CARE HOMES FOR OLDER PEOPLE
Rosewood Villas 106-108 Broomy Hill Road Throckley Newcastle upon Tyne NE15 9LP Lead Inspector
Glynis Gaffney Announced Inspection 29 and 30 September 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Rosewood Villas Address 106-108 Broomy Hill Road Throckley Newcastle upon Tyne NE15 9LP 0191 267 2373 0191 264 3497 NA Mrs Mary Watson Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Karen Palmer CRH 17 Category(ies) of OP Old age - 17 registration, with number of places Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 31/03/05 Brief Description of the Service: Rosewood Villas is located in the heart of Throckley close to local amenities and local bus routes. Street parking is available. The bedrooms are spread over the ground and first floors and single room accommodation is offered. A range of communal space is available as follows - dining room; a large lounge area; a conservatory The premises were well maintained with a pleasant patio to the rear of the building. The Home had recently been re-decorated throughout and was nicely furnished. Rosewood Villas provides care and support for 17 older persons.. Nursing care is not provided. Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was announced, took place over nine hours and involved one inspector. A tour of the premises was undertaken and a sample of care and other records were examined. Three residents, two relatives and three staff were spoken to. The Home’s Manager was also interviewed. The Proprietor and her daughter were available throughout the inspection and offered every assistance. As part of the inspection, residents’ relatives were asked to comment upon the quality of care provided. Of the ten returns received, all were satisfied with the quality of care provided at Rosewood Villas. Detailed below are a sample of some of the comments received: ‘We are very well satisfied.’ ‘My aunt has been a resident at Rosewood for 22 months and together we have been very satisfied with the care and management. As a frequent visitor I have observed the excellent care given to all of the residents.’ ‘The care my mother has received is warm and caring for which I am thankful.’ ‘Owner and staff always very friendly. Residents always seem happy and well cared for.’ What the service does well:
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 building upon their strengths and abilities. It was also evident that staff were very proud of the standard of care they provided. The menu for each day is clearly displayed in the dining room. Residents felt that the quality of meals served was very good. The Home was clean, tidy and provided a domestic and homely atmosphere. The building is maintained in a good condition and is regularly refurbished. Residents live in a home which is run and managed by a person who is fit to be in charge, is of good character and able to discharge her responsibilities fully.
Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 6 The Manager provides consistent leadership, guidance and direction to staff and ensures that residents receive good quality care. Staff morale was high. Arrangements have been put in place to protect the health and safety of residents and staff. Visitors to the Home are warmly welcomed and made to feel at home. 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.
Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 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 standard(s) 1 and 3. The Home’s Service User Guide and Statement of Purpose provide existing and prospective residents with good information about the services provided at Rosewood Villas. Prospective residents’ needs are assessed by people trained to carry out need assessments. The Home obtains a copy of the Care Management assessment and care plan to ensure that its staff are able to meet residents’ individual needs. EVIDENCE: A Service User Guide and Statement of Purpose were in place. Previous visits to the Home have confirmed that they contain the required information. Care Management assessment and care plan information is obtained before a resident is admitted into the Home. A pre-admission assessment visit is carried out by the Manager to ensure that the Home is able to meet each person’s care needs. A pre-admission assessment was available in each of the care records examined. Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10. Residents’ care plans ensure that staff are provided with the information they need to satisfactorily meet residents’ needs. The health care needs of residents were satisfactorily met. The systems in place to support the safe administration, storage and disposal of medication were considered satisfactory and to promote good health. Staff were seen to provide personal support in such a way as to promote and protect residents’ privacy, dignity and independence. EVIDENCE: Individual plans of care were in place for each resident. The care plans checked were up to date and had been reviewed monthly. Arrangements have been put in place to ensure that regular checks of the quality of care records are undertaken. Residents are encouraged to read and sign their care plans. In one of the care records examined, the resident had signed each of their care plans. A Key Worker system was in place and staff interviewed felt that residents benefited from this. Evidence that recent six monthly reviews had taken place were available in each of the care records examined. The Manager has recently introduced a new Key Worker system, details of which are posted
Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 10 in residents’ bedrooms. A member of staff interviewed was able to clearly describe the role and responsibilities of a Key Worker. An examination of residents’ care records confirmed that they were provided with access to medical, nursing, dental and chiropody care on a regular basis and more often if needed. Advice and input from the Community Nursing Service is sought where residents develop pressure area care needs. Risk assessments covering the following areas were in place: susceptability to falling; pressure area care, nutritional care; manual handling. Monthly weight checks had been completed. Residents’ records were stored in an area which could be secured. Residents interviewed felt that there health care needs were well met. No matters of concern were raised. Staff were observed providing personal care to residents in a kind, considerate and helpful manner. Staff respected residents’ right 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 they had chosen to wear. All of the residents interviewed were smartly dressed and were proud of their appearance. A Medication Policy was in place. Residents’ medication records were satisfactorily completed. The systems in place for the storage, administration and disposal of medication were considered safe. Arrangements have been put in place to ensure that staff are able to follow good hygiene practices when administering medication. All staff administering medications have received accredited training. Staff were not undertaking delegated simple nursing tasks. A Controlled Drugs Register was available to promote good record keeping. Temperature checks of the area within which medications are stored had been undertaken. Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15. The provision of social activities is good and opportunities for stimulation through leisure and recreational activities are available. Rosewood Villas is good at making residents’ families feel welcome and involved in the life of the Home. The meals in this Home are good offering residents both choice and variety that take account of individual tastes and choices. Meals are served in pleasant surroundings by helpful staff who are willing to provide whatever assistance is required. Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 12 EVIDENCE: A 4-week menu cycle is used within the Home. Residents are offered three full meals each day with at least one of these being a hot meal. Hot and cold drinks and, in-between meal snacks, are available throughout the day and night where required. Alternatives to the main meal choices are available. China, table cloths and serviettes are colour co-ordinated and the tables were beautifully set. There are identified times for meals although these can be changed to meet the needs of residents, the majority of whom eat in the dining room. Details of the breakfast, lunch, tea and supper-time meals were displayed on the noticeboard in the dining room. The quality of the lunch-time meal was excellent and appeared to be enjoyed by all residents who participated in the meal. Staff were on hand to provide residents with support throughout the meal time in a caring and sensitive manner. Residents expressed their satisfaction with the quality of meals served at the Home. A programme of weekly activities was in place. A different activity is offered every morning and afternoon, for example – on a Friday, residents are offered the opportunity to play bingo in the morning and join in board games in the afternoon. The Home’s Social Programme states that individual interests will also be catered for. Residents confirmed that birthdays and festive occasions are celebrated. Information is collected covering residents’ past histories, hobbies and interests. Care plans addressing residents’ social care needs were in place. Residents interviewed felt that the Home offered ‘more than enough’ social activities and in-house entertainment. Residents’ families are made to feel welcome. Two relatives were spoken to during the inspection and both felt that the Manager and her staff team made every effort to make them feel welcome. This was confirmed by residents interviewed. Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18. The majority of staff have received Adult Protection Awareness Training which enables them to take appropriate steps to protect residents from abuse. A satisfactory Adult Protection Policy was in place to ensure a proper response to any suspicion or allegation of abuse received by the Home. EVIDENCE: The Home’s Adult Protection Policy complied with the relevant guidance and legislation. There have been no adult protection concerns raised with either the Home, or the Commission, since the last inspection. Arrangements are in place to ensure that all staff receive adult protection training. Staff were able to satisfactorily describe the action that they would take to deal with an allegation of abuse. Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards 19 to 26 not assessed on this occasion. EVIDENCE: Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 30. The Home has sufficient numbers of staff on duty to meet residents’ assessed needs. Staff generally have the skills, competencies and qualities to meet service users’ needs. EVIDENCE: A staff rota was in place showing which staff were on duty and in what capacity. The following staffing levels have been agreed with the Commission: Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 16 8.00am to 8.00pm 3 care staff including a senior carer 8.00pm to 8.00am 2 night care staff A Manager is also available during office hours - Monday through to Friday. The Provider and her daughter are also often present in the Home. Following an examination of one week’s rota (week commencing 19 September 2005), it was confirmed that the above levels of staffing had been provided. The number of staff scheduled on duty throughout the working day was in line with that recommended by the Residential Forum for the Provision of Staffing in Care Homes for Older People. Although there has been a significant turnover of staff since the last announced inspection, a suitable explanation was given for this. Shortfalls in the staff rota are covered by the Home’s own staff. Agency workers are not used. 25 of the care team have obtained a relevant care based qualification. Other staff were in the process of obtaining the same qualification. During the last 12 months, staff have also been provided with opportunities to undertake induction and refresher training in key areas. Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32 and 38. Residents live in a home which is run and managed by a person who is fit to be in charge, is of good character and able to discharge her responsibilities fully. The Manager provides consistent leadership, guidance and direction to staff and ensures that residents receive good quality care. Staff morale was high. Arrangements have been put in place to protect the health and safety of residents and staff. EVIDENCE: A Registered Manager was in post and is in the process of completing a relevant management qualification. Mrs Palmer has many years experience of working with older people and regularly updates her training. Staff interviewed said that the Manager had made it clear to them the standards of care that they were expected to work to. One carer was able to clearly describe the purpose, aims and objectives of the Home. Staff felt that they
Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 18 knew what was going on within the Home and felt able to raise any matters of concern with the Manager. Service contracts and maintenance reports relating to such matters as gas, electrical and fire safety, and servicing of the Home’s hoisting equipment and the lift, were available for inspection. A tour of the premises revealed no health and safety concerns. However, a check of the Home’s water systems to the test for the presence of the Legionella Bacteria had not taken place during the last 12 months. The Manger said that this was an oversight and agreed to rectify this matter following the inspection. Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 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 x 15 4
COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 2 3 x x x x x 3 Rosewood Villas B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 20 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. 2. 3. Standard 18 28 29 Regulation 13(6) 18(1) Schedule 29 Requirement Timescale for action 01/01/06 Ensure that all staff receive training in the protection of vulnerable adults. Ensure that at least 50 of the 31/12/05 care team have obtained a Level 2 NVQ. Undertake, at regular intervals, a 01/11/05 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. A previously set timescale had not expired at the time of the inspection. 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 7 Good Practice Recommendations Provide residents with their own copies, wherever practicable, of the Homes Statement of Purpose, Service Users Guide and Complaints Procedure.
B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 21 Rosewood Villas Commission for Social Care Inspection Northumbria House Manor Walks Cramlington 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 B53-B03 S453 Rosewood Villas V235934 290905 Stage 4.doc Version 1.40 Page 22 - 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!
