Inspection on 01/03/07 for Rosewood Villa

This inspection was carried out on 1st March 2007.

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

Rosewood Villa 31/03/06

Rosewood Villa 29/09/05

Rosewood Villa 31/03/05

Rosewood Villa 20/08/04

Rosewood Villa 12/03/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Rosewood Villas 106 - 108 Broomy Hill Road Throckley Newcastle Upon Tyne Tyne & Wear NE15 9LP Lead Inspector Glynis Gaffney Key Unannounced Inspection 28 February 2007 10:00 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 Rosewood Villas DS0000000453.V302840.R02.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. Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rosewood Villas Address 106 - 108 Broomy Hill Road Throckley Newcastle Upon Tyne Tyne & Wear NE15 9LP 0191 267 2373 0191 264 3497 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) Mrs Mary Watson Vacant Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st March 2006 Brief Description of the Service: Rosewood Villa is located in the heart of Throckley close to local amenities and bus routes. Both street parking and off street parking was available. Rosewood Villa provides care and support for 17 older persons, some of who had dementia. Nursing care was not provided. The bedrooms were spread over the ground and first floors. There were 13 single and two double rooms. There was a range of communal space as follows - dining room; a large lounge area and small reception seating area; a conservatory. The premises were well maintained with a pleasant patio to the rear of the building. The home was nicely decorated and furnished throughout. The fees charged at the home range from £375 (place in a shared room) to £398 (single room.) Information about fee charges is included in the service user guide. Extra charges are made for hairdressing, newspapers, tv licence, dry cleaning, private chiropody services, outings and in-house entertainment where funds have not been raised to cover the costs. A copy of the most recent inspection report was available to residents, visitors and staff in the home’s reception area. Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced, took place over eight hours and involved one inspector. A tour of the premises was undertaken and a sample of records was examined. Three residents and four members of staff were spoken to. The acting manager and administrator were also interviewed. Following the resignation of the previous manager, the provider was in the process of making application to the Commission for the post of registered manager to be occupied by two people – the Care Team Leader, Ms L Hadaway, and Ms J Watson, the home’s administrator. The regional registration team is currently considering the provider’s application. Six relatives and one resident returned quality surveys. Their comments have been included throughout this report. What the service does well: A relative said that: “The home has without doubt the most caring staff. They care for everyone’s relatives as if they were their own. I would not have my aunt anywhere else and she loves it at the home.” Of the six relatives who returned surveys, all but one said that they were happy with the overall care provided. One relative said that they were satisfied most of the time. Residents’ care plans were well written and easy to understand. been reviewed on a regular basis. They had Staff were kind, respectful, considerate and had developed warm and caring relationships with the people in their care. Residents were very satisfied with the care and support provided. Staff communicated with residents in a positive manner. It was evident that staff were very proud of the standard of care they provided. The menu for the day was clearly displayed in the dining room. Residents said that the quality of meals served at the home was very good. The lunchtime meal was nicely served by the staff on duty. A list of residents’ likes and dislikes was available in the kitchen. The dining room had been attractively decorated and furnished and, the tables were attractively set. Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 6 The home was clean, tidy and provided a domestic and homely atmosphere. The building and grounds were well maintained. Residents’ bedrooms were pleasantly decorated and had been personalised. The kitchen was very clean and tidy. Visitors were made to feel welcome when they entered the building. On the day of the inspection, the provider and her staff had made arrangements to attend the funeral of a resident who had lived at the home. Mourners arriving at the home were made to feel welcome and staff provided them with the support they needed to get through such a difficult time. A small area in the large lounge had been set aside for social activities. What has improved since the last inspection? What they could do better: Prepare an annual development plan for the home. This will help ensure that residents and their families are able to see that there is a written programme that sets out how the home’s furnishings, fittings and fabric of the building are to be renewed, repaired and improved. They will also be able to see how staff intend to improve the care and services provided at the home. Ensure that 50 of staff have obtained a relevant qualification in care. This will help ensure that staff have the skills and knowledge they need to meet residents’ needs. Ensure that an application is made to the Commission to register a manager for the home. This will help ensure that the home is managed and run by a person with an appropriate qualification. Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 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. Rosewood Villas DS0000000453.V302840.R02.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 Rosewood Villas DS0000000453.V302840.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s arrangements for assessing the needs of prospective residents were satisfactory. This meant that the home had access to all of the information needed to make an informed decision about whether to offer a placement. EVIDENCE: Ms Hadaway said that admissions into the home had not taken place until a full needs assessment had been completed by social services. There was evidence that the home had obtained a social services assessment and care plan for one of the most recently admitted residents. The home had also completed its own Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 10 pre-admission assessment before reaching a decision about whether to offer a placement. An in-house needs assessment completed by an experienced senior member of staff was available in each resident’s care record. Rosewood Villas DS0000000453.V302840.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were clear care planning and review processes in place. This meant that staff were clear about how they should meet residents’ needs. The health care needs of residents had been satisfactorily met enabling them to lead healthy and comfortable lives. Staff respected residents’ needs and wishes regarding privacy, dignity and independence. This meant that residents felt valued and able to retain control over the way they wanted to live their lives. EVIDENCE: Three residents’ care records were examined. Each resident had a care plan that addressed their physical, health and social care needs. For example, in Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 12 one resident’s records, there were care plans covering – washing, dressing, continence care, moving and handling, social activities, religious beliefs and health care. Residents’ care plans had been reviewed on a monthly basis and were up to date. Checks of the quality of information held in residents’ records had been undertaken on a regular basis. Where able, residents had signed their care plans to confirm their agreement with the contents. There was a key worker system that staff felt had positive advantages for residents. Staff interviewed spoke knowledgeably about the roles and responsibilities of a key worker. There was evidence that the home had reviewed residents’ needs on a six monthly basis. There was evidence that residents had been provided with access to optical and chiropody care on a regular basis. Medical care had been arranged as and when residents required this. Nutritional and skin care risk assessments had been completed for each resident. It was confirmed that should a resident develop pressure area care needs, advice would be sought from the community nursing teams. ‘Falls’ risk assessments had been completed for residents considered to be at risk of falling. Monthly weight checks had been completed for each person. Care records were securely stored. Residents interviewed felt that their health care needs were well met. A resident who returned a quality survey said that they always received the personal and medical care they needed. The home had a medication policy that provided staff with guidance on how medication was to be handled within the home. Residents’ medication records contained the required details. All medication was safely locked away. Arrangements had been put in place to ensure that staff were able to follow good hygiene practices when administering medication. All staff administering medication had received accredited training. It was also confirmed that the majority of staff, with the exception of new starters, were in the process of completing a 12-week learning distance course in handling medicines safely. Ms Hadaway confirmed that staff were not undertaking any simple nursing health care tasks at the time of the inspection. Staff were observed providing personal care to residents in a kind, considerate and helpful manner. Staff respected residents’ rights to privacy and dignity. Staff knocked on residents’ bedroom doors before entering. Bedroom doors were closed whilst staff attended to residents’ personal care needs. Residents spoken to said that they could meet with their visitors in private and, make and receive private telephone calls without being overheard. Staff were aware of the importance of dealing with residents’ personal affairs in a confidential manner. Residents’ were dressed in clothes that they had chosen to wear. All of the residents interviewed looked well cared for. Rosewood Villas DS0000000453.V302840.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable arrangements were in place to provide residents with opportunities to participate in social activities. This meant that residents could choose to lead stimulating and fulfilling lives that reflected their personal preferences. Suitable arrangements were in place to support residents to maintain contact with their families and friends. Satisfactory arrangements were in place to ensure that residents received a nutritional diet that offered variety and choice. Mealtimes were relaxed and staff were patient, helpful and ensured residents had the time they needed to finish their meal. EVIDENCE: A programme of weekly activities was in place. A different activity is offered every morning and afternoon, for example – on a Tuesday afternoon, residents Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 14 are offered the opportunity to join in armchair exercises. On a Thursday, residents are able to visit the hairdresser and have a manicure. Residents confirmed that birthdays and festive occasions are celebrated. For example, over the last Christmas holiday, staff had performed a ‘Stars in their Eyes’ show. It was also confirmed that a trip to the coast had been arranged but had had to be cancelled at the last moment due to poor weather. Information about residents’ past social histories, hobbies and interests had been obtained. Care plans addressing residents’ social care needs were in place. Staff were observed interacting with residents on a regular basis and encouraged them to join in discussions about every day matters. Residents said that they felt satisfied with the social activities and in-house entertainment provided at the home. But, in the six quality surveys returned, two relatives said that: “Because of the shortage stimulation/activities.” of staff, residents don’t receive much “A lot of money has been raised this year to be spent on trips and very little seems to have been spent on outings etc which is disappointing…also the lighting is very poor in the conservatory.” The provider confirmed that extra lighting had recently been fitted in the conservatory. The inspector was also told that funds had been, and were being raised, to purchase a canopy to allow residents to sit outside during the summer months without getting burnt. A resident who returned a quality survey said that: • • Social activities were usually arranged by the home; They always liked the meals served at the home. Residents spoken to during the inspection said that their families were always made to feel welcome. Staff were observed welcoming visitors and talking with them in an understanding and supportive manner. Residents said that visitors could be seen in private or in the lounge and dining areas. None of the residents spoken with could recall the home placing any restrictions upon their visitors. It is the home’s policy to support residents to maintain control of their own financial affairs. Ms Watson said that lockable facilities and day-to-day support with managing personal monies and valuables would be provided where needed. Residents said that they had been encouraged to bring their own personal possessions with them when moving into the home. A number of bedrooms were visited and it was evident that residents had been encouraged to personalise their own private spaces. Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 15 There was a four-week rotating menu that offered residents three full meals each day. Alternatives to the main meal choices were available. The inspector was advised that hot and cold drinks and, in-between meal snacks, were available throughout the day. During the inspection, staff were observed placing jugs of water and juice in residents’ bedrooms. China, tablecloths and serviettes were colour co-ordinated and the tables were attractively set. Details of the breakfast, lunch, tea and suppertime meals were displayed on the notice board in the dining room. The quality of the lunchtime meal was good and appeared to be enjoyed by all residents who participated in the meal. Staff were on hand to provide residents with support throughout the mealtime in a caring and sensitive manner. Residents expressed their satisfaction with the quality of meals served at the home. The kitchen was tidy and hygienic. The cupboards were well stocked and the cook confirmed that she had access to whatever was needed to cook to the home’s menus. Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 16 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A satisfactory complaints procedure was available. views and opinions were listened to. Residents felt that their The arrangements in place to protect residents from the potential risk of harm or abuse were satisfactory. This meant that residents could feel safe and protected in their own home. EVIDENCE: The home had a detailed complaints procedure, which included the recommended information. Residents said that they would be happy to raise concerns with any member of staff. Neither the Commission nor the home had received any complaints since the last inspection. A resident who returned a quality survey said that they knew who to speak to if they were unhappy about something. Of the six relatives who returned quality surveys, five said that they had been made aware of the home’s complaints procedure. One said that they had not. Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 17 The home’s adult protection policy complied with the relevant guidance and legislation. There had been no adult protection concerns raised with either the home, or the Commission, since the last inspection. The majority of staff had received training in the protection of vulnerable since the last inspection. Arrangements had been made for the remaining staff to complete this training. Staff were able to satisfactorily describe the action that they would take to deal with an allegation of abuse. Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 18 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment was good providing residents with an attractive and homely place to live. The overall quality of the furnishings and fittings was good. This meant that residents were able to live in a safe, wellmaintained and comfortable environment that encouraged independence. EVIDENCE: The home was hygienic, tidy, well maintained and attractively decorated. Residents’ bedrooms, the communal areas, toilets and bathrooms were clean and domestic in appearance. Bedrooms were nicely decorated and had been personalised. Radiators throughout the home were guarded. The home was Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 19 warm, well lit and free from offensive odours. A range of aids and adaptations were available such as a mobile hoist and an adapted sit-down shower facility. The laundry was clean and hygienic. The washing machine and dryer were in good working order. Hazardous materials were locked away to prevent accidents occurring. Fire doors checked were in good working order. Fire escapes and corridors were free of obstacles that could prevent residents leaving the building in an emergency. Information about the fire evacuation procedure had been placed at different points around the building. The temperature of hot water supplied to residents’ bathing areas was checked and did not exceed the recommended level. No health and safety concerns were identified. The kitchen was very clean and hygienic. No concerns were identified. Residents interviewed said that they were very satisfied with the standard of accommodation provided. Rosewood Villas DS0000000453.V302840.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had sufficient numbers of staff on duty to meet residents’ assessed needs. This meant that residents could be sure that there were enough staff on duty to support and care for them. Staff had been supported to undertake suitable induction training. This provided them with the knowledge and skills they required to care for residents. Satisfactory arrangements were in place to enable staff to undertake training in key mandatory areas. Satisfactory arrangements were also in place to ensure that the figure of 50 trained care staff with a NVQ at Level 2 was exceeded. This meant that staff could provide safe care in a professional manner. Generally, sufficient documentary evidence was available confirming that robust pre-employment checks had been carried out for all staff employed at the home. This was an important step in ensuring that staff considered unsuitable to work with vulnerable adults would not be employed at Rosewood Villa. Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 21 EVIDENCE: There was no registered manager in post, but the provider was in the process of making an application. At the time of the inspection, the provider’s daughter, Ms Watson, had taken over responsibilities for staffing and Ms Hadaway, Care Team Leader, had been delegated overall responsibility for the well being of residents. The provider, Mrs Watson, although semi-retired, was still heavily involved with the home and visited daily. Ms Hadaway had worked at the home for a number of years and had obtained a Level 3 National Vocational Qualification in Care and a qualification enabling her to assess progress made by her staff in obtaining such qualifications. Ms Hadaway had recently updated her training in key areas such as food hygiene and first aid. The provider and her staff team are committed to ensuring and improving the quality of care and services provided at Rosewood Villa. At present, staff are provided with an opportunity during bi-monthly supervision sessions to comment upon any concerns that they might have about the running of the home. Staff are also asked about whether they feel that there is anything else that could be done to further improve the quality of care offered at Rosewood Villa. The home had recently adopted the use of a quality assurance system that the provider felt would better suit the needs of Rosewood Villa. Ms Hadaway was in the process of overseeing its introduction and felt that some of the documentation such as the work task sheets was proving very useful. Ms Hadaway said that residents, staff, relatives and other professional visitors had not been surveyed about how well they thought the home was meeting its objectives during the last 12 months. An annual development plan was not available. “The home does not appear to have a manager which I feel has had a detrimental effect on the day to day management, I also think that it puts pressure on staff who are very hard working and caring and dedicated.” Of the seventeen care staff employed at the home five had obtained a relevant qualification in care and eight others were in the process of doing so. The provider hoped to exceed the figure of 50 trained staff by the end of May 2007. Arrangements had been put in place to enable the home to address the minor shortfall against Standard 28 which requires providers to ensure that 50 of their care staff have obtained a NVQ at Level 2. At the time of this inspection, the home had already obtained a figure of 48 . In addition to this, 50 of the home’s support services team, i.e. housekeeping, maintenance and catering staff, had obtained a NVQ at Level 2 in Support Services. Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 22 12 staff had left the home since the last inspection. Although this was considered high, a reasonable explanation was given for why each member of staff had left. There had been no use of agency or bank staff in the eight weeks preceding the inspection. A sample of staff personnel records was examined and it was identified that: an application form had been completed by each member of staff; a Criminal Records Bureau check had been carried out; a contract of employment was available on each file as was verification of identity and confirmation of physical health. With the exception of one person, all staff had confirmed on their application form whether they had any convictions or cautions. There was also evidence that the home had tried to obtain two written references for each applicant. There were unexplained gaps in some staff employment histories. Ms Watson agreed to check this matter and provide a written record in the files of the staff concerned. Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The person overseeing the care provided to residents was suitably experienced but did not have an appropriate qualification at the required level. Residents, their families and other relevant people, had not been formally consulted about the quality of the service provided at the home. This meant that they did not have the opportunity to fully contribute to the development of the service. The arrangements for carrying out formal staff supervision were satisfactory. This meant that staff were receiving a good level of support and guidance in meeting the needs of residents living at the home. Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 24 Steps had been taken to promote the health and well being of service users and to protect them from potential hazards. This meant that service users were able to stay in a home where health and safety concerns were taken seriously and their well-being protected. EVIDENCE: There was no registered manager in post, but the provider was in the process of making an application. At the time of the inspection, the provider’s daughter, Ms Watson, had taken over responsibilities for staffing and the Care Team Leader, Ms Hadaway, had been delegated overall responsibility for the well being of residents. The provider, Mrs Watson (who was recently semiretired) was still heavily involved with the home and visited daily. Ms Hadaway had worked at the home for a number of years and had obtained a Level 3 National Vocational Qualification in Care and a qualification enabling her to assess progress made by her staff in obtaining such qualifications. Ms Hadaway had recently updated her training in key areas such as food hygiene and first aid. The home had recently adopted the use of a quality assurance system that the provider felt would better suit the needs of Rosewood Villa. Ms Hadaway was in the process of overseeing its introduction and felt that some of the documentation such as the work task sheets was proving very useful. Ms Hadaway said that residents, staff, relatives and other professional visitors had not been surveyed about how well they thought the home was meeting its objectives during the last 12 months. An annual development plan was not available. The home was not acting as an ‘appointee’ for any of the residents accommodated and it did not handle any money on behalf of residents. There were no residents subject to Power of Attorney or Guardianship Orders that the home was aware of. Following the departure of the previous manager, Ms Watson and Ms Hadaway had taken over responsibility for staff supervision in 2006. From that point onwards, staff had received supervision at the frequency set out in the National Minimum Standards. For example, there was evidence that two of the staff whose files were checked had received four supervision sessions since June 2006. A tour of the premises identified no health and safety concerns. The home’s external health and safety adviser had recently introduced new documentation for recording health and safety checks. An up to date gas safety certificate was in place. The home’s lift had been serviced twice in 2006 and its mobile Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 25 hoist in August 2006. The home had a current contract for the safe disposal of waste. Fire alarms had been checked and tested on a weekly basis. The alarm system had been serviced on three separate occasions in 2006. Two fire drills had been held at the home during the last four months. All staff whose files were checked had received mandatory fire prevention training in the last 12 months. Electrical installations and wiring had recently been checked. A record of all accidents occurring within the home had been kept. Water systems had been checked for the presence of legionella during 2006. Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 3 Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 27 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 OP28 Regulation 18(1) Timescale for action Ensure that at least 50 of the 01/10/07 care team have obtained relevant qualifying training. (The timescale for complying with this requirement expired on 01/10/06) 2. OP31 9 Make arrangements for an 01/06/07 application to be submitted to the Commission to register a manager for the home Ensure that the person appointed as manager of the home has a relevant qualification in care and management, or is provided with the opportunity to undertake training leading to such a qualification. 3. OP33 Schedule 26 Undertake, at regular intervals, a 01/10/07 review of the quality of care provided at the home. A copy of the review should be forwarded to the Commission upon completion. Residents, and their relatives, should play an important part in this process. DS0000000453.V302840.R02.S.doc Version 5.2 Page 28 Requirement Rosewood Villas (The timescale for complying with this requirement expired on 01/10/06) Prepare an annual development plan for the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Rosewood Villas DS0000000453.V302840.R02.S.doc Version 5.2 Page 30 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!