had the time to do this, although the staff member was supervised during her induction period. All residents spoken to said that the staff are kind, caring and friendly, with time to sit and chat with them. Information in the staff rota shows that extra staff are on duty in a morning to cope with the increased workload involved in getting people up, bathed and dressed. The staff training programme offers staff access to mandatory training and some specialist subjects linked to the needs of the service users, although staff said that they pay for all training. 37 of the care staff have achieved an NVQ 2 or 3 with eight others doing the training.
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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) 31, 36 and 38. Since the last inspection the management planning around staff supervision and the support of new staff members has deteriorated and could present a risk to the health, safety and welfare of the residents. EVIDENCE: The acting manager has submitted his application for registered manager with the Commission and this is being processed. Trained staff and care staff are not receiving formal supervision from their line managers, although staff on duty said that they have informal supervision on a daily basis. Maintenance certificates are in place and up to date for all the utilities and equipment within the building. The acting manager has completed generic risk assessments for the premises since the last announced inspection and a fire risk assessment has been completed and reviewed. Staff are undergoing training in all safe working practices and accident books are filled in appropriately. It is recommended that the acting manager obtain the new format for accident books in line with data protection legislation
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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. Where there is no score against a standard it has not been looked at during this inspection. 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 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 3
COMPLAINTS AND PROTECTION 2 x x x x 2 x 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 1 x x x x 1 x 3 Rose Villa Care Home (N) Limited J54_S50391_ Rose Villa_V221188_190405_Stage 4.doc Version 1.20 Page 16 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. Standard 9 Regulation 17 Requirement Accurate records must be kept of all medications , recieved, administered, leaving the home or disposed of to ensure there is no mishandling. The premises must be kept in a good state of repair and all parts of the home must be clean and reasonably decorated. Door locks must be fitted to all residents bedrooms unless the individual specifically requests this not to be done, this information must be documented (timescale of 1/11/04 was not met). Residents must be provided with keys unless their risk assessment suggests otherwise (timescale of 1/11/04 was not met). Staffing numbers and skill mix of qualified/unqualified staff must be appropriate to meet the needs of the residents and support the supervision and development of the staff. Staff providing personal care to the residents must be at least aged 18.
J54_S50391_ Rose Villa_V221188_190405_Stage 4.doc Timescale for action 1/7/05 2. 19 23 1/7/05 3. 24 12 1.9.05 4. 24 12 1/9/05 5. 27 18 1/7/05 6. 27 18 1/7/05 Rose Villa Care Home (N) Limited Version 1.20 Page 17 7. 29 19 8. 29 19 9. 30 18 10. 11. 12. 30 31 36 18 8 18 13. 36 18 There must be a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users, which is followed for all prospective employees. New staff are confirmed in post only after completion of a satisfactory police check, and satisfactory check of the Protection of Children and Vulnerable Adults and NMC lists. All members of staff have induction training to NTO specification within 6 weeks of appointment to their posts. All staff must have three paid days training per year (including in house training). A manager must be registered with the Commission. The employment policies and procedures and procedures adopted by the home and its induction, training and supervision arrangements must be put into practice. Care staff must have formal supervision at least six times a year and all other staff must be supervised as part of the normal management process on a continuing basis (timescale of 9/8/04 was not met). 1/7/05 1/6/05 1/7/05 1/7/05 1/7/05 1/7/05 1/7/05 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. 2. Refer to Standard 28 31 Good Practice Recommendations 50 of care staff should have achieved and NVQ 2 by 2005. The registered manager must complete an NVQ4 in management by 2005.
J54_S50391_ Rose Villa_V221188_190405_Stage 4.doc Version 1.20 Page 18 Rose Villa Care Home (N) Limited 3. 38 The acting manager should obtain the new format of accident book to comply with data protection legislation. Rose Villa Care Home (N) Limited J54_S50391_ Rose Villa_V221188_190405_Stage 4.doc Version 1.20 Page 19 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
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