Inspection on 23/10/06 for Rose Villa Care Home (N) Limited

This inspection was carried out on 23rd October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Rose Villa Care Home (N) Limited 08/12/05

Rose Villa Care Home (N) Limited 19/04/05

Rose Villa Care Home (N) Limited 28/10/04

Rose Villa Care Home (N) Limited 17/05/04

Rose Villa Care Home (N) Limited 21/02/04

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

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 Key Unannounced Inspection 09:30 23rd October 2006 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 Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 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. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rose Villa Care Home (N) Limited Address 269 - 271 Beverley Road Kingston Upon Hull East Yorkshire HU5 2ST 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) 01482 472151 Dr Chanshyam Singh Chauhan Mr Alexander Bauld Care Home 36 Category(ies) of Dementia - over 65 years of age (36), Old age, registration, with number not falling within any other category (36), of places Physical disability (36), Physical disability over 65 years of age (36) Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. 8th December 2005 Date of last inspection 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 independently. 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. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager of the home. The latest inspection report for the home is kept in the manager’s office and copies are available on request. Information given by the manager on 12/07/06 within the Pre-Inspection Questionnaire indicates the home charges fees from £327.50 per week for residential care to £327.50 plus the nursing band payment for nursing care. There is a ‘top-up’ fee of £5.00 per week for a double room or £10.00 per week for a single room. Residents will pay additional costs for optional extras such as hairdressing, private chiropody treatment, toiletries and newspapers/magazines. Information on the specific charges for these can be obtained from the manager. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit was carried out with the registered manager, staff and residents of Rose Villa Nursing Home. The visit took place over 1 day and included a tour of the premises, examination of staff and resident files and records relating to the service. Two of the staff on duty and four of the residents were spoken to; their comments have been included in this report. Information was gathered from a number of different sources before the inspector visited the home. Questionnaires were sent out to a selection of relatives, residents and staff and their written response to these was good. The inspector received 7 back from relatives (50 ), 5 from staff (33 ) and 10 from residents (77 ). The manager completed a pre-inspection questionnaire and returned this to the Commission within the given timescale. Since the last inspection (December 2005) the Commission has received one formal complaint about the care given at the home. The formal complaint was passed to the Social Service Team for Hull City Council, the team carried out investigations and gathered sufficient information to find the complaint was unproven. What the service does well: What has improved since the last inspection? The registered person has invested money into the redecoration and refurbishment of the home, this has made it a very comfortable and relaxing place for the residents to sit in and enjoy each others company. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 4. Quality in this outcome area is good. 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents are provided with a copy of the Service Users Guide and there is a monthly newsletter giving individuals more information about events taking place within the home. Copies of the newsletter are available in the reception area of the home. Information from the surveys showed that all the residents who responded had been provided with written information about the service before they came into the home. These individuals have also received a contract/statement of terms and conditions from the home. One individual said ‘my initial contact was through social services, but a subsequent visit to the home by my husband and Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 9 sister left very favourable impressions and I decided to accept the placement offer’. Each resident has their own individual file and four of those looked had a need assessment completed by the funding authority and the home has also completed its own needs assessment before a placement was offered to the resident. The manager said that he verbally tells individuals if the home can meet their needs, and this process is to be developed into a written format. The home develops a care plan from the assessments, identifying the individual’s problems, needs and abilities using the information gathered from the resident and family. Those residents at the home who receive nursing care have undergone an assessment by a NHS registered nurse from the local Primary Care Trust, to determine the level of nursing input required by each individual. 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. The home employs three staff from India and South Africa. These individuals offer staff an insight into different cultures and informal discussion with the staff indicates they work well together as a team. Residents are able to make a limited choice of staff gender when deciding who they would like to deliver their care, as the home has two male staff (including the manager) as well as the female members. The staff training files and the training matrix show that new staff go through an induction before starting work and that the home has a training programme in place. Information from the files and matrix indicates that not all staff are up to date with their basic mandatory safe working practice training, although they are booked on to courses this year. Checks on the staff files, indicates that staff support and guidance through supervision is carried out using training sessions and staff meetings as discussion and feedback opportunities, as well as more formal 1-1 time with individual staff. The employment records show that the manager is using a selective approach to recruitment; ensuring new staff have the right skills and attitude to meet the needs of the residents. Information from the Pre-Inspection Questionnaire and discussion with the residents indicates that the majority of the residents are white/British nationality. Two individuals are from other ethnic groups, although they both speak some English and have adopted British culture and lifestyles. Staff ensure effective communication with these individuals is maintained through use of clear speech and the family of one person has translated the care notes into a more familiar language for the resident. One individual has a touch board with words in English and Lithuanian to aid his communication needs. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 10 Comments from the relatives and residents surveys indicate they are pleased with the care being given and have a good relationship with the staff. The home does not accept intermediate care placements so standard six is not applicable to the service provided. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. Improvements to the staff performance around record keeping within the medication system must be made, to ensure the residents’ health and welfare are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home continues to produce and keep clear and well-written care plans for the residents. Individual care plans are in place for all residents and the four examined set out the health, personal and social care needs identified for each person. 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. Risk assessments were seen to cover pressure sores, nutrition, moving/handling and activities of daily living. Information about the resident’s social interests, likes and dislikes, spiritual needs and wishes regarding death and dying are included within the individuals care plan. The funding authorities are carrying out yearly reviews of the care plans and the minutes of these meetings show Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 12 that residents have input to this process (where possible), and family/representatives are also invited to the reviews with the resident’s permission. One area where the care plans could improve is to ensure that residents or their relatives (as appropriate) sign the plans to indicate they have had input to and agreed the contents. Four residents said that they have good access to their GP’s, chiropody, dentist and optician services, with records of their visits being written into their care plans. They all have access to outpatient appointments at the hospital and records show that they have an escort from the home if wished. Responses to the surveys indicated that the residents and relatives are satisfied with the level of medical support given to the people living at the home. Entries in the care plan specify where individuals have dietary needs, including PEG feeds, supplement drinks and pureed diets. The staff weighs everyone on a regular basis and evidence in the plans show that dieticians are called out if the home has particular concerns about an individual. Pressure areas are monitored carefully and proactive measures include risk assessments and special mattresses and seat cushions. Information from the pre-inspection questionnaire and discussion with the manager indicates that currently there are four residents with pressure sores, their wounds are documented in their care plans and wound care is given as appropriate. The nurses within the home carry out specialist tasks such as stoma care, PEG tubes/feeding regimes and wound dressings. Checks of the wound care records indicates the staff ask the tissue viability nurse for advice, where needed, and they document each time the wound dressing is changed. The inspector recommended that the staff include a description of the wound at least once a week to ensure that its progress can be monitored and audited easily. The medication policy for the home says that individuals can self-medicate if they want to and after a risk assessment has been completed and agreed. Completed risk assessments were seen in the care plans and the manager said no one at the home was currently self-medicating. All of the residents spoken to prefer to have staff administer their medication. Checks of the medication records showed that overall these are well maintained and kept up to date, however there were a few areas in which they could be improved. These included •Where staff are hand writing medication onto the sheets (transcribing), they are not following best practice. Staff must include the amounts of medication received or brought forward, and have two staff sign the entry to indicate they have both witnessed that the information on the sheet is correct. •It was noted that medication already held in the home when a new delivery is receipted in is not added to the supplies on the medication record sheets. This should be done so as to ensure a running total is available at all times. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 13 •Staff must sign in all medication received into the home. Checks of the controlled drugs and register showed that these are up to date, accurate and well managed. Resident and relative comments show they are very satisfied with the care and support offered by the staff. Chats with the residents revealed that they are happy with the way in which personal care is given at the home, and they feel that the staff respect their wishes and choices regarding privacy and dignity. Two individuals spoken to said ‘ the staff are lovely, they are always around to offer help and support when we need it and are very considerate of our feelings’. One person wrote that ‘ many residents stay in their rooms during the day, so those in the lounge do not always get an immediate response to the call bell’. Six surveys said that ‘ staff respond quickly to call bells and we are very satisfied with the care given’. One person commented that ‘the home is comfortable and staff are supportive, I am extremely happy with the care I receive’. Observation before the lunchtime meal showed that staff worked quickly and efficiently to toilet and see to the care needs of all the dependant residents before lunch was served. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. Residents are provided with choice and diversity in the meals and activities provided by the home. Relatives and visitors are made welcome at the home and good links to the community enrich the residents social and leisure opportunities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One member of staff who works in the administration office has two afternoons a week to carry out activities with the residents and the care staff organise events on a daily basis. Information from the resident surveys showed that everyone is extremely satisfied with the social activities on offer and individuals felt there was always something they could participate in. Monthly entertainment is booked from external groups and the home hires specialist transport when a trip out is organised. There is a monthly newsletter that keeps residents informed of ongoing events and forthcoming attractions, and there are resident meetings held every two months with minutes kept. Residents are able to celebrate Christian festivals such as Birthdays, Easter and Christmas and plans are in motion for a Halloween party. On the day of Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 15 this visit one resident was having a ‘Birthday tea’ and the cook had prepared a special buffet and cake for the occasion. Discussion with the residents indicates that they have good contact with their families and friends. Everyone said they were able to see visitors in the lounge or in their own room and they could go out of the home with family or staff would take them into the town. Visitors were seen coming and going during the day, staff were observed making them welcome and there clearly was a good relationship between all parties. Four residents spoken to were well aware of their rights and said that they had family members who acted on their behalf and took care of their finances. Information in the pre-inspection questionnaire indicates that there is only one resident who manages his/her own finances and the home does not act as an appointee for anyone. The manager said he is aware of the advocacy groups in the community that residents can access, and the contact information is on display within the home. All the residents said that the home encouraged them to bring in small items of furniture and personal possessions to decorate their bedrooms. Discussion with the residents showed that they were aware of their care plans and were able to input to them and access them through their key workers. Comments from the surveys received from staff, residents and relatives indicate that overall there is a good level of satisfaction with the meals provided by the home. Two individuals said ‘we would like to change the way the food is presented’, whilst another wrote that ‘the food is adequate and there is room for improvement’. Observation of the lunchtime meal showed that thought had gone into the contents of the menu, with the meat being braised and tender and the puddings specially prepared so even the diabetics could enjoy the same as everyone else. However there were some aspects of the dining experience that could be improved on, these include •The presentation of the meal was adequate, with pureed foods being prepared separately. The look of the meal was not ideal as food was put onto the plates ‘any old way’ and this spoilt the overall effect. •One resident is known to eat without implements and would benefit from being provided with ‘finger food’, instead he was eating mash potato and meat in gravy with his hands and this was not pleasant for other people to watch whilst eating their own meal. •Some residents were sat in their armchairs with a small table in front of them. These were not cleared of paperwork or objects before the meal was served and a number of individuals did not have the right cutlery in place so there was a delay before they could enjoy their meal. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 16 Those residents spoken to during the meal said ‘ the food is good, and we can have different things if we do not like what is on the menu’. The number of empty plates going back to the kitchen also showed that the residents had eaten well and liked the food offered. Staff were organised and ensured those individuals who ate in their room were served with hot food, and people who needed some help with eating and drinking were offered support and assistance. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. The home has a satisfactory complaints system with some evidence that residents’ views are listened to and acted upon. Visitors and residents are confident about reporting any concerns and the manager acts quickly on any issues raised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Checks of the complaints record shows that the home has not had any formal complaints since the last inspection. Discussion with the manager indicates he would deal with any ‘niggles or grumbles’ on a daily basis. The home has a complaints policy and procedure that is included in the statement of purpose and service user guide. It is also on display within the home and can be found in every bedroom. Eleven resident survey responses showed individuals have a clear understanding about how to make their views and opinions heard and those residents spoken to said ‘the manager comes round every day to see us and will discuss any problems at this time. He will take immediate action, if needed, to resolve any issues brought to his attention’. One resident said ‘my husband visits daily and staff are always ready and willing to listen if we have any concerns’. The staff on duty displayed a good understanding of the vulnerable adults procedure and four residents spoken to said they ‘felt safe at the home’. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 18 Discussion with the manager indicated that he has attended the ‘manager awareness’ training provided by the local Protection of Vulnerable Adults team. Staff cover this subject in their NVQ training, but it is recommended that the manager ensures that staff are able to access this information on an ongoing basis and it is put onto the staff training programme. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, management of service user monies and finances, physical intervention and restraint. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24 and 26. Quality in this outcome area is good. 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has a record of the ongoing maintenance and renewal programme within the home and this indicates that the provider is committed to improving the facilities and environment within the home. Since the last visit in December 2005, the home has purchased seven hospital beds for high dependency residents, and redecorated about 50 of the bedrooms including new en-suite flooring to two rooms and new curtains for three others. Metal railings and improved security lighting have been put into place around the perimeter of the site and at the time of this visit the home was fitting a new kitchen to the small room used by relatives and visitors for making drinks and Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 20 snacks. More up to date lighting has been fitted to the hallways and staircases within the building and this has improved visibility in these areas. Inspection of the home showed that it has been designed and built to meet the needs of disabled individuals. Doorways to bedrooms, communal space, corridors and toilet/bathing facilities are wide enough for people in wheelchairs or with walking frames to pass by comfortably. The home is built on three floors with flat walkways inside and out, providing safe and secure footing for people with limited mobility. Access to the upper floors is by use of a staircase or the passenger lift. Discussion with the staff indicates that there is a wide range of equipment provided to help with the moving and handling of the residents and to encourage their independence within the home. This includes mobile hoists, stand aids, slide sheets, moving belts and handrails. Four residents spoken to were very pleased with their individual rooms and said that they had ‘brought in a number of personal possessions to make them feel more at home’. The rooms are decorated to a high standard and supplied with sufficient furnishings to meet the needs of the residents. Double rooms are supplied with privacy curtains that can be drawn across the room when individuals are receiving personal care. The provision of bedroom door locks and keys remain outstanding requirements from previous inspections (December 2005, April 2005). Discussion with the manager indicated he is looking at fitting door locks that use a ‘Master Key’ system within the next 12 months. Lockable drawers are provided in each bedroom so residents can kept their monies and valuables safe. The environment is safe, warm and comfortable and no malodours were present. Comments from the surveys indicate that the residents find the home to be clean and fresh and are satisfied with the laundry service provided by the home. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is (excellent, good, adequate or poor). The standards of recruitment, induction and training of staff are good with appropriate employment checks being carried out and staff demonstrating a clear understanding of their roles, ensuring that residents are protected from risk and looked after by motivated and knowledgeable people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Comments from relatives, residents and staff indicate that there are some concerns about the number of staff on duty. Three individuals said that they felt ‘there are insufficient numbers on duty to meet the needs of the residents’’; another said ‘staff struggle to cover sick leave and absences, although everyone works hard as a team’. Staff morale on the whole is good, and individuals said that there is a good working atmosphere at the home. Discussion with the manager indicates that staffing numbers are lower, but this is because of fewer resident placements. As resident numbers increase so will the staffing levels. At the moment there are 25 residents living at the home, with one nurse and five care staff on duty in a morning, one nurse and four care staff in the afternoon and one nurse and three care staff at night. The manager’s hours are supernumerary to these figures. Observation of the staff showed that the home is busy, but well organised. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 22 Information from the pre-inspection questionnaire and staff rotas about the number of staffing hours provided and the dependency levels of the residents, was used with the Residential Staffing Forum Guidance and showed that the home is meeting the recommended guidelines. There is an induction and foundation course for new members of staff, and 68 of the care staff have achieved an NVQ 2 or 3. The home provides a mandatory staff-training programme and additional, more specialised training that reflects the different care needs of the client group. There is no evidence that staff have received training around equality, diversity and disability rights and this should be included in the rolling programme of staff training and development. Information from the staff-training matrix indicates that some safe practice training sessions have not taken place in the last 12 months, but the notice board has posters saying that Food Hygiene and First Aid training is taking place before the start of 2007. The inspector recommended that health and safety training is added to the mandatory rolling programme of training subjects for staff. The home has an equal opportunities policy and procedure. Information from the staff personnel and training records and discussion with the manager, shows that that this is promoted when employing new staff and throughout the working practices of the home. The manager said that he has tried to recruit more male carers in the past as he is aware that the majority of staff are female, but this has proved difficult as there have been few suitable applicants. He is aware that this may affect resident’s wishes regarding gender choice for giving of personal care, and this is discussed before an individual is offered a placement at the home. Comments from the manager indicate that the majority of the residents are from a white British background, but the home is able to offer a range of services when they are approached from someone of another culture or ethnic group. The home has a recruitment policy and procedure that the manager understands and uses when taking on new members of staff. Checks of four staff files showed that police (CRB) checks, written references, health checks and past work history are all obtained and satisfactory before the person starts work. Nurses at the home undergo regular registration audits with the Nursing and Midwifery Council to ensure they are able to practice. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. The management of the home is satisfactory overall and the home regularly reviews aspects of its performance through a good programme of audits and consultations, which includes seeking the views of residents, staff and relatives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home is registered with the Commission; he is a Registered Nurse and has an active registration with the Nursing and Midwifery Council. The manager has completed the Registered Managers Award and keeps his skills and knowledge up to date through regular training and up date sessions. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 24 The home has achieved the Hull City Council’s Quality Assurance Award (QDS 1 and 2), and there is evidence of regular audits being carried out by the manager. Meetings for the staff and residents are taking place; minutes are kept and are available for any interested parties to read. Policies and procedures are up dated and reviewed as an ongoing practice and action is being taken to ensure the requirements of the inspection reports are met. Feedback is sought from the residents and relatives through regular meetings and satisfaction questionnaires, although there is no annual development report produced as part of this process to highlight where the service is going or indicate how the management team is addressing any shortfalls in the service. The annual development report must be produced to ensure the service meets the resident’s needs and is run in their best interests. Checks of the finance systems were carried out at the last inspection (December 2005) and no problems were found. As the administrator was on leave during this visit the inspector was unable to discuss the system in detail. Talks with the manager indicated he has access to resident monies and is keeping a record of any transactions whilst the administrator is away. This standard will be assessed in full at the next inspection. Maintenance certificates are in place and up to date for all the utilities and equipment within the building. Accident books are filled in appropriately and regulation 37 reports completed and sent on to the Commission where appropriate. Staff have received training in safe working practices or are booked to attend later in the year, and the manager has completed generic risk assessments for a safe environment within the home. Risk assessments were seen regarding fire, moving and handling, bed rails and daily activities of living. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 25 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 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 26 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 OP9 Regulation 17 Requirement Timescale for action 01/01/07 2. OP24 12 3. OP24 12 4. OP33 24 Accurate records must be kept of all medications, received, administered, leaving the home or disposed of to ensure there is no mishandling. Door locks must be fitted to all 01/12/07 residents’ bedrooms unless the individual specifically requests this not to be done, this information must be documented (timescales of 1/11/04, 01/09/05 and 01/06/06 were not met). Residents must be provided with 01/12/07 keys unless their risk assessment suggests otherwise (timescales of 1/11/04, 01/09/05 and 01/06/06 were not met). The registered person must 01/04/07 ensure there is an annual development plan for the home based on a systematic cycle of planning, action, review, reflecting the aims and outcomes for service users. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 27 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. 3. 4. 5. 6. 7. Refer to Standard OP7 OP8 OP9 OP15 OP18 OP30 OP30 Good Practice Recommendations The manager should ensure that residents or their relatives (as appropriate) sign the plans to indicate they have had input to and agreed the contents. The staff should include a description of the wound on the wound care chart, at least once a week to ensure that its progress can be monitored and audited easily. Transcribed medications should have two staff signatures on the MAR chart to indicate that the information written down has been checked and is accurate. Staff should ensure food is presented in an attractive manner, in order to maintain appetite and nutrition. The manager should ensure that staff are able to access POVA training on an ongoing basis and it is put onto the staff training programme. Staff should receive training around equality, diversity and disability rights and this should be included in the rolling programme of staff training and development. The manager should ensure that health and safety training is added to the mandatory rolling programme of training subjects for staff. Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Rose Villa Care Home (N) Limited DS0000050391.V316469.R01.S.doc Version 5.2 Page 29 - 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. 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