Inspection on 02/02/06 for Salroyd Villa

This inspection was carried out on 2nd February 2006.

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.

Other inspections for this house

Salroyd Villa 25/07/07

Salroyd Villa 27/07/06

Salroyd Villa 27/09/05

Salroyd Villa 26/01/05

Salroyd Villa 09/09/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Salroyd Villa 21 - 23 Salroyd Road Low Moor Bradford West Yorkshrie BD12 0JN Lead Inspector Mary Bentley Unannounced Inspection 2nd February 2006 10:30 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 Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 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. Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Salroyd Villa Address 21 - 23 Salroyd Road Low Moor Bradford West Yorkshrie BD12 0JN 01274 603887 01274 411294 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 Kathleen Ellwood Mr Ian Patrick Ellwood Mrs Kathleen Ellwood Care Home 16 Category(ies) of Dementia - over 65 years of age (4), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (11), Physical disability over 65 years of age (1) Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: Salroyd Villa is situated in a residential area just off the main Cleckheaton Road at Low Moor. Car parking is permitted on the road in front of the property. The home is close to local bus routes. There is disabled access to the home at the front of the building. There are gardens and a patio area to the front of the property that residents can use. The home has been converted from two semi-detached buildings and is registered as a care home providing personal care for sixteen older people. Accommodation is provided on the ground and first floor and there is a stair lift linking both floors. There are two bedrooms and a toilet on the first floor that are not accessed by the stair lift. There are fourteen single bedrooms, one of which has en suite facilities, and one double room. The home has two communal bathrooms and four toilets. There are two communal rooms on the ground floor, one is a large lounge/dining area and the smaller room is used as a dining room and as a quiet area for visitors. Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year, from April until March, care homes have a minimum of two inspections; these may be announced or unannounced. This was the second inspection of this home and it was unannounced; the first inspection was also unannounced and took place in September 2005. One inspector carried out the inspection and spent approximately four hours in the home. There have been no additional visits to the home since September 2005. The methods used during the inspection included talking to residents, staff and management. I looked at care records and carried out a partial tour of the home. The home prefers the term “resident” to “service user” therefore that is the term that will be used throughout this report. Comment cards were left at the home for residents and relatives; these cards provide an opportunity for people to share their views of the service with the CSCI. Comments received in this way are discussed with the provider without revealing the identity of those completing them. What the service does well: What has improved since the last inspection? All the requirements from the last inspection have been dealt with. The bathroom on the ground floor has been refurbished and now provides a nicer environment for residents when they are bathing. The home has implemented a form to record the risk of developing pressure sores; any residents identified as being at risk are referred to the District Nurse. Staff have been provided with new uniforms and looked very smart. Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 Page 6 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. Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 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 Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 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): These standards were not inspected on this visit; please refer to the report dated 27 September 2005. EVIDENCE: Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 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): 9 Residents are protected by the home’s systems for dealing with medicines. For information on the remaining standards please see the report dated 27 September 2005. EVIDENCE: All the staff that are involved in administering medicines have been trained. None of the residents in the home were managing their own medication. Medicines are stored safely and the records were up to date and accurate. Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 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 Residents are helped to exercise choice and control over their lives. EVIDENCE: Residents can choose whether to spend their time in one of the communal areas or in their bedrooms. Daily routines are fairly flexible and adapted to fit in with residents’ preferences. Residents are offered a range of activities in the home and opportunities to go out either with staff or with family/friends. Residents who are able to are supported in managing their personal allowance money. Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 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): These standards were not inspected on this visit for details please refer to the report dated 27 September 2005. EVIDENCE: Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 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 & 22 Residents live in a clean and comfortable environment. EVIDENCE: All areas of the home were clean and reasonably well maintained. There were no unpleasant smells. Since the last inspection the ground floor bathroom has been refurbished, some new furniture and beds have been purchased and the home is in the process of replacing many of the existing commodes. The first floor bathroom needs to be improved and the floor covering replaced. Call bells are available in all areas used by residents. Residents’ bedrooms are comfortable and in the rooms seen residents’ had their personal belongings around them. Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 Page 13 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): 28 & 29 Staff are supported in developing their skills and knowledge. Residents are protected by the home’s recruitment procedures. EVIDENCE: There is an ongoing NVQ (National Vocational Qualification) training programme, 33 of staff are qualified and a further three staff are doing NVQ training. The deputy manager said that the home is having difficulty reaching the target of 50 because of staff turnover. Training has been provided during the past 12 months covered subjects such as dementia care, health & safety, infection control, healthy eating and food hygiene and palliative care. The home has not employed any new staff since the last inspection. The deputy manager said that all the required checks are done before new staff start work in the home. The home uses an external organisation to get CRB (Criminal Record Bureau) checks and the deputy manager confirmed that POVCA (Protection of Vulnerable Adults) First checks are done. Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 Page 14 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, 35, 37 & 38 Overall the home is well managed and residents benefit from living in a homely and informal setting. The financial interests of residents are safeguarded despite there being some shortfalls in the record keeping systems. Some improvements are needed to make sure that the health and safety of residents and staff are promoted and protected. EVIDENCE: The deputy manager is the owners’ daughter and she takes responsibility for the day-to-day management of the home. The deputy manager has the relevant experience for this role and has successfully completed the Registered Managers Award. Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 Page 15 The home manages money for one resident; this is a long-standing arrangement. The home now has a policy of not becoming involved in the management of residents’ finances, if necessary residents are helped to find independent support with managing their finances. The home holds small amounts of spending money on behalf of residents; receipts are kept for most transactions but are not provided by the hairdresser and chiropodist who visit the home. The home does not always get two signatures for cash transactions. While some improvement has been achieved there is still too much personal information about residents in the homes’ diary. Information provided by the home showed that most of the required maintenance checks were up to date, however the current gas safety certificate was not available. The deputy manager was not sure if Legionella checks had been done and was not able to confirm if all the fire officers’ recommendations had been implemented. Requirements have been made about these matters. Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 Page 16 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 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 X 17 X 18 X 2 X X 3 X X X X STAFFING Standard No Score 27 X 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 2 X 2 2 Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 Page 17 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 2 3 Standard OP19 OP35 OP38 Regulation 23(2) 17 Sch. 4 13(4) Requirement The floor covering in the first floor bathroom must be replaced. The home must obtain receipts for all money spent on behalf of residents. The registered persons must make sure that gas appliances are checked annually and the CSCI must be provided with a copy of the current gas safety certificate, (Landlords certificate). The registered persons must check hot water temperatures to make sure that the valves are working properly and temperatures are being maintained at as close to 43 0 C as possible. The registered persons must make sure that water systems are checked for compliance with Legionella. The registered persons must provide the CSCI with confirmation that the recommendations of the fire DS0000001287.V280686.R01.S.doc Timescale for action 31/03/06 31/03/06 31/03/06 4 OP38 13(4) 31/03/06 5 OP38 23(4) 31/03/06 Salroyd Villa Version 5.1 Page 18 officers’ report have been complied with. 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 OP35 Good Practice Recommendations Two signatures should be obtained for all cash transactions. To reduce the number of cash transactions in the home consideration should be given to invoicing residents for additional services. The diary should not be used to record personal information about individual residents. To safeguard the wellbeing of residents and staff care staff should be discouraged from working excessively long shifts. Carried forward from the last inspection. 2 3 OP37 OP38 Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Salroyd Villa DS0000001287.V280686.R01.S.doc Version 5.1 Page 20 - 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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