CARE HOMES FOR OLDER PEOPLE
Rosewood Villas 106 - 108 Broomy Hill Road Throckley Newcastle Upon Tyne Tyne & Wear NE15 9LP Lead Inspector
Glynis Gaffney Unannounced Inspection 16:00 31st March 2006 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 DS0000000453.V273410.R02.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. DS0000000453.V273410.R02.S.doc Version 5.0 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 Mrs Karen Michelle Palmer Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places DS0000000453.V273410.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 29th September 2005 Brief Description of the Service: Rosewood Villas is located in the heart of Throckley close to local amenities and local bus routes. Street parking was available. Rosewood Villas provided care and support for 17 older persons. Nursing care was not provided. The bedrooms were spread over the ground and first floors. Single room accommodation was mostly offered, although two double rooms were also available. There was a range of communal space 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 was nicely decorated and furnished throughout. DS0000000453.V273410.R02.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced, took place over five and a half hours and involved one inspector. A tour of the premises was undertaken and a sample of records were examined. Three residents and one member of staff were spoken to. The Home’s Providers and Manager were also interviewed. What the service does well: What has improved since the last inspection?
Armchairs in the lounge areas had been replaced. A new sofa had also been purchased. The Home’s dining furniture had been replaced. DS0000000453.V273410.R02.S.doc Version 5.0 Page 6 The communal lounges had been re-decorated. On the day of the inspection, the Provider had been shopping for ornaments and pictures to improve the appearances of these areas. New flooring had been fitted in the following areas: toilets; bathrooms; the kitchen and the corridor leading into it; laundry. New lighting had been fitted in the lounge areas and the dining room. New bed linen and throws had been purchased for all bedrooms. New commode covers had been provided. Two additional domestic staff had been recruited. The Home now employs one full-time and two part-time domestics. New crockery and kitchen equipment had been purchased. Additional protection had been fitted to some of the walls. 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. DS0000000453.V273410.R02.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 DS0000000453.V273410.R02.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): Key Standard 3 was assessed as part of the 2005 Announced Inspection. Key Standard 6 was not applicable. EVIDENCE: DS0000000453.V273410.R02.S.doc Version 5.0 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 the following standard(s): Key Standards 7, 8, 9 and 10 were assessed as part of the 2005 Announced Inspection. EVIDENCE: DS0000000453.V273410.R02.S.doc Version 5.0 Page 10 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): 14. Key Standards 12, 13 and 15 were assessed as part of the 2005 Announced Inspection. Residents were encouraged and supported to make decisions about everyday matters. This allowed residents to retain as much control as possible over how they lived their lives. EVIDENCE: It is the Home’s Policy to support residents to maintain control of their own financial affairs. The Provider 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 permitted and 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. Residents also said that they decided when to get up, go to bed, what to eat and when to have a bath. Two residents said that they had as much independence as they did when they lived at home. Once person said that she was relieved not to have too much independence.
DS0000000453.V273410.R02.S.doc Version 5.0 Page 11 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. Key Standard 18 was assessed as part of the 2005 Announced Inspection. Satisfactory arrangements had been put in place to enable residents to make complaints. Generally residents felt that their views and opinions were listened to. EVIDENCE: The Home had a detailed complaints procedure, which included the recommended information. Residents spoke with said that they would be happy to raise concerns with any member of staff. The Home had received no complaints since the last inspection. The Commission had received no complaints concerning the conduct of the Home. DS0000000453.V273410.R02.S.doc Version 5.0 Page 12 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. Residents were provided with a safe and well-maintained environment in which to live enabling them to lead independent and comfortable lives. The Provider and her staff team had worked very hard to ensure that residents were able to live in a clean, pleasant and hygienic home. EVIDENCE: Residents’ bedrooms, the communal areas, toilets and bathrooms were clean, tidy and domestic in appearance. Bedrooms were nicely decorated and had been personalised. Radiators throughout the Home were guarded. The Home was 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. DS0000000453.V273410.R02.S.doc Version 5.0 Page 13 The laundry was clean and hygienic. The washing machine and dryer were seen to be in good working order. Hazardous materials were locked away to prevent accidents occurring. Residents’ clothing was well looked after. A number of fire doors were checked and observed to be in a good working condition. Fire escapes and corridors were free of obstacles ensuring that residents and staff could exit the building in an emergency. Information about the Home’s fire evacuation procedure had been placed in different points around the Home. 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 with the exception that a window restrictor fitted in the first floor toilet was not in working condition. However, this matter had been resolved shortly after the inspection. DS0000000453.V273410.R02.S.doc Version 5.0 Page 14 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 and 29. Key Standards 27, 28 and 30 were assessed as part of the 2005 Announced Inspection. The Home had sufficient numbers of staff on duty to meet residents’ assessed needs. Residents were supported and protected by the Home’s recruitment policy and practices, although the required information was not available in some of the staff files examined. EVIDENCE: A staff rota was available showing, which staff were on duty and in what capacity. The following staffing levels agreed with the Commission were in place: DS0000000453.V273410.R02.S.doc Version 5.0 Page 15 8.00am to 8.00pm 3 care staff including a senior carer 8.00pm to 8.00am 2 night care staff A Manager is usually available during office hours - Monday through to Friday. However, at the time of the inspection the Manager was on sick leave. The number of staff scheduled on duty throughout the working day was in line with recommended levels. In recent weeks, the Home had experienced problems meeting the above staffing levels due to sickness and annual leave commitments. However, staffing levels had not been reduced and shortfalls in the rota had been covered in-house. The staff rota contained the required information with the exception of the Manager’s hours. A sample of staff personnel records were examined and contained the required information with the following exceptions: 1. A full employment history had not been obtained for a recently appointed member of staff; 2. A prospective member of staff had not declared whether she had any relevant convictions on her application form. The Provider agreed to rectify these matters immediately. DS0000000453.V273410.R02.S.doc Version 5.0 Page 16 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 and 33. Key Standards 31 and 38 were assessed as part of the 2005 Announced Inspection. The Manager provided consistent leadership, guidance and direction to staff and ensured that residents received good quality care. Arrangements were not in place to enable the Provider and Manager to review aspects of the Home’s performance through a programme of self-review, which included seeking the views of staff, relatives and residents. EVIDENCE: Staff interviewed told the Inspector that the Manager had made it clear to them the standards of care that they were expected to work to. Staff were able to clearly describe the purpose, aims and objectives of the Home. Staff
DS0000000453.V273410.R02.S.doc Version 5.0 Page 17 said that they knew what was going on within the Home and felt able to raise any matters of concern with the Provider and Manager. The Provider said that although some quality assurance initiatives were underway within the Home, a decision had not been reached as to the quality assurance system to be used within Rosewood Villas. Advice was provided to the Provider regarding this matter. DS0000000453.V273410.R02.S.doc Version 5.0 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X 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 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X x X X x DS0000000453.V273410.R02.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes 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. 4. Standard OP18 OP28 OP29 OP33 Regulation 13(6) 18(1) Schedule 2 Schedule 26 Timescale for action Ensure that all staff receive 01/10/06 training in the protection of vulnerable adults. Ensure that at least 50 of the 01/10/06 care team have obtained relevant qualifying training. Ensure that the staff personnel 01/10/06 records contain the required information. Undertake, at regular intervals, a 01/10/06 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. Requirement 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 DS0000000453.V273410.R02.S.doc Version 5.0 Page 20 DS0000000453.V273410.R02.S.doc Version 5.0 Page 21 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
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