Inspection on 25/07/07 for Salroyd Villa

This inspection was carried out on 25th July 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

Salroyd Villa 27/07/06

Salroyd Villa 02/02/06

Salroyd Villa 27/09/05

Salroyd Villa 26/01/05

Salroyd Villa 09/09/04

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Larchfield Manor

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The Grove Waltham

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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 Key Unannounced Inspection 25 July 2007 09:15 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.V345110.R01.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. Salroyd Villa DS0000001287.V345110.R01.S.doc Version 5.2 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.V345110.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th July 2006 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 home. The home is close to local bus routes. There is access for disabled people at the rear of the building. There are gardens and a patio area to the front of the house that people can use. The home has been converted from two semi-detached buildings and provides personal care for sixteen older people. The accommodation is 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 can only be reached by going up some steps, these rooms are only offered to people who are able to walk up the steps. 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. The home has a no smoking policy. In July 2007 the weekly fees ranged from £349.00 to £384.70. Additional services such as hairdressing and newspapers are not included in the fees. Salroyd Villa DS0000001287.V345110.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. I did this unannounced inspection in one day and spent approximately 6.5 hours in the home. The purpose of this visit was to assess how the home is meeting the needs of the people who live there. During the visit I spoke to people living in the home, staff and management. I observed staff caring for people in the communal rooms; I looked at various records relating to care, staff, and maintenance and looked at some parts of the building. Before the visit we sent a number of comment cards to people living in the home, relatives and health care professionals who visit the home. Comment cards give people the opportunity to share their views of the service with us. The information we get is shared with the home without identifying who has provided it. In total 11 cards were returned. A number of the people who live in the home have dementia or some degree of confusion and would not necessarily be able to complete these cards. The majority of those returned were from relatives. Before the visit the home provided us with a completed quality assurance selfassessment form. We have used some of that information as well as the information from the surveys in this report. What the service does well: Salroyd Villa is a family run business, the atmosphere is informal and friendly, and it offers a “homely” place for people to live and be cared for. One person said their relative had been worried about moving into the home however “ The staff made her feel very welcome and she soon settled in after realising that her own room was her own domain. All her needs are looked after. She particularly praises the food as this is always fresh and varied”. The following are some other comments made by relatives of people living in the home: • • • • “A very good friendly home from home, respectful, helpful and jolly, people laugh” “Welcoming and friendly” “Treat visitors like family”. “The staff are approachable at all times if any problems need to be discussed.” Salroyd Villa DS0000001287.V345110.R01.S.doc Version 5.2 Page 6 People said the home provides good care and they are kept informed of any changes affecting their relatives. People said the home is clean and never has any unpleasant smells. What has improved since the last inspection? What they could do better: We asked people what the home could be better. People said the activities programme needed to be improved; they felt there was not enough mental and physical stimulation for people. The manager is already dealing with this. Another person said it would be good to see the television turned off more often. One person said the home was looking a bit “jaded” and needed redecoration, this is also being dealt with. Some people were concerned that there weren’t always enough staff available and felt this was something the home should look at. Salroyd Villa DS0000001287.V345110.R01.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. The summary of this inspection report can be made available in other formats on request. Salroyd Villa DS0000001287.V345110.R01.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 Salroyd Villa DS0000001287.V345110.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 & 5. Standard 6 does not apply to this service People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are given the information they need to help them decide if the home is suitable for them. EVIDENCE: The majority of the people who completed a questionnaire for us said they had been given enough information about the service before admission. People are invited to visit before making a decision about moving in. One person said choosing a care home had been a difficult experience and very little information had been provided by any of the agencies involved. The records showed that detailed pre-admission assessments are done before people are offered a place. The first four weeks are a trial period for all new people; at the end of this time a review takes place to decide if the home is suitable to meet the persons needs. Salroyd Villa DS0000001287.V345110.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s personal and health care needs are met in a way that respects their privacy and dignity. Some improvements are needed to the systems for recording medicines to reduce the likelihood of people being placed at risk. EVIDENCE: I looked at three people’s care records. The care plans show how personal, health, and social care needs will be met. The care plans include information on people’s spiritual and cultural needs and how these will be addressed. There are risk assessments in place for falls, nutrition, and the risk of developing pressure sores. The home does not provide nursing care and uses these risk assessments to identify when they need to involve the district nurses. Salroyd Villa DS0000001287.V345110.R01.S.doc Version 5.2 Page 11 People have access to other health and social care professionals as needed, for example they have regular eye tests. A number of people living in the home have dementia and could not give an account of their experience of living there. However, observing practices throughout the day it was clear that they feel comfortable and safe in their environment. For example people are allowed to walk around freely and staff only intervene when it is necessary for their safety or the well being of other people. The people I spoke to said they are well cared for. Relatives said they are happy with the care and are kept well informed. One person said, “Physical needs are met and there is a caring atmosphere. My mother is always nicely dressed and clean.” A health care professional who visits the home made the following comment: “Well organised, patient centred, professional, I would send my mother there.” The care plans include information on end of life care. The home works closely with the district nurses to make sure that people’s health care needs are met at all times and particularly when people are in the last stages of life. The majority of staff have completed palliative care training. The systems for managing medicines were looked at. Generally they were satisfactory. The home does not have a controlled drugs register as recommended by the Royal Pharmaceutical Society Guidelines. There is no system for keeping account of the stock balance for medicines that are given on an “as required” basis. This is needed to make sure that medicines are being stored and given as prescribed. Salroyd Villa DS0000001287.V345110.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home has a relaxed and informal atmosphere that promotes flexibility in daily routines and encourages people to exercise choice and control over their lives. The home is working towards improving the way social care needs are met to make sure that people can continue to experience a varied and interesting lifestyle. EVIDENCE: The home has a very relaxed atmosphere and daily routines are flexible. People can choose where to spend their time, one person said she likes to go to her room in the afternoon to listen to music or read the newspaper. There are some activities such as bingo, chair exercises, sing a longs and games. Some people said this aspect of the service needed to be improved; the manager is aware of this and has plans to provide a more regular and varied programme of social activities. Salroyd Villa DS0000001287.V345110.R01.S.doc Version 5.2 Page 13 Some relatives acknowledged that this was not always easy because of the different needs of people living in the home. People can receive visitors at times that are convenient to them. One person said, “We are able to visit at any reasonable time and are always welcomed by the care staff”. Everyone living in the home at present is of the Christian faith. No one goes out to church however representatives from the local Roman Catholic and Church of England church visit people in the home. People living in the home said they enjoyed the food. The lunchtime meal looked appetising and was nicely presented. Where necessary people were helped or encouraged discreetly. Salroyd Villa DS0000001287.V345110.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People can be confident that any concerns they have will be listened to, taken seriously, and acted on. There are systems in place to make sure that people are protected from abuse. EVIDENCE: Most people said they know how to make a complaint if necessary. Several people said they had no need to complain but felt they could talk to the staff if they had any concerns. One person said “I haven’t raised any specific concerns as such but find the staff approachable if I want to ask about some general thing regarding my mother and her needs physical and emotional.” The home has a complaints’ procedure. They have had one complaint since the last inspection; this was dealt with by the home and recorded. We have not received any complaints or concerns about this service. Training on adult protection is included in the induction training and the majority of staff have attended external training provided by Bradford Social Services. Staff have a good understanding of what constitutes abuse and know how to report concerns. Salroyd Villa DS0000001287.V345110.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, 25 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Salroyd Villa provides a clean, comfortable, and homely place for people to live. EVIDENCE: The home is clean and there are no unpleasant odours. People said it is usually clean, one person said it is “clean but jaded, and in need of decoration. The home continues to make improvements to the environment. The first floor bathroom has been improved and the new bath is suitable for use by people who need help bathing. Some bedrooms have been refurbished over the last year; this has included providing new furniture and carpets. Salroyd Villa DS0000001287.V345110.R01.S.doc Version 5.2 Page 16 The bedrooms are properly equipped to meet people’s needs. People have lots of their personal belongings such as ornaments, photographs, and personal memorabilia in their rooms. One person said, “------- has a pleasant room with a large window. The room is always clean and furniture is nicely arranged with all her bits and pieces”. Thermostatic valves control hot water temperatures. Water temperatures are checked to make sure the valves are working effectively and to reduce the risk of scalding. The laundry is suitably equipped to meet people’s needs. There are systems in place to reduce the risk of cross infection. The home has been awarded a 3 star rating (the maximum is 5) by Environmental Health for its standards of food safety and hygiene. Salroyd Villa DS0000001287.V345110.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There are usually enough staff to make sure that people get the care and support they need. The staff are well trained and have the knowledge and experience they need to care for people properly. The recruitment procedures are good and they must always be followed to make sure that people are protected. EVIDENCE: The number of staff on duty varies depending on how many people are living in the home. At present there are usually 2 care staff, a cook and a cleaner in the morning and 2 care staff from mid afternoon to 10.00pm. Overnight there are 2 staff. Several people commented on the kindness of the staff. These are some of the comments we received: • • “They always display a caring attitude and patience with those who have difficulty walking etc. and need help to move around” “All the staff are loving, caring people” DS0000001287.V345110.R01.S.doc Version 5.2 Page 18 Salroyd Villa • • “They all appear to be very experienced and caring” “I think they are great, they give -------- such love and care”. One person said that at times there did not seem to be enough staff available. Four (40 ) of care staff have an NVQ (National Vocational Qualification) at level 2 or above and 4 more are doing NVQ training. The staff files showed that in most cases the required checks are completed before new staff start work. The deputy manager said she was still trying to get a second written reference for one person who was already working in the home. A verbal reference had been obtained but this is not sufficient. The records showed that new staff receive induction training to make sure they have the skills and knowledge they need to care for people properly. All staff have done food hygiene training and most have completed first aid training. All have had health and safety training and the deputy manager was in the process of organising updates on infection control training. Staff training is recorded. Salroyd Villa DS0000001287.V345110.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31. 32. 33, 35, 37 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The management team works hard to make sure that people are supported in making decisions and exercising choice. They encourage people to share their views and respond positively to ideas/suggestions for improving the service. EVIDENCE: The management structure is clearly defined; although Mrs Elwood is the registered manager her daughter, the deputy manager, is responsible for the day-to-day running of the home. The deputy manager has the appropriate knowledge, skills, and experience for her role and has completed the Registered Managers Award. The owners continue to be closely involved with the home mainly dealing with the accounts, maintenance, cooking and shopping. Mrs Elwood regularly works as a member of the care staff team. Salroyd Villa DS0000001287.V345110.R01.S.doc Version 5.2 Page 20 Staff said they enjoy working in the home and are well supported by the management team. People said they are kept well informed about matters relating to their relatives care and they find staff and management approachable. The manager does regular audits of the building and the kitchen to make sure the home is being kept clean and safe. The home sent questionnaires to people in June this year, so far 3 have been returned. Some people said they would like to see improvements to the activities programme. People who replied to our questionnaire also mentioned this. The deputy manager is addressing this; she has devised a weekly activities programme and is planning to start meetings for people living in the home and their relatives. The home does not get involved in dealing with people’s personal finances. Small amounts of spending money are held for some people. Receipts are obtained and records are kept of all transactions made on people’s behalf. Information provided by the home showed that the checks required to keep installations and equipment in safe working order are carried out at the required intervals. Some maintenance records were looked at, they were up to date. Salroyd Villa DS0000001287.V345110.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X 3 3 Salroyd Villa DS0000001287.V345110.R01.S.doc Version 5.2 Page 22 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. Standard OP9 Regulation 13(2) & 17 Requirement A controlled drugs register to record the receipt, administration, and disposal of controlled drugs must be provided. Previous timescale of 29/9/06 not met. 2 OP29 19 All the required checks must be completed before new staff start work in the home to make sure that people are protected. 28/09/07 Timescale for action 30/11/07 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 OP9 Good Practice Recommendations There should be a system for keeping account of the stock balances of medicines given on an “as required” basis. 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