CARE HOMES FOR OLDER PEOPLE
Salroyd Villa 21-23 Salroyd Road Low Moor Bradford BD12 0JN Lead Inspector
Mary Bentley Unannounced 27 September 2005, 10.35am
th 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. Salroyd Villa 20050927 Salroyd Villa UN Stage 4 S1287 V283479 J52.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Salroyd Villa Address 21-23 Salroyd Road, Low Moor, Bradford BD12 0JN 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) 01274 603887 01274 411294 Mrs Kathleen Ellwood Mrs Kathleen Ellwood Care Home Only 16 Category(ies) of Old age (11) Dementia Over 65 (4) Physical registration, with number Disability Over 65 (1) Mental Disorder Over 65 of places (1) Salroyd Villa 20050927 Salroyd Villa UN Stage 4 S1287 V283479 J52.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None. Date of last inspection 26 January 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 20050927 Salroyd Villa UN Stage 4 S1287 V283479 J52.doc Version 1.40 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 a year; these may be announced or unannounced. The last inspection was unannounced and took place in January 2005. There have been no further visits until this unannounced visit. This inspection was done by one inspector and lasted approximately five hours. The people who live in the home prefer the term resident; therefore this will be the term used throughout this report. During the inspection we looked at records, spoke to residents, management and staff and looked at some parts of the home. Comment cards/questionnaires for residents and visitors were sent to the home before the inspection. These provide an opportunity for people to share their views of the home with the Commission for Social Care Inspection. Comments received in this way are shared with the provider without revealing the identity of those completing them. Two were returned to the CSCI. What the service does well: What has improved since the last inspection?
Since the last visit the owners have moved out of the premises and as a result staffing levels on night duty have been increased. The owner said she had benefited from the move and it had helped her to look more objectively at aspects of the service, particularly the environment. The owners continue to
Salroyd Villa 20050927 Salroyd Villa UN Stage 4 S1287 V283479 J52.doc Version 1.40 Page 6 be available to help out outside of their usual working hours as they are living nearby. There were three requirements following the last inspection and these have been dealt with. A new format for care planning has been introduced and the care plans give a good picture of each individuals current needs and past life. The deputy manager has successfully completed the Registered Managers Award. A new fire alarm system has been fitted to all parts of the home. 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 20050927 Salroyd Villa UN Stage 4 S1287 V283479 J52.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 Salroyd Villa 20050927 Salroyd Villa UN Stage 4 S1287 V283479 J52.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) 3 & 5. Prospective residents and/or their relatives are given the information they need to make an informed decision about the suitability of the home to meet their needs. Residents are not admitted until their needs have been assessed. EVIDENCE: The deputy manager explained how pre-admission assessments are done; prospective residents, their representatives and other professionals are involved. Completed pre admission assessment forms were seen in the care records. Prospective residents and /or relatives are encouraged to visit the home before admission; in most cases it is the relatives who visit. Salroyd Villa 20050927 Salroyd Villa UN Stage 4 S1287 V283479 J52.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, 10 & 11 Residents’ needs are met in a way that respects their privacy and dignity. EVIDENCE: Three care plans were looked at; a new format for care plans has been introduced since the last inspection. The plans had some good detail on residents’ personal and social care needs and residents looked well cared for. The home is well supported by District nurses and GPs in meeting health care needs. Risk assessments for falls and nutrition were available. Despite the fact that the home works closely with the District Nurses to monitor the risk of pressure sores there are no records of pressure sore risk assessments available. Residents have access to opticians and hearing tests as required, and a dentist visits the home. Residents’ wishes in relation to care before and after death are respected, whenever possible they remain in the home, in these circumstances the home gets good support from community health care professionals. There was evidence of involvement of residents and relatives in the care plans and reviews.
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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 & 15 Residents are encouraged to take part in social and leisure activities and are supported in maintaining links with their friends and family, however this was not fully evidenced in the care records seen. EVIDENCE: Daily routines are flexible and residents’ wishes are respected, they can spend their time either in the communal areas or in their own bedrooms. One resident was seen wandering quite happily around the ground floor, staff have put a multi coloured sign on her door to help her identify her own bedroom as she likes to go and have a lie down from time to time. Residents looked relaxed and “at home” in the environment. Activities and entertainment are organised but records of activities were not maintained consistently and therefore it was difficult to get an accurate picture of how residents spent their time. Three residents were seen playing Dominoes in the afternoon. There are no restrictions on visiting and during the inspection a number of visitors were seen coming and going. Some residents go out with family or friends. Salroyd Villa 20050927 Salroyd Villa UN Stage 4 S1287 V283479 J52.doc Version 1.40 Page 11 Residents said the food was good, it is a relatively small home and the manager has a good knowledge of peoples likes and dislikes and takes these into account when doing the weekly shopping. Lunch was observed, it was braised steak with potatoes and vegetables, and there was treacle sponge for dessert. One resident who did not want the main course was given an omelette. The food is simple and wholesome, it is well presented and staff were seen to help and encourage residents where necessary. Salroyd Villa 20050927 Salroyd Villa UN Stage 4 S1287 V283479 J52.doc Version 1.40 Page 12 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) 16,17 & 18 Residents are safe and safeguarded against abuse; their legal rights are protected. EVIDENCE: The complaints procedure is available in the home; there have been no complaints since the last inspection. The home has a copy of the local authority adult protection procedures and all staff are made aware of this, the deputy is going to arrange external training on abuse and adult protection for all staff. The files seen had information on people’s wishes in relation to voting, for example whether or not they wanted to be registered for postal voting. Information on advocacy services is available in the home. Salroyd Villa 20050927 Salroyd Villa UN Stage 4 S1287 V283479 J52.doc Version 1.40 Page 13 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) 19, 22, 24 & 26 Salroyd Villa provides a clean, safe and comfortable home for residents; some improvements are needed to make sure that the environment is maintained to an acceptable standard. EVIDENCE: The home was clean and there were no unpleasant smells. External cleaning contractors cleaned a number of bedroom carpets on the day of the visit. The manager and deputy had just completed an internal audit of the building and had identified areas that needed improvement. In some of the rooms seen leads were missing from the call bells. The bedrooms seen were clean and comfortable and residents had their personal belongings around them. The ground floor bathroom needs refurbishment. A new fire alarm system has been installed since the last inspection. There are good infection control systems in place.
Salroyd Villa 20050927 Salroyd Villa UN Stage 4 S1287 V283479 J52.doc Version 1.40 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 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, 29 & 30. There are enough staff to meet residents needs, staff are supported in understanding and meeting residents needs by a good training programme. The recruitment procedures are not always followed and this creates the opportunity to place residents at risk. EVIDENCE: Although the home was short one member of staff on the day of the inspection there are generally enough staff available to meet residents needs. The owners live nearby and are available to provide additional help if it is needed. Since the owners moved out of the upstairs flat night staffing levels have been increased. The home was in the process of recruiting an additional domestic assistant to work 15 hours a week. The file of one newly appointed member of staff showed that only one written reference had been obtained and a POVA (Protection of Vulnerable Adults) check had not been done before commencement of employment. There is a good training programme, all mandatory training was up to date, this includes moving & handling, infection control, fire safety, health & safety, food hygiene and first aid. Five staff have completed training on healthy eating and nutrition and three are enrolled on Dementia training. The home has 36 of its staff qualified to NVQ (National Vocational Qualification) level 2 or above, another has almost completed NVQ level 3 and two are doing NVQ level 2.
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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, 33, 37 & 38 The home is well managed and for the most part is run in the best interests of residents. Residents benefit from the homely and informal atmosphere however the manager must guard against this leading to the development of poor working practices that could put the wellbeing of residents and staff at risk. EVIDENCE: The deputy manager has achieved the Registered Managers Award. Questionnaires are issued to residents, relatives and professionals involved with the home approximately every six months, although the response rate is low action is taken to address any issues that are raised. In the most recent survey some relatives commented that if they wanted to visit in private there was nowhere other than the residents bedroom to do this, as a result some tables and chairs were moved into the small lounge to make it easier to use this room for visiting.
Salroyd Villa 20050927 Salroyd Villa UN Stage 4 S1287 V283479 J52.doc Version 1.40 Page 16 All the records required by regulation were available and in good order, the diary contained too much personal information about residents, this compromises confidentiality and is not in keeping with the Data Protection Act. The duty rosters showed that some staff are regularly working shifts in excess of 12 hours, this is not good practice and is not in the best interests of residents or staff. Some staff were wearing open toe shoes, this puts them at risk and should be discouraged. Salroyd Villa 20050927 Salroyd Villa UN Stage 4 S1287 V283479 J52.doc Version 1.40 Page 17 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 x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3
COMPLAINTS AND PROTECTION 2 x x 2 x 3 x 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x 3 x x x 2 2 Salroyd Villa 20050927 Salroyd Villa UN Stage 4 S1287 V283479 J52.doc Version 1.40 Page 18 No 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 19 22 29 Regulation 23(2)(b) & (c) 23(2)(c ) 18 Requirement The ground floor bathroom must be upgraded. The call bell system must be easily accessible to residents in all parts of the home. The registered persons must make sure that all the required pre-employment checks are done before new staff start work in the home. Timescale for action 26 January 2006 26 January 2006 30 Ocotober 2005 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. 2. 3. 4. Refer to Standard 1 8 37 38 Good Practice Recommendations Consideration should be given to producing a large print version of the Service User guide. The home should keep records of pressure sore risk assessments. 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. Staff should to discouraged from wearing open toe shoes.
Salroyd Villa 20050927 Salroyd Villa UN Stage 4 S1287 V283479 J52.doc Version 1.40 Page 19 Salroyd Villa 20050927 Salroyd Villa UN Stage 4 S1287 V283479 J52.doc Version 1.40 Page 20 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
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