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Inspection on 08/12/05 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 8th December 2005.

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 home offers palliative care services to residents requiring terminal care. Previous residents families have commented, as has the GP, that the care is very good and they felt comforted and reassured that their loved one was well looked after. The environment is continuing to be improved.

What has improved since the last inspection?

The home is now beginning to show signs of stability since the last owners and manager have left. Management have built a strong team of professional staff who work together to achieve high standards of care delivery. The requirements had been either addressed fully or in the process of being completed.

What the care home could do better:

Activities, although these are offered, could be more individually orientated to particular residents. Better communications must be evident between relatives to ensure that they are aware of what events have taken place during the day. More activity coordinator hours are needed to provide stimulation and outside visits. A volunteer is due to start in the New Year along with a student from the local school.

CARE HOMES FOR OLDER PEOPLE Rose Villa Nursing Home 148/150 Eccleshall Road Stafford Staffordshire ST17 9AA Lead Inspector Mrs Joanna Wooller Unannounced Inspection 8th December 2005 11:30 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.V271482.R01.S.doc Version 5.0 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.V271482.R01.S.doc Version 5.0 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 Mr Jayantical James Bhikhashai Patel 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.V271482.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD Minimum age 60 yrs Date of last inspection 13th 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 aims to offer a high standard of care and accommodation for thirty-five residents. The home has mostly single bedrooms, all with ensuite facilities. There are three 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 now 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 residents have a choice of several lunges 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 the activities is also available with the assistance of the activity organiser. Good home cooking is provided and special dietary needs are catered for. The residents have access to all areas of the home including the gardens. There is ample parking space for visitors. Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection on Thursday 8th December 2005, which commenced at 11.30hrs. 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 7 hours, which included pre –inspection and fieldwork prior to the visit. Jenny Davies the Manager was in the home during the visit. The Deputy manager, Susie was on duty with one other trained nurse. Ancillary staff in the home included the Cook who had one kitchen assistant with her and there were two domestics on duty. The activity coordinator was not on duty for the inspection. The maintenance man was present in the home. There were 31 service users in the home with enquiries being placed for the remaining beds. The inspection included: • A tour of the building including service users bedrooms • Reading of care records and care plans • Talking to residents • Talking at length with relatives • Inspection of management records • Discussion with the staff on duty Residents had individual file for care records, which included their individual health; personal and social care needs including specific choices. Relatives and residents spoken to say the activities are enjoyed alot, 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 found to be in good order. The health, safety and welfare of the service users and staff are monitored through the homes policies and procedures. What the service does well: Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 Page 6 The home offers palliative care services to residents requiring terminal care. Previous residents families have commented, as has the GP, that the care is very good and they felt comforted and reassured that their loved one was well looked after. The environment is continuing to be improved. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 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 Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 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): 1, 2 and 5 The management have personalised all the documentation to demonstrate the new provider and rewritten relevant literature to reflect the ethos of the new management structure. Some reorganising is to be completed. Pre admission procedures continue as previously evidenced. EVIDENCE: The Statement of Purpose and Service User Guide have been rewritten to reflect the new provider and new managers’ ethos. The information will need to be reorganised and then redistributed to the residents and relatives. The residents and relatives felt that they had all the information they needed and asked staff if they were unsure. They had been issued with a letter to demonstrate that the home could meet the individual needs whilst at the home. Each resident is issued with a contract that is signed on admission by the resident, this document includes all relevant information required by them to be aware of their rights. Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 Page 9 Personal care, mobility and medication were documented within the care records. There was again 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. Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 Page 10 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 and 10 Individual service users needs were being considered and met, however the resident and their relatives must be involved with the plan of care and sign relevant documentation. Privacy and dignity is evidenced throughout the care day. 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. 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. Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 Page 11 Carers assist where necessary with personal care needs; key workers ensured that service users toiletries were available. Residents 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. Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 Page 12 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): 12 and 15 Service users confirmed to the inspector that they enjoyed seeing their relatives and friends who visited them and that they had activities and events at the home to keep them busy. EVIDENCE: The home had an activity programme, arranged over the week to attempt 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. It was identified at the visit that some more one-to-one sessions would benefit certain residents and also trips out in the community. Two volunteers are due to start in the New Year at the home but a recommendation to increase the activity coordinators hours was made. Visitors were welcomed at any time. There were visitors in the home throughout the day and the inspector spoke to two daughters for some time. Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 Page 13 Each individual resident was encouraged to exercise ‘daily control’ in respect of his or her life style. One relative commented that they were very pleased with the care and attention that their relative was receiving. She said that the members of staff are very kind and caring, which she commented adds to the pleasant environment. 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. Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 Page 14 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 its own complaints procedure which complied with the National Care Standards for Older people. 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. Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 Page 15 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 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. Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 Page 16 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 previous visit. Plans were to commence in the New Year. Residents lived in a comfortable safe environment where all the necessary checks and risk assessments were in place. Equipment and adaptations were provided as necessary to maximise service users independence. Extra cot side bumpers had been 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 on a previous visit that individual basin water temperatures were exceeding 50 degrees c. This had been rectified with the installation of thermostatic controls. Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 Page 17 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 Staffing levels were appropriate for the numbers of residents in the home. EVIDENCE: Consideration is made to ensure appropriate skill mix and qualifications of staff on the rota. Staffing rota’s were evidenced and found to be in order. Christmas duties were completed. Residents dependencies are monitored to ensure the correct amount of staff are on duty to meet their individual needs. Additional staff are employed as the residents needs increase. Two vacancies were being advertised for full time carers on days and nights. These shifts are covered by regular staff and occasionally agency staff. Ancillary staff are employed on a rota system to cover their duties and maintain the homes hygienic state. Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 Page 18 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): 32, 33 and 38 Documentation now reflects the new owners and management of the home identifying that the home is run in the best interest of the residents. The health, safety and welfare of residents and staff is promoted and protected. EVIDENCE: The new manager remains unregistered with the commission, due to a delay in completing the relevant CRB forms. This must be rectified in the near future. 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 at the last visit that the manager and the provider need to personalise the home as ‘theirs’ and this has commenced. Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 Page 19 The manager continues to demonstrate an open and inclusive style of management and this is beginning to be communicated throughout the home and the documentation. Some quality audits have continued to be carried out; the maintenance man performs room audits weekly and records the action taken. A new quality audit system is being organised to reflect that the National Minimum Standards, once the policies and procedures have been rewritten. Financial procedures were robust and no issues were raised. 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. Risk assessments were in place and signed appropriately. Accidents and incidents were documented. Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 X X X X 3 Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 Page 21 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 OP12 Regulation 16 (2m,n) Requirement Suitable activities must be available to meet the residents’ social needs. Suitable equipment must be purchased to stimulate certain residents. Residents or representatives must be involved with the plan of care and this must be evident within the documentation. Signatures must be gained. Timescale for action 07/02/06 2 OP7 15 (2c) 07/01/06 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 OP22 Good Practice Recommendations Consideration should be made to replace one of the less used baths with a walk in shower facility. Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Stafford Office 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. Extracts may not be used or reproduced without the express permission of CSCI Rose Villa Nursing Home DS0000061869.V271482.R01.S.doc Version 5.0 Page 23 - 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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