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Inspection on 18/09/07 for Rose Villa Nursing Home

Also see our care home review for Rose Villa Nursing Home for more information

This inspection was carried out on 18th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

The staff at the home assists the Service Users to live in a homely environment with some support to remain as independent as possible. The carers spoken to were kind and motivated to provide a good service to the Service Users. The home has a good relationship with local doctors and nurse specialists who support the care offered in the home. Meals are planned to be appealing, nutritious and home cooked. Service Users told the inspector that they enjoyed the meals and could chose an alternative if they preferred.On a board in one of the passageways, there were nine fairly recent letters and thank you cards all of which were profuse in their praise for the way the staff had looked after a former or late resident of the home. During the course of this inspection staff were only observed or overheard to be friendly and solicitous of the needs of the people living in the home, and to be concerned for their well-being.

What has improved since the last inspection?

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Rose Villa Nursing Home 148/150 Eccleshall Road Stafford Staffordshire ST17 9AA Lead Inspector Mrs Joanna Wooller Key Unannounced Inspection 18th September 2007 08:30 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 Nursing Home DS0000061869.V347775.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 Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rose Villa Nursing Home Address 148/150 Eccleshall Road Stafford Staffordshire ST17 9AA 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) 01785 254760 F/P 01785 214263 Mr Jayantical James Bhikhashai Patel Mrs Jennifer Lyn Davies Care Home 35 Category(ies) of Physical disability (35), Physical disability over registration, with number 65 years of age (35), Terminally ill (3) of places Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD Minimum age 60 yrs Date of last inspection 31st July 2006 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 two lounges to choose from, one with views to the back of the property and one with views to the front. The opportunity to become involved with activities is also available with the homes activity organiser. Home cooked food 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. Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 18th September by the lead inspector. The Manager was in charge of the home supported by her deputy manager and care assistants. The inspection included the following elements; A tour of the building, Observation and inspection of records relating to provision of care, Discussions with several service users, Discussions with several of the staff members on duty, Observation and sampling of other services provided such as catering and laundry, and an inspection of the managerial aspects such as staffing issues, training, recruitment and health & safety. The Inspector was made welcome in the home and assistance was given to gain the evidence required for the report. Two complaints had been received by the Commission for Social Care Inspection since the last inspection. One other inspector accompanied the lead inspector due to the complaints information being investigated. Service Users spoken to at the visit were complimentary about the home. One lady stated she enjoyed the food and activities and talking to her visitors. Relatives in the home were very complimentary about the staff and the care they delivered. What the service does well: The staff at the home assists the Service Users to live in a homely environment with some support to remain as independent as possible. The carers spoken to were kind and motivated to provide a good service to the Service Users. The home has a good relationship with local doctors and nurse specialists who support the care offered in the home. Meals are planned to be appealing, nutritious and home cooked. Service Users told the inspector that they enjoyed the meals and could chose an alternative if they preferred. Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 6 On a board in one of the passageways, there were nine fairly recent letters and thank you cards all of which were profuse in their praise for the way the staff had looked after a former or late resident of the home. During the course of this inspection staff were only observed or overheard to be friendly and solicitous of the needs of the people living in the home, and to be concerned for their well-being. What has improved since the last inspection? • • One of the five requirements made at the last visit had been fully met which was the laying of new hall/corridor carpets. Three of the requirements made at the last visit had been partially met which included care plans improvements 1. Communication and social care plans but these needed further individualised information and outcomes 2. Relatives signatures were to be evident in all areas of the care plans where assessments had been made 3. GP visits were to be clearly written in the care plan and results/\follow up recorded. • And one requirement had not been met which was the dirty mesh in the kitchen window was still present What they could do better: The management of the home has been brought to question on this visit. Many requirements were made which need great attention and the Commission For Social Care Inspection will then expect to see sustained improvement. Many of the day-to-day issues of the home had not been addressed. In the case of the kitchen, general hygiene standards were not being met (see report) along with hotel standards within the communal areas and bedrooms. Refurbishment in some areas of the home is required with regard to fixtures, fittings and soft furnishings. Some furniture was seen to be broken. The maintenance person is required to work in the home full time and be given the opportunity to correct issues, which he is responsible for. His absence to support other homes in the group is evident in the home current state. The domestic hours also need to be increased for a home of this size, as it was obvious to the inspector that the home is not been deep cleaned in all areas. Listed below is the documentation that was not available for the inspector Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 7 • • • • • • Accident records Quality audits Staff references (Two should be on each file) Induction records for new staff Staff supervision records Staff training records Although previous guidance had been identified the Statement of Purpose and Service User Guide were still not as required by Schedule 1 of the National Minimum Standards. 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 Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide although they are informative and available - do not hold all the information required by Schedule 1 of the National Minimum Standards. Service Users said they received lots of verbal information from the home manager and other staff in the home. EVIDENCE: The Statement of Purpose and Service User Guide continue to require further information to ensure they meet with Schedule 1 of the National Minimum Standards. There is no doubt that Service Users and their relatives receive the information verbally and they do have an informed admission. Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 10 Visitors spoken to said that staff ensured they were fully informed of all events in the home regarding their relatives’ health and well being. They said the staff welcomed them and gave them a cup of tea. The potential Service Users and their relatives were encouraged to visit the home prior to admission and most did so. There as no evidence that relatives or the Service Users if possible signed the initial agreement regarding the care plan and this was made a requirement at the visit. Rose Villa Nursing Home DS0000061869.V347775.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): Standards 7, 8, 9 and 10 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Each Service User had a care plan, which recorded most of their care needs, however these required individualising and the information within the record needed to reflect the current condition of the Service User. Social care plans required further information to be written relating to meeting the needs and the outcome of the activity etc. Medication administration was not always correctly signed for and gaps were noted for refusal. Service Users stated that they were treated with respect and their dignity upheld. EVIDENCE: The inspector evidence that each service user had an individual plan of care, which includes elements of their health and personal care needs and some social care needs. Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 12 The care plans seen by the inspector did not reflect the care that the case tracked service users were receiving and although the records were updated at least monthly this did not give any information with regards to needs being met, any progress or outcomes. Named nurses and key workers were identified on the records but these had since changed and the new named nurse had not been rewritten. • There was again little evidence that the service users were involved in the plan of care and this is required to be completed. Relatives must be shown the individual plan of care and asked to sign the relevant risk assessments if Service Users are unable to do so. There was no Service User photograph in the care plans seen at this visit. Annual social service reviews were not identified and not all had been completed. There was evidence that staff knew lots of personal information about Service Users but this is not written in the care plan. Manual handling risk assessment reviews were not completed annually or as needs altered. • • • • Carers assist where necessary with personal care needs; key workers ensured that service users toiletries were available. Service Users spoken to say that they continued to feel that they were treated with dignity and respect. They said the carers encourage them to be as independent as possible in a caring way. Care records had not progressed as they should have done since the last inspection and although it was noted that communication and social care plans had been introduced there had been no development to their content or any outcomes recognised. Risk assessments although in place for some Service Users they had not been signed and agreed by the Service Users themselves or their relatives. Plans to ensure signatures are gained must be put into practice immediately. Medication administration in the home was checked and found to have many gaps within the records. Gaps were due to refusal by the Service User and the code for this, although available, had not been used. Ongoing refusal of prescribed medication should be brought to the attention of the GP. Medication stock appeared satisfactory. Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 – 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service Users commented that they had sufficient activities to keep them entertained and their preferences were expressed. Families and friends visited as desired. Service Users stated that they did have choices over their daily life supported by the carers. Service Users do enjoy the food at the home and their preferences are recorded. EVIDENCE: There was evidence in the home of an activity programme, which was activities that were arranged over the week to attempt to meet the needs and capabilities of the Service Users. This was distributed to each individual Service Users in their bedrooms. The activity organisers continue to encourage less able or active individuals to join in some events. There were photographs displayed in the Hall and this confirmed evidence of the activities arranged. It was identified at the last visit that some more one-to-one sessions would benefit certain Service Users and also trips out in the community. Trips out had Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 14 been arranged including pub lunches and trips to the garden centre and these had continued. Visitors were welcomed at any time. There were several visitors in the home throughout the visit by the Inspector and those spoken to expressed their sincere praise for the staff in the home and the care and compassion given to the relatives and themselves. Each individual Service User continues to be encouraged to exercise ‘daily control’ in respect of his or her life style. The menus for the week were displayed for all Service Users to observe. The records seen by the inspector offered choice, good variety and a well balanced diet. The meal for the day was observed being prepared by the cook. Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 to 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service Users felt confident that if they had any concerns they would be dealt with. Their legal rights are supported and Service Users are protected from abuse. EVIDENCE: The inspector evidenced the complaints process and procedure displayed with the reviewed local office address for the Commission For Social Care Inspection. Each of the Service Users had been provided with a copy of the homes complaint procedure in the event of having any concerns or a complaint. Staff told the inspector that training and supervision covers issues of abuse, its identification ad types of abuse. The Whistle Blowing policy is also in place to support staff in reporting of any untoward incidents. The Commission For Social Care Inspection had received two complaints and these were dealt with on the day of the inspection. 1. One mainly reported staff attitude and approach to the Service Users. 2. The other was mainly about the unhygienic state of the home and this also mentioned staff attitude. Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 16 The cleanliness of the home was made a requirement along with the introduction of a customer care type training to ensure staff do approach Service Users and relatives and visitors in the correct manner. Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 17 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): Standards 19 to 26 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The homes maintenance programme was identified as having some gaps with regard to cleanliness and repair of some items. Communal facilities are showing signs of wear and tear and in need of refurbishment. Equipment had been serviced and was in good condition. Service Users rooms were generally comfortable, but some in the older part of the home require refurbishment of fixtures, fittings and bedding. The home was found to be generally safe and comfortable but the homes cleanliness was brought to question with hygiene and hotel standards in some areas not being acceptable, especially the kitchen, kitchen dry store area and laundry area. General cleanliness of bedrooms and lounges required attention too. EVIDENCE: Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 18 The inspector visited the kitchen first and found this area and the dry storage areas to require a deep clean, including walls, floors, equipment, dry store cupboards, cupboards and the condiments and vinegar pots. The window mesh was extremely dirty as was the window. The kitchen ceiling required repainting. The records needed to be kept in clean accessible folders and the cook was asked to change her apron, as it appeared stained and dirty. The vegetables were stored in boxes on the floor and these must be stored in vegetable racks off the floor. Brooms and mops require a designated store away from food and the dry store cupboard should not house broken equipment or out of date items (food colouring). The tops of the fridge/ freezer and other counters were cluttered and in need of a tidier system for a safe and hygienic, working kitchen. The sink was full of dirty, greasy water, which needed to be emptied as soon as the task was complete. The cooks qualifications and course certificates must be available in the home and on display in the work area. The kitchen would probably benefit from a complete refit of new cupboards and work surfaces, as they are looking tired and repaired. No apron or coat was available for those entering the kitchen although some staff did tell the inspector that they are not allowed to go into the kitchen. The Environmental Health Officer had visited the home in February 2007 and no requirements were made. Other areas in the home came under question too. • The laundry and toilet extractor fan covers were exceedingly dirty as was the shelves in the ironing area and the sluice. • Milton and upholstery cleaner were found in unlocked cupboards • The hand washing sink in the sluice was not being used due to items stored in it • Notices were stuck to walls in the sluice, laundry and kitchen, which were not only unsightly, but also unhygienic. • One of the side doors to the home had a broken pane of glass • Tops of wardrobes in some bedrooms were used for storage • Vases of fresh flowers were seen with extremely dirty water in them The seating in the lounge areas is dated and institutionalised, replacement chairs, which are more comfortable and homely, should be considered. The bathrooms were uninviting and cold. The ensuite areas require shelving or better use of the cupboards, which were in some ensuites. Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 19 Storage of any items on the toilet cisterns or on the ensuite floor is not acceptable and it is a major infection control hazard. Toilet and bathrooms were evidenced to be clean and no malodours were apparent at this visit. Some Service Users are using bed wedges rather than cot sides to assist their security whilst in bed. Specialist Profile beds to aid the Service Users comfort have replaced a few beds. The hall and corridors have been recarpeted which has improved this area immensely. It was unfortunate that the whole corridor had not been recarpeted to avoid the extension of the home looking disjointed. Redecoration is to continue as required on the homes rolling maintenance plan. The outside area of the home is to be developed to assist Service Users to sit outside in fine weather. Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 20 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): Standards 27 to 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service Users needs were being met by sufficient and capable care staff, the staff told the inspector that they had been trained in the home, however there were no training records available for the inspector. The recruitment policy and procedure is in place but this is not being fully followed. EVIDENCE: The staffing numbers were appropriate for care of the Service Users in the home at the present time. Some staff were seen by the inspector to be competent and capable of carrying out their daily tasks. Carers were seen approaching Service Users with respect and protected their dignity. The homes recruitment policy and procedure are in the home but not being fully followed. The manager assured the inspector that new recruits complete a comprehensive induction package but non were available for the inspector to evidence. Staff files were inspected but these also did not follow the recruitment procedure. The files inspected did not have the two references, interview checklist, birth certificates, next of kin, etc as required, however Criminal Record Checks were in order. Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 21 Staff training plan was not available, there was evidence of training with some dates in the diary and some certificates but the inspector was unable to see evidence that all staff were appropriately trained and updated. Domestic staff hours were not sufficient to ensure that the home is maintained in a clean and hygienic state. Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 22 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): Standards 31 to 38 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. There was evidence that the home has not been managed in a manner that the National Minimum Standards require. Records required by the Commission were not available and it is the managers’ responsibility to maintain the home in a safe and professional manner. Staff had not received any structured supervision from the manager and supervision of any kind had not been recorded. Record keeping in all areas showed signs of weakness and lack of leadership. The homes financial procedures were in order. The maintenance man had maintained the Health and Safety aspects of the home with regard to equipment, fire checks and electrical checks. Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager is registered with the Commission For Social Care Inspection and holds the Registered Managers Award. The inspector found a lack of leadership in the home, which has led to several areas in the home being mismanaged. Clear lines of accountability need to be revisited to ensure trained staff are aware of their role and responsibilities in the home. The manager needs to show leadership of her team in a positive manner to ensure the staff are working to the best of their ability to support her. The Service Users and relatives views are welcomed by the home and there was evidence of a company quality assurance system in place but no evidence of results was in the home. • Policies and procedures require annual update to ensure research based - good practice is being followed. Last updated 2006. Regulation 26 visits are carried out, however the inspector found that these needed to be reported on more precisely using the National Minimum Standards as guidance. Financial procedures were checked and found to be in order. Service Users monies were correct and records were in place. • • Staff supervision had not been arranged and no practical supervision records were available either. Record keeping in all areas had fallen below an acceptable standard. This is to be addressed not only by the manager but also by the homes administrative support. Safe working practices were checked but no evidence was available to confirm that training for moving and handling, fire safety, first aid, food hygiene and infection control had been carried out. Some certificates were available but this did not give the inspector an overview of the training requirements of the home and the staff attendance. The maintenance man had carried out safety checks for boilers, electrics, and fire safety, lighting and water tests. • • The inspector, in unlocked areas of the home, found Milton solution and upholstery cleaning fluid. Risk assessments were in place but Service Users assessments were not signed and agreed by the Service User or a relative. DS0000061869.V347775.R01.S.doc Version 5.2 Page 24 Rose Villa Nursing Home • • Accidents forms, records or any incident forms were not available in the home. The manager was unable to find them. Staff in the home told the inspector that they had completed a thorough induction programme when they started to work in the home however the manager had no evidence to show the inspector at the visit. It was noted in the kitchen that following is required to be attended to • • • • • • • • • • • • • • • • • The window grills must be deep cleaned The floor needed deep cleaning The walls needed cleaning The ceiling needed painting The cupboards needed cleaning out The salt, pepper and vinegar containers all needed cleaning The cooks apron was dirty The cooked and extractor hood required a deep clean The vegetables must be stored in racks off the floor The storage areas must be kept clean There must be suitable storage for equipment (brooms/mops etc) Some food colouring was out of date Consideration that the kitchen may need to be refitted with new units should be taken Qualifications of the cook and her assistant must be displayed in the kitchen area White coats/aprons must be available for visiting inspectors The tops of fridge/freezers must be clean and uncluttered Sinks and preparation surfaces must be kept clean at all times The Provider of the home Mr Patel was present in the home and all these issues were brought to his attention and he assured the inspector that this would be dealt with immediately. It was noticed during the tour of the environment that some of the fire doors did not have strips, and daylight could be seen through some doorjambs when they were closed. Whilst many doors had appropriate devices (door guards) to ensure that they would close if the fire alarm sounded, on the ground floor one had been wedged open with a footstool. Rose Villa Nursing Home DS0000061869.V347775.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 2 3 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 1 2 2 2 3 1 2 1 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 2 1 3 3 1 1 2 Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 OP1 Regulation 4, Schedule 1 Requirement The registered person shall ensure that the Statement of Purpose and Service User Guide have all the relevant information to meet the National Minimum Standards. The registered person shall ensure that the Service Users admitted to the home have all relevant personal information recorded in their care plan and their care plan signed by the Service User or a relative. The registered person shall ensure that Service Users care plans reflect the Service Users current condition and kept under review. Initial admission assessment forms must be updated and not used as a continuing baseline for the plan of care. The registered person shall ensure that all information required in Schedule 3, is present in the care plan for each Service User. The registered person shall ensure that Service Users DS0000061869.V347775.R01.S.doc Timescale for action 18/11/07 2 OP3 14 18/11/07 3 OP7 14(2a) 18/11/07 3 OP7 15 (Sch 3) 18/11/07 4 OP8 12 18/11/07 Rose Villa Nursing Home Version 5.2 Page 27 5 OP9 13(2) 6 OP19 23 7 OP21 23(2d) 8 OP22 23 (2m) 9 OP24 16 (2c) 10 OP25 23(2) 11 OP26 13 (3) 12 OP29 18 13 OP30 18 (1a) personal information regarding their health is documented then monitored and reviewed at least monthly. The registered person shall ensure that trained staff adheres to the administration of medication policy and procedure. The registered person shall ensure that Service Users live in well-maintained environment. Routine maintenance and renewal of fabric and décor is planned and records are to be kept. The registered person shall ensure that bathrooms are suitably decorated to make bathing a warm and pleasurable event. The registered person shall ensure that appropriate storage is available for each Service User in their bedrooms and ensuites. The registered person shall ensure that each Service Users bedroom has suitable furniture and soft furnishings. The registered person shall ensure that all areas of the home and centrally heated. The bathrooms must be warm and comfortable at all times. The registered person shall ensure that all areas of the home is kept in a clean, hygienic state. See lists in report for Standard 26 and 38. The registered person shall ensure that recruitment policies and procedures are followed and evidence of this is available in the home at all times. The registered person shall ensure that all staff employed at the home is suitably trained and competent to work in the care home, record of which must be DS0000061869.V347775.R01.S.doc 18/11/07 18/11/07 18/11/07 18/11/07 18/11/07 18/11/07 18/10/07 18/11/07 18/11/07 Rose Villa Nursing Home Version 5.2 Page 28 14 OP31 9 15 OP32 11 16 OP33 24 17 OP37 Sch 3 /4 18 19 20 OP38 OP38 OP38 13 (4a) 13(4a/c) 13 (4b) 21 OP19 23(4) 22 OP38 37 (1f) available in the home. The registered person shall ensure that the manager is supported at all times and is supervised appropriately. The registered person shall ensure that the manager communicates a clear leadership style and fully understands the aims and purpose of the home through a strong ethos. The registered person shall ensure that a robust Quality Assurance system is in place and evidence of this is in the home. The registered person shall ensure that all records required by the National Minimum Standards are maintained in the home at all times. The registered person shall ensure that wardrobes are secured to the walls by rag bolts. The registered person shall ensure that all hazardous substances are safely stored. The registered person shall ensure that all Service Users have appropriate risk assessments which a suitably reviewed and reassessed. The registered person shall ensure that suitable fire precautions are in place. Doorjambs and closure must allow the doors to shut without gaps being identified. The registered person shall ensure that all accidents are recorded in the home and the records are available in the home at all times. 18/11/07 18/11/07 18/11/07 18/11/07 18/11/07 18/10/07 18/11/07 18/11/07 18/11/07 Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 29 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 Refer to Standard OP20 OP36 OP38 OP27 OP27 Good Practice Recommendations Furniture in communal rooms is to be domestic in character and of good quality. Staff must be suitably supervised and records maintained in the home as evidence. Staff must complete a full induction package when employed at the home. Evidence must be retained in the home at all times. Domestic staff must be employed in sufficient numbers to maintain a clean and hygienic home at all times. Maintenance staff must be given sufficient time to carry out their tasks to maintain a safe environment. Rose Villa Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Local Office Commission for Social Care Inspection 1st Floor, Ladywood House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Nursing Home DS0000061869.V347775.R01.S.doc Version 5.2 Page 31 - 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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