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Inspection on 15/11/06 for Starmount Villa Residential Care Home

Also see our care home review for Starmount Villa Residential Care Home for more information

This inspection was carried out on 15th November 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Before residents went into the home one of the senior members of staff visited them in their own homes or in hospital to make sure that the care they needed could be provided by the home. Comments were made to the Inspector such as, "The home is excellent. My mother`s care is of paramount importance. Nothing is too much trouble". " It is like a first-class hotel, 5-star standard" A relative commented, "My mother has had a much better quality of life since coming into this home. All the residents and myself couldn`t be better looked after".People visiting the home are made welcome and can visit at any time. Great importance is attached to ensuring that meals and mealtimes are a pleasurable experience. Enough staff are on duty to meet the needs of the residents. The staff make sure that the residents are clean, comfortable and well dressed. The staff team work well together and good systems are in place for sharing information about residents. Management has a commitment to ongoing staff training and learning and has provided the care team with the knowledge and skills they need to protect and meet the needs of the residents.

What has improved since the last inspection?

The staff look at whether or not the residents have any problems with their diet and fluid intake. They also make sure that they record if there is any risk around this and also record how often a resident is to be weighed. Management are continuing with a redecoration and refurbishment programme. New windows have been fitted to the south side of the property and parts of the outside of the home have been painted. In addition the dining room and two bedrooms have been redecorated.

What the care home could do better:

Senior staff need to continue to look at ways of improving the care plans so that they give a much clearer picture of the residents` health and social care needs.

CARE HOMES FOR OLDER PEOPLE Starmount Villa Residential Care Home Browns Road Bradley Fold Bolton Lancs BL2 6RG Lead Inspector Grace Tarney Unannounced Inspection 15th November 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.V298017.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. Starmount Villa Residential Care Home DS0000008408.V298017.R01.S.doc Version 5.2 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 care@starmountvilla.co.uk 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 (26), Physical disability (1) of places Starmount Villa Residential Care Home DS0000008408.V298017.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should at all times employ a suitably qualified experienced manager who is registered with the Commission for Social Care Inspection. 14th March 2006 Date of last inspection Brief Description of the Service: Starmount Villa is a care home providing personal care for mainly older people. It is a detached converted and extended house providing accommodation on two floors. It 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. 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. The home 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. The bedrooms on the first floor are reached either by stairs or a passenger lift. The toilets and bathrooms have aids to assist any resident with a disability or mobility problem Starmount Villa Residential Care Home DS0000008408.V298017.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not told that this inspection was to take place although the home was aware that an inspection was due. This was because several weeks before the inspection survey comment cards were sent out to the residents, their relatives and to the home itself. Some were also sent out to the GPs and district nurses who visit the home. These survey comment cards asked what people thought of the quality of the service and the facilities provided. 35 were returned. 20 were from relatives, 10 were from residents, 2 from GPs and 3 from district nurses. This is an excellent response rate. The Inspector spent a total of 7 hours at the home. During this time she looked at care and medicine records to ensure that the health and care needs of the residents were being met. 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 and train their staff. To make sure that the home and the equipment in it was safe, the Inspector looked at some of the maintenance and service records of the equipment within the home. The Inspector then looked around the building at the bedrooms, bathrooms toilets and sitting areas to check if they were clean and well decorated. The Inspector also looked at what the residents had for their lunch and evening meal. In order to get further information about the home the Inspector also spent time speaking to 3 residents, 1 relative, the cook and the deputy manager. She also spent time with the manager and the administrator, who are the owners of the home. A copy of the last inspection report is kept on display in reception and is included in the Service User Guide. The provider informed the inspector that the fees within the home ranged from £341.00 to £ 383.97.00 per week. This information was received on the 30/9/06. What the service does well: Before residents went into the home one of the senior members of staff visited them in their own homes or in hospital to make sure that the care they needed could be provided by the home. Comments were made to the Inspector such as, “The home is excellent. My mothers care is of paramount importance. Nothing is too much trouble”. “ It is like a first-class hotel, 5-star standard” A relative commented, “My mother has had a much better quality of life since coming into this home. All the residents and myself couldnt be better looked after”. Starmount Villa Residential Care Home DS0000008408.V298017.R01.S.doc Version 5.2 Page 6 People visiting the home are made welcome and can visit at any time. Great importance is attached to ensuring that meals and mealtimes are a pleasurable experience. Enough staff are on duty to meet the needs of the residents. The staff make sure that the residents are clean, comfortable and well dressed. The staff team work well together and good systems are in place for sharing information about residents. Management has a commitment to ongoing staff training and learning and has provided the care team with the knowledge and skills they need to protect and meet the needs of the residents. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Starmount Villa Residential Care Home DS0000008408.V298017.R01.S.doc Version 5.2 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.V298017.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The system for ensuring that all prospective residents had a detailed assessment undertaken before their admission to the home, gave an assurance both to residents, relatives and staff, that a resident was only admitted if the home could meet their needs. EVIDENCE: Before any resident was admitted to the home an assessment of their needs was undertaken either by the manager or a senior member of the care staff from the home, or from the professional i.e. care manager, requesting their admission. Inspection of 3 resident care files showed that assessments had been undertaken prior to admission. These assessments were very detailed. At the time of inspection they did not contain all the requirements of Standard 3, such as foot care and family involvement. These are now in place. Standard 6 does not apply. The home does not provide Intermediate Care. Starmount Villa Residential Care Home DS0000008408.V298017.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of the residents were met in a very caring and dignified way. EVIDENCE: Individual care plans were in place for each resident. The care files of 3 of the residents were inspected. The admission assessment document gave some useful information about what a resident was able to do and also how they liked to spend their day, their social history and their likes and dislikes. The care plans however addressed only the residents’ problems. The care plans need to be expanded so that all aspects of the residents care can be recorded. The care plan of one resident did not contain enough detail about how the staff were actually caring for this resident who was at risk of developing pressure sores. On admission the staff had identified that this resident was at risk and promptly referred the resident to the district nursing services. The district nurses were overseeing this residents’ care and pressure-relieving equipment was provided. The type of equipment and the steps to be taken to reduce any pressure, were not however being recorded on the homes’ care plan. Starmount Villa Residential Care Home DS0000008408.V298017.R01.S.doc Version 5.2 Page 10 The staff looked at whether or not there was any risk in relation to the residents developing pressure sores and also if they were at risk due to problems with their diet and fluid intake. The manager is presently looking at a different system for assessing any nutritional risk to residents. Staff also looked at and they wrote down, how any resident was to be assisted with being moved around and by how many members of staff and what equipment, if any, was to be used to assist in safe moving and handling. These are called risk assessments. Risk assessments were also in place for whether a resident was at risk of falling. 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. The manager told the Inspector that they were in the process of implementing a system whereby they had regular reviews with the residents/relatives and as part of this they would be discussing and agreeing the care plan. From the care plans inspected it was evident the residents were weighed at least on a monthly basis and any weight loss identified and acted upon. Inspection of care plans identified that the residents had access to other health care services including hearing, sight tests and a visiting chiropodist. Of the 10 survey comment cards received from residents they all said that they always received the medical support that they need. The survey cards from the visiting GPs commented that the home communicates clearly and works in partnership with them and that staff demonstrate a clear understanding of the residents’ care needs. A district nurse commented, “ I feel all the residents are well cared for and individual care needs are met”. Another nurse stated, “I have always found the care to be of a good standard”. Another nurse said, “ It is a good example of a residential care home”. Residents made the following comments in the survey comment cards: “I am cared for at all times to an excellent standard” “I couldnt wish to be looked after any better” Relatives made the following comments in the survey comment cards: “I am very satisfied with the care provided for my mother”. “The family feel that Mum is getting the best possible care. She belongs to one big family”. “We are extremely pleased with the level of care given to our relative. She receives the best of care”. Residents were well groomed and dressed. Overall a safe system of medication management was in place. The home does not have a locked medication room but the medicine trolley is kept locked and secured to the wall when not in use. Management ensure that only staff responsible for the administration of medicines have access to the medication keys. The home has a controlled drug cupboard and controlled drugs were securely stored. It was identified however that other medicines besides controlled Starmount Villa Residential Care Home DS0000008408.V298017.R01.S.doc Version 5.2 Page 11 drugs were being stored in this cupboard. Only controlled drugs should be stored in a controlled drug cupboard. Management agreed to remove the other medications and store them elsewhere. Only suitably trained and designated care staff administer the medications. The following areas of concern were identified: One resident had a handwritten prescription for Paracetamol. There was no further information in relation to how many and how often they were to be given. One resident was prescribed 1 or 2 painkillers every 4 to 6 hours. Staff were not writing just how many tablets had been given. Handwritten instructions for medicines (Transcriptions) were not signed, checked and countersigned. Signing and checking transcriptions reduces the risk of drug errors Personal support to residents is offered is such a way so as to promote and protect their privacy, dignity and independence. This was confirmed by a number of residents who said that the staff treat them with respect and that their dignity is valued. Those residents spoken with said that the staff were “patient and respectful” Starmount Villa Residential Care Home DS0000008408.V298017.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. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home enabled residents to have as much personal freedom and choice as possible. EVIDENCE: The residents spoken to said that they were satisfied with the way they were allowed to spend their day The home does not employ an activities organiser. The staff undertake activities with the residents, mainly in the afternoons. The residents take part in games, quizzes and reminiscence therapy. The home also has a library with large print books. In addition outside entertainers are brought in on a very regular basis. Information taken from the minutes of a residents and relatives meeting showed that various events had been organised for the residents. The residents had recently been on a trip to Blackpool for fish and chips and to see the Illuminations. A Halloween and a bonfire party had been organised during the month of October and November and the home were in the process of organising a ‘Taste of Christmas’ festive afternoon tea at the end of November. In answer to the question on the comment card that asked “Are there activities arranged by the home that you can take part in?” 4 residents answered “always” & 6 answered usually”. Starmount Villa Residential Care Home DS0000008408.V298017.R01.S.doc Version 5.2 Page 13 A relative confirmed that there were no unreasonable restrictions to him visiting at the home and that visits could be conducted in the privacy of the resident’s room or quieter areas of the home. This visitor said that the staff make him feel welcome when visiting. He said, “ They are really very, very good”. Comments received from the relative questionnaires were: “Whenever we visit we are very impressed by the atmosphere, the staff and the management” “ I always receive a warm and friendly welcome even when I have called at mealtimes”. The Inspector did not dine with the residents but observed lunch being served. There was a choice of main course and dessert. The tables were nicely set with napkins and condiments. Hot and cold drinks were available. Comments received from the resident questionnaires in answer to the question, Do you like the meals at the home? were: “The food and choice are excellent, always fresh and well cooked”. “No complaints at all” “The meals are always good. There is a choice” “Breakfast time is very flexible”. “Tea and biscuits are served regularly. No complaints at all”. The residents spoken to made the following comments: “ The food is good,” “ “Its all very nice”. One of the residents was talking to the Inspector at the dining table when a member of staff approached the table to ask the resident which cold drink she would prefer. This member of staff was extremely courteous and patient and did not interrupt the resident while she was talking. The residents have the main meal at lunchtime and a lighter meal in the evening. They are actually asked on the day what they would like for their meal. Fresh fruit was available in the lounge area. The Inspector was told that the staff make a point of offering fresh fruit at teatime. Members of staff told the Inspector that the kitchen and food stocks are available at all times and that residents are always offered a supper of milky drinks and snacks such as toast, tea cakes and sandwiches. Starmount Villa Residential Care Home DS0000008408.V298017.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 and a relative showed that there was a general awareness of how to make a complaint. The complaints procedure was displayed and it is also included in the Service User Guide. It was easy to understand and gave an assurance that complaints would be responded to within 28 days. In answer to the comment card question, “Do you know how to make a complaint?” 7 residents stated always and 3 stated usually. 1 resident stated, “There is no reason to make a complaint”. No complaints have been made to the home or to the CSCI within the last 12 months. 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.V298017.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 20 21 24 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in suitably adapted, clean, comfortable and very pleasant surroundings. EVIDENCE: The inspector walked around the home. There are 3 lounge areas and a separate dining room downstairs. These were clean, warm, nicely decorated and well furnished. There were enough toilets and bathrooms to meet the needs of the residents. Toilets were in close proximity to bedrooms and communal areas. In addition 12 of the bedrooms had an en-suite toilet. Each toilet and bathroom had a lock on the door to ensure privacy and the facilities were clearly marked. The toilets were clean and were suitably adapted for disabled use. The bedrooms were bright, well decorated and very personalised. Each bedroom door had yale type lock in place that allowed privacy for the resident but could be opened by staff in an emergency situation. Residents also had a fixed lockable space in their room. Starmount Villa Residential Care Home DS0000008408.V298017.R01.S.doc Version 5.2 Page 16 The heating within the home was adequate. All the rooms were centrally heated with most of the radiators suitably protected. It was identified during the inspection that the radiators in a downstairs bathroom and a toilet opposite room 11 were not guarded. The registered provider informed the Inspector by letter 3 days later that these had now been fitted with guards. There were some unguarded radiators on the corridor and a lounge area. The registered provider told the Inspector that he intended to undertake a risk assessment in relation to these and if a risk was identified, then appropriate action would be taken. Thermostatic control valves were in place on immersion baths and showers. The home was clean and free from odours. Hand washing facilities were in place in bathrooms and toilets but not in bedrooms where personal care was being provided. To reduce the risk of cross infection staff hand washing facilities must be provided wherever personal care is provided. The laundry was clean, adequate equipment was in place and protective clothing was available for the staff. Starmount Villa Residential Care Home DS0000008408.V298017.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 Quality in this outcome area is excellent. This judgment has been made using available evidence including a visit to the service. The residents’ needs were being met and they were being cared for by caring and conscientious staff that were safely 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 and residents identified that there was sufficient staff on duty over a 24-hour period to meet the needs of the 26 residents. Between the hours of 8am to 6pm there are 5 care assistants on duty and between 6pm to 8pm there are 4. Two care staff cover the night duties between the hours of 8pm –8am. In addition, the manager/owner works at the home 6 days per week and is supported by her husband who is responsible for the administration within the home. In answer to the question asked on the relative comment card: In your opinion are there always sufficient numbers of staff on duty? All 20 relatives stated that they felt that there was. 1 relative commented that despite her relative being hard work for the staff, the carers and the manager always have time for her and that she is always kept nice and clean. Other relative comments were: “The atmosphere is wonderful. The care and support the staff give are second to none”. Starmount Villa Residential Care Home DS0000008408.V298017.R01.S.doc Version 5.2 Page 18 “All the staff are friendly and courteous and always available to help any resident”. “The management and staff are friendly and approachable and give me reassurance”. Of the 21 care staff employed 11 have obtained their NVQ level 2 or above in care. This is 52 and therefore the home has met the Standard. The personnel files of 3 staff members were inspected. All were in order and these staff had been properly and safely employed. They had a completed application form, 2 professional references, an enhanced criminal record disclosure (CRB) check and a health status declaration A detailed induction-training programme was in place. This was in accordance with the Skills for Care Induction Standards. The Inspector was given a training matrix that shows what training has been undertaken by the staff, what is outstanding and when it has been scheduled. Training continues to be provided in the following: Fire. Moving and Handling. First Aid. Protection of Vulnerable Adults. Food Hygiene. Medication. Health and Safety. Dementia. Starmount Villa Residential Care Home DS0000008408.V298017.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 33 35 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The managers’ experience and qualifications should ensure that there continues to be effective leadership and guidance to the staff, thereby ensuring that the residents receive safe, consistent quality care. EVIDENCE: The manager has been the owner and registered manager at the home for over 5 and a half years and she has a recognised management qualification. There was evidence to show that she has undertaken periodic training to update her knowledge, skills and competence. The manager has recently undertaken training in Anti Discriminatory Practice. The staff spoken to said that they felt they all worked well as a team and that the owners/manager were very open and approachable. One resident said, “She knows her job, she is wonderful, they both are” (The owners) Starmount Villa Residential Care Home DS0000008408.V298017.R01.S.doc Version 5.2 Page 20 A quality assurance system was in place. The home has employed the services of a company who undertake an annual audit of the home and produce a report. In addition the home has developed questionnaires that they send out to residents and relatives asking what they think of the services the home provide. Regular residents meetings are held and the Inspector was given a copy of the notes taken at the meeting. It was clear that residents were consulted about the facilities and services within the home. The home has also achieved the Investors in People award. The home does not handle the residents’ personal money. If a resident needs anything the home pays and the resident or relative are invoiced. The home had a detailed 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. Regular checking and testing of fire detection system, fire exits and emergency lights was undertaken and documented. Any accidents that happen are properly recorded and monitored. The information taken from the pre inspection questionnaire showed that the equipment and services within the home were serviced on a regular basis in accordance with the individual requirements. In addition the Inspector checked the documentation in relation to the servicing of the small appliances in the home. This was up to date. Starmount Villa Residential Care Home DS0000008408.V298017.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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 2 10 3 11 x 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 3 3 x x 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Starmount Villa Residential Care Home DS0000008408.V298017.R01.S.doc Version 5.2 Page 22 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. Standard OP7 Regulation 12 (1) & 15 (1) Requirement When it has been identified that a resident is at risk of developing pressure sores, then a care plan for prevention of pressure sores must be put in place. Staff must also document in the care plan the type of pressure relieving equipment being used Staff must document the actual amount/number of tablets being given. Risk assessment must be in place for the unguarded radiators in the communal areas of the home. If a risk is identified, then appropriate action must be taken. Staff hand washing facilities must be provided in any resident areas where personal care is being delivered. Timescale for action 15/11/06 2. 3 OP9 OP25 13(2) 13(4) 15/11/06 31/12/06 34 OP26 13(3) 31/12/06 Starmount Villa Residential Care Home DS0000008408.V298017.R01.S.doc Version 5.2 Page 23 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 Refer to Standard OP7 OP9 Good Practice Recommendations The care plans need to be expanded so that all aspects of the residents care can be recorded is To ensure the accuracy of a transcription, handwritten transcriptions should be checked with another member of staff, signed and countersigned Starmount Villa Residential Care Home DS0000008408.V298017.R01.S.doc Version 5.2 Page 24 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V298017.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!