Inspection on 14/03/06 for Starmount Villa Residential Care Home

This inspection was carried out on 14th March 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Starmount Villa Residential Care... 15/11/06

Starmount Villa Residential Care... 24/10/05

Starmount Villa Residential Care... 21/03/05

Starmount Villa Residential Care... 23/06/04

Starmount Villa Residential Care... 22/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Starmount Villa Residential Care Home Browns Road Bradley Fold Bolton Lancs BL2 6RG Lead Inspector Grace Tarney Unannounced Inspection 14th March 2006 10:00 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 Starmount Villa Residential Care Home DS0000008408.V286146.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. Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Starmount Villa Residential Care Home Address Browns Road Bradley Fold Bolton Lancs BL2 6RG 01204 525811 01204 525588 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) Starmount Villa Residential Care Limited Mrs Lesley Swinnerton Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 27 service users to include: Up to 27 service users in the category OP (Older People). The service should at all times employ a suitably qualified experienced manager who is registered with the Commission for Social Care Inspection. 24th October 2005 Date of last inspection Brief Description of the Service: Starmount Villa is a care home providing personal care and accommodation for 27 people aged 65 years and over. Starmount Villa is located on the outskirts of Bolton towards Bury. The home is set in its own grounds in a quiet residential area and close to a country park. It comprises of twenty-six single bedrooms, twelve with en-suite and one double bedroom. There is a large lounge, smaller quiet lounge, large dining room and a second dining room for those who require additional support. Accommodation is provided on two floors and was found to be tastefully decorated, clean and odour free. A passenger lift is also available. There is a large garden at the front of the building and a second to the rear, which are well maintained and easily accessible. Garden furniture is provided for residents to sit out and enjoy the good weather. Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not made aware that this inspection was to take place. This was an unannounced inspection. The inspector spent 5 hours at the home. . During this time she looked at care records to check that the health and care needs of the residents were being met. To make sure that the home and the equipment in it was safe, the Inspector looked at the maintenance and service records. She also looked at how many staff were provided on each shift to make sure the residents needs were being met, and also looked at how management recruit their staff. In order to obtain information about the home, the inspector also spent time speaking to 4 residents in the small lounge. She also spent time talking to one of the care supervisors who had been left in charge that day. Not all the National Minimum Standards were looked at on this visit. The Inspector looked at the Standards that had not been looked at during the last inspection. The Standards that are looked at during inspections are those that are considered to be important for the residents’ safety and well-being. What the service does well: What has improved since the last inspection? What they could do better: Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 Page 6 The care plans need to give a much clearer picture of the residents’ health and social care needs. More attention must be given to understanding the reasons for, and the importance of, nutritional risk assessments. This will reduce the risk of any possible harm to residents. More attention must be given to recording how often a resident is to be weighed. Regular weighing of residents and recording the results is necessary so that any weight loss can be as identified and the possible cause looked into. 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. Starmount Villa Residential Care Home DS0000008408.V286146.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 Starmount Villa Residential Care Home DS0000008408.V286146.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): EVIDENCE: Not inspected on this visit. Starmount Villa Residential Care Home DS0000008408.V286146.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): 7 & 8. The care plans did not fully reflect the support needs of the residents and did not show what a resident was able to do. The failure of staff to undertake risk assessments for nutrition could result in risks going unnoticed, resulting in possible harm to residents. EVIDENCE: Individual care plans were in place for each resident. The care plans of 4 residents were looked at. The care plans were not detailed enough and only dealt with problems in relation to personal hygiene, toilet needs, mobility and medications. The care plans addressed only the residents’ problems and did not give a “clear picture” of what the residents were able to do. Following a discussion with a staff member it was evident that staff were aware of the residents capabilities but this was not being recorded. Inspection of one care plan identified that there was a good plan of care in relation to this residents’ diabetes. The details of the district nurses’ responsibilities in relation to the care of this resident were well documented. There was also clear guidance for staff on how to deal with any related emergency. Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 Page 10 There was however no care plan in relation to this residents’ diet and no nutritional risk assessment in place. This resident had lost 3 kg in weight within a six-week period but there was no care plan in place for this. There was evidence to show that there was input from the chiropodist. The care plan of another resident identified that there was a nutritional risk assessment but this was not dated. The risk assessment stated that any weight issues were to be reported directly to this residents’ GP. This resident had not been weighed however, on a monthly basis. She had been weighed in July & November 05 and then in March 06. Between November 05 and March 06 she had lost 3 kg in weight. Residents must be weighed in accordance with their nutritional risk assessment but at least on a monthly basis. A moving and handling risk assessment was in place and a good plan of care had been implemented in relation to the risk of falling out of bed or a chair. This plan of care had been written in February 05. When the Inspector asked if this was still relevant she was told that it was not. All risk assessments in conjunction with the care plans must be evaluated as and when needs change, but at least on a monthly basis. Inspection of another care file showed that there were very few details on the assessment form. The following areas of the documents had not been filled in: working and playing, rising and retiring and eating and drinking. There was a moving and handling assessment, a falls risk assessment but no nutritional risk assessment. The care plan of the other resident identified that there had been a weight loss and that a fluid and diet chart was in use. It was also recorded that food supplements had been prescribed. Dieticians were visiting this resident whilst the Inspector was present in the home. Inspection of her weight record showed that she had gained .3 of a kilogram in a short space of time. This shows that staff do access the services of the residents’ GP and the dietician when a problem has been identified. They must ensure however that this vigilance is timely and is extended consistently to every resident. In the view of the inadequate and inconsistent system for weighing the residents the Inspector looked at a further 4 weight charts. All 4 residents had been weighed on the 19/01/06 and then again on the 1/3/06. They had all lost a small amount of weight but there was no care plan in place to address this and none of them had a nutritional risk assessment There was no evidence to show that residents/relatives had been involved in the drawing up of the care plan. Residents and relative must be involved to ensure that important and relevant information is obtained, thereby ensuring an accurate and agreed care plan is in place. Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 Page 11 Inspection of the care files identified that the residents had access to health care professionals, such as dentists, opticians, chiropodists and district nurses. Equipment necessary for the prevention and treatment of pressure sores was readily available within the home or could be accessed via the district nurses. Continence aids were in use and the staff were aware of how to contact the continence nurse advisor for advice, if deemed necessary. . Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not inspected during this visit. Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 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 the following standard(s): 16,17 & 18. The complaint system in place enabled the residents to feel that their views were listened to and acted upon. Staff had a good knowledge and understanding of adult protection procedures thereby reducing the possible risk of harm or abuse EVIDENCE: A discussion with the residents indicated that there was a general awareness of how to make a complaint. The complaints procedure was displayed in the office. The Inspector was told that it is also attached to the Service User Guide. It was easy to understand and gave an assurance that complaints would be responded to within 28 days. The complaints procedure needs to be amended to inform complainants that they can contact the CSCI at any stage. Staff told the Inspector that the residents used their postal vote in the local and general elections. A resident spoken to by the Inspector confirmed this. A copy of the Local Authorities Vulnerable Adults Procedure was in place and a discussion with the senior staff identified that they were very aware of the procedure to follow in the event of any allegation of abuse. Training in the protection of vulnerable adults has been undertaken by some staff and is ongoing. Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: Not inspected on this visit. Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 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 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 & 29 The residents were cared for by sufficient numbers of staff that were suitably recruited and trained and therefore had the knowledge and skills to meet the residents’ needs. EVIDENCE: Examination of the duty rotas and a discussion with staff identified that there was sufficient staff on duty over a 24-hour period to meet the needs of the 27 residents. Between the hours of 8am to 6pm there are 5 care assistants on duty and between 6pm to 8pm there are 4. Two wake-in staff cover the night duties. The Inspector was informed that the registered manager/owner works at the home nearly every day of the week. There was evidence to confirm this, however the hours she was working were not recorded on the duty rota for that week. The personnel files of three staff members were inspected. These contained all the requirements of Schedule 2. They had a completed application form, 2 professional references and a health status declaration. The inspector was not able to access the enhanced CRB disclosure checks as they were kept secure in the registered persons’ office and both registered persons were on holiday at the time of the inspection. There was evidence in the personnel files to show that the correct information for completing a CRB check had been received. The CRB disclosures will be looked at on the next inspection. Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 Page 16 The Inspector checked compliance with the requirement from the last inspection in relation to Standard 30. This was in relation to staff training. Training in the protection of vulnerable adults has been undertaken by some staff and is ongoing. The Inspector was also shown the induction handbooks that had recently been delivered to the home. These handbooks incorporated the Common Induction Standards to meet the GSCC code of practice. Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 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 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): 33 35 & 38. Current practices within the home in relation to the maintenance of a safe environment, promoted and safeguarded the health, safety and welfare of the people using the service EVIDENCE: The home has achieved the Investors in People award. There was no evidence of an annual development and business plan or a quality assurance system being in place. This Standard will be looked at in more detail during the next inspection. The systems in place for the management of residents’ money could not be inspected as the registered manager/provider was on holiday and the records were kept secure. This Standard will be looked at in more detail during the next inspection. The equipment and services within the home were serviced on a regular basis in accordance with the individual requirements. Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 Page 18 The home had a Health & Safety Policy. Fire risk assessments and risk assessments for all safe working practices were performed and outcomes recorded. The fire logbook was up-to-date Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 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 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 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 x x x x x x x x 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 3 Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 Page 20 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 OP7 Regulation 12/15 Requirement That the care plan and assessment documents are completed in full detailing the needs of the residents and how they are to be met. (Previous timescale of 30/12/05 not complied with) When a care problem has been identified a plan of care to address it must be implemented. There must be evidence to show that residents/relatives have been involved in the drawing up of the care plan. Care plans and risk assessments must be evaluated whenever there has been any change in circumstances but at least on a monthly basis. Nutritional risk assessments must be in place for all residents. Residents must be weighed in accordance with their nutritional risk assessment but at least on a monthly basis. The hours worked by the manager must be documented on the duty rota. Timescale for action 30/04/06 2 3 OP7 OP7 12/15 15 31/03/06 30/04/06 4 OP7 15 30/04/06 5 OP8 12 31/03/06 6 OP27 17 & Schedule 4 31/03/06 Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 Page 21 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 OP16 Good Practice Recommendations The complaints procedure should state that the complainant can contact the CSCI at any stage of a complaint investigation. Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Starmount Villa Residential Care Home DS0000008408.V286146.R01.S.doc Version 5.1 Page 23 - 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. 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