Inspection on 13/06/05 for Rose Villa Nursing Home

This inspection was carried out on 13th June 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.

Other inspections for this house

Rose Villa Nursing Home 05/02/08

Rose Villa Nursing Home 18/09/07

Rose Villa Nursing Home 31/07/06

Rose Villa Nursing Home 08/12/05

Rose Villa Nursing Home 15/12/04

Similar services:

Aston Court Nursing Home

Breme

Ravenhurst

Westmead

Ashcroft Hollow Nursing Home

Bricklehampton Hall Nursing Home

Briar Hill House

Radbrook Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Rosevilla 148/150 Eccleshall Road Stafford Staffordshire ST17 9AA Lead Inspector Joanna Wooller Announced 13 June 2005 09.15am 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. Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Rosevilla Address 148/150 Eccleshall Road Stafford Staffordshire ST17 9AA 0121 434 3966 0121 434 3996 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) Mr Jayantical Patel Care Home 35 35 35 3 Category(ies) of PD registration, with number PD(E) of places TI Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) PD Minimum age 60 years Date of last inspection 13 June 2005 Brief Description of the Service: Rosevilla is situated on the Eccleshall road leading to the M6 (junction 14), in a residential area about one mile from Stafford town centre. Rosevilla is a registered care home offering 24 hour nursing care, which aim to offer a high standard of care and accommodation for thirty-five service users.The home has mostly single bedrooms, all with en-suite facilities. There are 3 double rooms for those who prefer to share, but these may be used as larger singles.The home started life as two large properties that have been extensively extended to provide the facilities it offers. Rosevilla consists of two floors, serviced by a lift in the original building, and a purpose built ground floor unit of single rooms with ensuite facilities. The service users have a choice of several lounges to choose from, one with views to the back of the property and two with views to the front. The opportunity to become involved with activities is also available with the homes activity organiser.Good home cooking is provided and special dietary needs are catered for.The service users have access to all areas of the home including the gardens.There is ample parking space for visitors. Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this announced inspection on Monday 13th June, which commenced at 09.15hrs. The National Minimum Standards for Older People was used as guidance to assess the standards within the home. The total amount of time spent on this inspection was 9 hours, which included pre –inspection and fieldwork prior to the visit. Jenny Davies the Manager was in the home supported by Cindy, Mr Patel’s administrator. The Deputy manager. Susie was on duty and one other trained nurse. Ancillary staff in the home included the Cook who had one kitchen assistant with her and there were three domestics on duty. The activity coordinator was not on duty for the inspection. The maintenance man was present in the home. There were 30 service users in the home The inspection included: • A full tour of the building including service users bedrooms • Reading of care records and care plans • Talking to some service users • Management records • Discussion with the staff on duty Pre admission assessments had been completed for all new admissions and service users had received an acceptance letter to ensure their individual needs could be met at the home. Service users had individual file for care records, which included their individual health; personal and social care needs including specific choices. Service users spoken to say they enjoyed the activities, and their families’ involvement at some of the events. The inspector observed a balanced menu record. The environment was found to be clean, pleasant, hygienic and well maintained. Staffing levels were observed and duty rosters were seen. The inspectors observed the staff to be delivering a high standard of care and attention to the service users. The provider and his personal assistant visit the home and forward Regulation 26 reports to the Commission For Social Care Inspection on a monthly basis. No issues were raised relating to service users finances. Medication systems were checked and found to be in good order. Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 6 The health, safety and welfare of the service users and staff are monitored through the homes policies and procedures. What the service does well: What has improved since the last inspection? What they could do better: There are several areas that the home needs to improve and develop and they are aware of these. The Statement of Purpose, service user guide, complaints procedure, policies and procedures to name but a few all need` to be personalised and updated to reflect the new provider and new managers’ ethos. Care staff discussed that they sometimes feel unsupported by the trained staff and the inspector informed the nurses of this. The staff must all recognise each other’s roles and support each other to achieve their tasks. This will hopefully be rectified as new teams of staff settle into the new managements way of working. It was identified by the inspector that cot side bumpers were not in sufficient numbers for all cot sides used at the home. A requirement was made to purchase more of this item. A fax was received on Wednesday 15th June from the manager at the home to inform us that these had been purchased and the delivery slip was forwarded as evidence. Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 7 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. Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 to 5 The management must personalise all the documentation to the new provider and also rewrite relevant literature to reflect the ethos of the new management structure. EVIDENCE: The Statement of Purpose and Service User Guide need to be rewritten to reflect the new provider and new managers’ ethos. The information will need to be reorganised and then redistributed. The service users felt that they had all the information they needed and asked staff if they were unsure. Service users or relatives were issued with a letter to demonstrate that the home could meet the individual needs whilst at the home. Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 10 Each service users is issued with a contract that is signed on admission by the service users, this document includes all relevant information required by the service user to be aware of their rights. Personal care, mobility and medication were documented within the care records. There was little evidence of relatives/representatives being included in this procedure. All necessary specialists needs were arranged as required. The care staff are trained and updated by the Nursing Staff in the home to ensure that they are skilled and experienced to care for the service users, and identify and meet their daily needs. In house and external training is arranged to take place. Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 to 11 Individual service users needs were being considered and met, however the service ser and their relatives must be involved with the plan of care and sign relevant documentation. EVIDENCE: Each service user had an individual plan of care, which includes health, personal, and social care needs. The care plans seen at the visit reflected the care that the tracked service users were receiving and these are updated at least monthly. Each plan of care was reviewed monthly, and these were found to be up to date on those inspected. Named nurses and key workers were identified on the records. There was little evidence that the service users were involved in the plan of care and this is to be developed as far as is possible. Relatives must be shown the individual plan of care and asked to sign the relevant risk assessments. Carers assist where necessary with personal care needs; key workers ensured that service users toiletries were available. Service users spoken to say that Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 12 they continued to feel that they were treated with dignity and respect. They said the carers encourage them to be as independent as possible. Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 to 15 Service users confirmed to the inspector that they enjoyed seeing their relatives and friends who visited them and that they had sufficient activities and events at the home to keep them busy. EVIDENCE: The home had an activity programme, arranged over the week to meet the needs and capabilities of the residents. This was distributed in the individual bedrooms for service users. The activity organiser is very committed to her role; she involves and encourages less able individuals. The numerous photographs displayed in the Hall confirmed evidence of the activities arranged. Visitors were welcomed at any time. There were visitors in the home throughout the day. Each individual resident was encouraged to exercise daily control in respect of his or her life style. One service user was enjoying attending a day centre. One relative commented that they were very pleased with the care and attention that their relative was receiving. He said that she tells him how content she is and that all members of staff are very kind and caring, which he comments adds to the pleasant environment. Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 14 The menus for the week were displayed for any person to observe. The records offered choice, variety and a well balanced diet. The meal for the day was observed being prepared in a clean well-maintained kitchen. Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 to 18 The inspector was satisfied that the complaints process and investigation methods were robust and followed the required guidelines. However these did need rewriting. Residents would be protected from abuse via the in-house formal and informal training of the staff. EVIDENCE: The inspector observed the complaints process displayed. The information contained in the document required updating. Each of the residents had been provided with a copy of the homes procedure in the event of having a complaint. Residents’ civic and legal rights were protected via a network of persons involved in the well being of individuals. The staff received formal training via the National Occupational Standards Awards in Care (TOPPS) induction. Consideration to complete the foundation course at the home is being taken. Training and general awareness of how to recognise and report any form of abuse was included. Staff spoken with confirmed they had received training for COSHH awareness. Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 to 26 Rosevilla provided a well-maintained environment with numerous homely touches in the decoration. Externally the home had mature gardens where residents can sit and enjoy the fresh air. Hotel and hygiene standards were very high. EVIDENCE: Rosevilla provides a clean, warm, well-maintained environment for residents located throughout the home. Accommodation was personalised to suit individuals. Lounges were located on the ground and first floor. Bathrooms and toilets were sited around the home. Carers had asked the inspector about the need for a shower room and one bathroom was identified as being suitable and the provider agreed this alteration during the day. Residents lived in a comfortable safe environment where all the necessary checks and risk assessments were in place. Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 17 Equipment and adaptations were provided as necessary to maximise service users independence. Extra cot side bumpers are to be purchased to ensure that all cot sides at the home are protected. The laundry operated over seven days and clean laundry was delivered to the residents’ room by the staff. The staff responsible for the hygiene of the home worked extremely hard to maintain the high standard. Emergency lighting was tested and recorded. Water storage was monitored and the temperature of bath water was tested prior to use. It was identified that individual basin water temperatures were exceeding 50 degrees c. These are to be adjusted with the use of thermostatic controls as soon as possible and warning signs sited until such time. Plumbing for new sluicing disinfector has been installed. Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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) Staff skill mix and numbers was found to be in line with the previously issued notice of staffing. Service users were evidenced to be receiving high quality of care and support. All staff were evidenced as being suitably trained to carry out their duties and the homes recruitment practices were in line with the National Minimum Standards. EVIDENCE: Staffing levels appeared suitable for the dependencies of the service users. The management were aware of the need to increase staffing should this rise and this must be adhered to. Interviews were performed with the care manager and one other senior member of staff depending which service is to be provided. Two written references were obtained for each employee. No volunteers were employed. Induction includes lifting and handling training; fire - knowledge and instruction, meeting the service users and the aims and objectives of Rosevilla. The new employee worked with a mentor from day one. The management provides training at the home, however the monitoring of this has lapsed and training is overdue. The inspector advised the manager to prioritise the individual staff needs and action this as soon as possible. The induction-training package is in conjunction with TOPPS requirements and the staff are to complete a Foundation programme following the induction Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 19 programme. Over 25 of the care staff were NVQ trained and 10 staff were completing NVQ 2 or 3 at the present time. Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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 to 38 The health, safety and welfare of the service users and staff were promoted and protected as far as reasonably practicable. EVIDENCE: The new manager is yet to be registered with the commission, however allnecessary documentation has now been received at the office. Mrs Davies has day-to-day control over the home and her deputy manager supports her. Both managers are completing the Managers Award. The inspector identified that the manager and the provider need to personalise the home as ‘theirs’. The manager demonstrates an open and inclusive style of management and this needs to be communicated throughout the home and the documentation. Some quality audits have taken place; the maintenance man performs room audits weekly and records the action taken. A new quality audit system needs to be organised to reflect that the National Minimum Standards, once the policies and procedures have been rewritten. Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 21 Financial procedures were robust and no issues were raised. Service users monies were in order although they were encouraged to look after their own finances with the support of relatives if required. Staff supervision has still to be formally organised and the inspector gave Mrs Davies some advise on ways to do this. No issues were raised relating to other record keeping checked on the day. The manager was fully aware of the need to ensure the health, safety and welfare of service users and staff. There was evidence that the manager monitored safe working practices and health and safety issues within the home. The manager is to write a written statement to support this. Risk assessments were in place and signed appropriately. All accidents and incidents were documented. All staff receives induction training and then encouraged to complete NVQ training. The introduction of TOPPs Foundation training is to be considered. Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 3 3 3 2 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 2 2 3 3 2 3 2 Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 23 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 1 Regulation 4 Requirement The Statement of Purpose must raflect the providers and managers aims, objectives and ethos of the home. The service user guide must include all necessary documents as listed in the regulations. Service users and representatives must be involved with the plan of care and sign as doing so. Care plans must be organised to assist the record keeping and maintain strict care records. Proper provision must be made to ensure staff are trained to support service users in the last stages of life. The complaints procedure must be robust and displayed with the correct information. Water temperatures in basin is to be monitored and temperature regulators are to be fitted. Staff must be suitably trained and an overview of training needs kept. The providers and managers ethos for the home is to be demonstrated`and documented Timescale for action 1 month 2. 3. 1 7.6 5 15.2 1 month 1 month 4. 5. 7.1 11.8 15.2b 12.1b 2 months 2 months 6. 7. 16 25.8 22 23 1 week 1 month 8. 9. 30 32 18c(1) 12 1 month 2 months Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 24 throughout the home. 10. 33 24 Quality assurance systems are to be put in place to ensure that the national minimum standards are checked and the home is run in the best interest of the service usres. There must be evidence that all staff are suitably supervised and care staff are supervised at least 6 times in 12 months. The manager must provide a written statement of the policy , organistaion and arrangements for maintaining safe working practices. Extra bumpers are to purchased to ensure that all cot sides are protected. 2 months 11. 36 18.2 2 months 12. 38.5 23 1 month 13. 22 23.2c 1week 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 33.9 Good Practice Recommendations Policies, procedures need to be rewitten to reflect the new management and all practices within the home. These must be regularly reviewed to promote good practice and changing legislation. Rosevilla E09 E51 S61869 Rosevilla V227698 130605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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