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

Also see our care home review for Rose Villa Care Home (N) Limited for more information

This inspection was carried out on 8th December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

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 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?

Recruitment and employment checks are carried out on all staff before they start work to ensure that residents` health and safety is protected. New and existing staff are given basic training when they start at the home, and then move onto more in-depth work based learning. This ensures residents are cared for by staff who understand their care needs. Induction and supervision of staff has got better and is helping to make sure the quality and continuity of care is maintained and the health, safety and welfare of the residents is promoted and safeguarded.

What the care home could do better:

The home has previously been asked to fit appropriate locks to the residents bedrooms so they can keep personal belongings safe and have uninterrupted privacy if wished. This has not been done.

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 Inspection 8th December 2005 09:30 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.V263867.R01.S.doc Version 5.1 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.V263867.R01.S.doc Version 5.1 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), Terminally ill over 65 years of age (36) Rose Villa Care Home (N) Limited DS0000050391.V263867.R01.S.doc Version 5.1 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. 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 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 DS0000050391.V263867.R01.S.doc Version 5.1 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 2 hours and included a tour of the premises, examination of staff and resident files and records relating to the service. Three residents and one visitor were spoken to and their comments have been included in this report. One additional visit has been made since the last unannounced inspection and was to follow up the progress being made towards meeting the requirements from the unannounced inspection in April 2005. The outcome of this visit was positive and showed that the practices within the home had moved forward and met a number of requirements made in the last inspection report. What the service does well: What has improved since the last inspection? What they could do better: The home has previously been asked to fit appropriate locks to the residents bedrooms so they can keep personal belongings safe and have uninterrupted privacy if wished. This has not been done. Rose Villa Care Home (N) Limited DS0000050391.V263867.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Rose Villa Care Home (N) Limited DS0000050391.V263867.R01.S.doc Version 5.1 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.V263867.R01.S.doc Version 5.1 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 the following standard(s): 3. 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: Standard 3 was met in full at the last inspection report and checks of the needs assessments and care plans indicates it continues to be met. Each resident has their own individual file and all four of those looked at had a full needs assessment completed within them. The information from the assessment process is used to formulate the individuals care plan. 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. Rose Villa Care Home (N) Limited DS0000050391.V263867.R01.S.doc Version 5.1 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 the following standard(s): 7, 9 and 10. The health, personal and social care needs of the residents are clearly documented and are being met by the service and staff. The staff have a good understanding of the residents support needs. This is evident from the positive relationships, which have been formed between the staff and residents. 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. Three 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. The care plans are well written and include detailed information about the needs and expectations of the residents and the care being given on a daily basis. Risk assessments around daily activities of living have been carried out and are recorded, where appropriate, within the individual resident’s plan. 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. All three of the residents spoken to prefer to have staff administer their Rose Villa Care Home (N) Limited DS0000050391.V263867.R01.S.doc Version 5.1 Page 10 medication. Checks of the medication records and the system used showed that these are up to date, accurate and well managed. Verbal comments from three residents and one visitor 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. Individuals said that ‘the care is ‘excellent’ and ‘the staff are very caring and supportive’. Two individuals commented that staff helped them to remain as independent as possible and they were offered choices throughout their daily routine of what they wanted to do, how, where and when. Three residents praised the staff for their care and support in helping them make such good progress. They were delighted with their improved health and put it down to the dedicated staff and their high standards of care and attention. Rose Villa Care Home (N) Limited DS0000050391.V263867.R01.S.doc Version 5.1 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 the following standard(s): 13 and 14. The home promotes the residents right to exercise choice and control over their lives and offers information and contact details so they or their families can contact external agents, who will act in their interests. EVIDENCE: There were a large number of visitors to the home during the morning and one individual said ‘ the staff are very welcoming and include you in all aspects of the residents care. The atmosphere within the building is friendly and makes you feel at home’. Open visiting hours at the home enable individuals to come at times suitable for the residents and which fit into their own busy work schedules. Discussion with three residents showed that they are offered choice in their daily activities and have a good awareness of their rights. Advocacy information is available throughout the home and the manager said he is aware of the services within the community that individuals can access. 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. Rose Villa Care Home (N) Limited DS0000050391.V263867.R01.S.doc Version 5.1 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 the following standard(s): 16. 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 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 and manager listens to their concerns and takes action if necessary. The complaints record shows that there have been no complaints made since the last unannounced inspection. Rose Villa Care Home (N) Limited DS0000050391.V263867.R01.S.doc Version 5.1 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 the following standard(s): 19 and 24. 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 only limited progress has been made on the provision of door locks. EVIDENCE: There is an ongoing programme of refurbishment and renewal at the home. The manager said that the ground floor corridor has been fitted with new floor covering since the last inspection and a new storeroom has been created on the second floor for the storage of medical products and incontinence pads. Carpets in the bedrooms have been deep cleaned since the last inspection and corridor walls have been repainted. All areas seen by the inspector were clean, well decorated and welcoming. Three 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 provision of bedroom door locks and keys remain Rose Villa Care Home (N) Limited DS0000050391.V263867.R01.S.doc Version 5.1 Page 14 outstanding requirements from the previous inspections. One bedroom is having a lock fitted to the door at the resident’s request, to offer the individual more privacy. Rose Villa Care Home (N) Limited DS0000050391.V263867.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30. The standards of recruitment, induction and training of staff are very good with appropriate 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. EVIDENCE: Information in the staffing rotas shows that there are two nurses and eight care staff on duty during the early shift and one nurse and five care staff on duty during the late shift. One nurse and three care assistants are on duty at night. Extra staff are called in to cover for taking residents to appointments and additional ancillary staff are on duty throughout the day. At the additional visit in August 2005 it was established that Alex Bauld (the manager) is now supernumerary to the staffing numbers and has the time to address the management role and responsibilities within his job description. Inspection of the staff files showed that there is only one staff member under 18 at the home and she is part of a YTS scheme and does not undertake any personal care within the home. All staff working at the home have a CRB in place and Alex Bauld is fully aware that any future staff members must be CRB checked or have a POVA first check before they start work. The staff-training programme offers staff access to mandatory training and some specialist subjects linked to the needs of the service users. All staff receive at least three days paid training each year, and only the over 25’s have to pay for their National Vocational Qualifications. Rose Villa Care Home (N) Limited DS0000050391.V263867.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 36. The management of the home is satisfactory overall, and robust accounting and financial systems are in place to protect and safeguard the interests of the residents. EVIDENCE: Since the last inspection Alex Bauld has been successful in registering with the Commission as the manager of Rose Villa. The home has an up to date quality assurance award from the local council (QDS 1 and 2). Feedback is sought from the residents and relatives through regular meetings and satisfaction questionnaires. 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. The Registered Provider is completing regulation 26 reports, but discussion with the manager revealed that he was not aware that a copy of these has to Rose Villa Care Home (N) Limited DS0000050391.V263867.R01.S.doc Version 5.1 Page 17 be sent to the Commission. The manager said that he would address this issue immediately and ensure the reports were sent to the Commission each month. Checks of the finance systems within the home found that the administrator on a daily basis up dates the residents’ individual records. Resident’s who have asked the home to look after their personal allowances are able to access their money on request. All monies are kept safe and secure within the home and only the administrator or manager has access to the funds. Each resident has their own wallet and all receipts are documented on their account sheet and kept with their money. Two accounts were checked and found to be up to date and accurate. Supervisions and appraisals for all staff have started and there is a plan of future dates and sessions in the manager’s office. Discussion with the manager indicated that he is doing both verbal supervision sessions and observations of practice to ensure the staff are working to a high standard of practice and understand their role and responsibilities. Rose Villa Care Home (N) Limited DS0000050391.V263867.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X 2 X X STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X X Rose Villa Care Home (N) Limited DS0000050391.V263867.R01.S.doc Version 5.1 Page 19 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 OP24 Regulation 12 Requirement Timescale for action 01/06/06 2. OP24 12 Door locks must be fitted to all residents’ bedrooms unless the individual specifically requests this not to be done, this information must be documented (timescales of 1/11/04 and 01/09/05 were not met). Residents must be provided with 01/06/06 keys unless their risk assessment suggests otherwise (timescales of 1/11/04 and 01/09/05 were not met). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP28 Good Practice Recommendations 50 of care staff should have achieved and NVQ 2 by 2005. Rose Villa Care Home (N) Limited DS0000050391.V263867.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Rose Villa Care Home (N) Limited DS0000050391.V263867.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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