CARE HOME ADULTS 18-65
Station Villa Station Villa 18 Station Hill Hayle Cornwall TR27 4NG Lead Inspector
Stephen Baber Unannounced Inspection 25th October 2005 09: Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 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 Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 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 Adults 18-65. 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. Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Station Villa Address Station Villa 18 Station Hill Hayle Cornwall TR27 4NG 01543 414222 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) Swallowcourt Limited Christine Barbara McLean Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 4th April 2005 Brief Description of the Service: Station Villa is a large detached house situated in a residential area near to the railway station in Hayle and within walking distance of the town. Swallowcourt Ltd purchased the home in January 2005 and is now the registered providers with Mrs C.Maclean as the registered manager. There are currently five single bedrooms and four doubles. Some of the residents at Station Villa attend day care facilities and others attend other centres for weekday activities. Bathing and toilet facilities are on the first and second floor of the house. Swallowcourt are investing substantially in the home to provide residents with toilet and bathroom facilities, which offer privacy, and meets the assessed needs of the residents. In the last few months a significant financial investment has taken place to improve the furnishings and decoration of the home. The improvements look impressive and improve the comfort and well being of the residents. Four of the residents are well into their seventies and one is over eighty years of age and still attending a day centre. In discussion with he manager she explained the aim of the team was to promote independence and individuality. Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection as part of the home’s annual inspection programme on 24th October 2005. commencing at 9.00 am and lasting for eight hours. The inspection consisted of the following activities: 1. Inspection of records, including assessment information and care plans 2. Discussion with the registered manager of the home on how it operates on a day-to-day basis 3. Inspection of the building 4. Discussion with the staff on duty. 5. Individual and group interviews with the residents. 6. Observation of the daily life of the home. The inspector would like to thank everyone who was involved in this inspection, including the registered manager, staff and residents, for their kind assistance on the day. The inspector also talked with the managing director and the learning disability team manager on the day of the inspection. What the service does well:
The residents said how happy they are with the manager and her staff. Residents are provided with a comfortable, homely environment and appropriate support from the manager and her staff whilst respecting resident’s individuality. There has been one recent admission to the home. All the other residents have lived there for many years. They told me how much they enjoy the improved facilities provided for them by the new management team. Residents said they are given choice and supported by the manager and her team to achieve their individual goals. The manager and staff try to ensure that the residents live as normal a life as possible in the community and all of the residents said how much things have improved for them since the company have taken over as the registered providers. As evidenced from my discussion with the residents and from the detailed care plans every consideration is given to the residents to make decisions for themselves and be actively involved in the running of the home. The manager is very skilled at networking all relevant professionals with the aim of providing a first class quality service to the residents. Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better:
The registered manager has plans to provide residents with copies of key information in formats that they can access directly to help their understanding of the services and facilities that Station Villa will provide. Whilst there has been significant improvement in the area of staff training the home falls short of the 50 of care staff in the home that should achieve NVQ level 2 by April 2005. Planned work to improve policies and procedures to ensure that residents are safe and protected need to be followed in line with the corporate approach, which is desired by the company. Arrangements in respect of ensuring fire safety needed immediate improvement I.E the recommended fire risk assessment provided by the fire authority and the emergency lighting system. Whilst inspecting the home several areas of concern where brought to the attention of the managing director who arranged to put them right immediately. Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 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. Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,and5. Prospective residents and their relatives have suitable information regarding the service provided so they can make a decision about where they wish to live. The home has suitable assessment procedures and links with external professionals so residents needs and aspirations and preferences can be met. New contracts of residence have been compiled to enable the residents to know what facilities and services they can receive from the home. EVIDENCE: The home has produced relevant information to assist and help prospective residents and their relatives to make an informed choice about where they wish to live. The Statement of Purpose and Service User Guide although plain in its presentation is packed with information about the home. A copy of the complaints procedure is included in the Statement Of Purpose and a summary version is included in the Service User Guide. Information regarding advocacy services is displayed on the notice board in the dining room. Some residents have limited literacy skills, however, the manager will be reviewing the documents and will make available suitable formats to enable the residents to understand. Most of the residents have lived at the home since it was registered and only one admission has taken place. Appropriate admissions procedures were put into place and the residents were involved in the decision to admit the new person as well as the residents being involved in the appointment of staff. Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 10 The home has appropriate links with external professionals such as GP’s, district nurses and social services, physiotherapy and occupation therapy. Newly compiled contracts for all residents have been written up in plain English for people to understand. The residents told me that management and staff sit down to explain things when they don’t fully understand. Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10 Individual care plans contain relevant information so residents needs can be met fully. Staff encourages residents to make decisions about their lives enabling residents to gain in confidence and a feeling of self worth. Through the risk assessment process staff support residents so they are not placed at risk. A policy and procedure on confidentiality has been produced and all staff are trained from induction. The residents know that information about them is handled appropriately, and their confidences are kept. EVIDENCE: Each resident has a written care plan that is subject to regular reviews. As there were no care plans inherited management have had to start from scratch. They are all up and running with the residents and their representatives encouraged to contribute and sign care plans as evidence of their agreement with them. Care plans list individual goals for residents with the aim of ensuring that residents are encouraged to develop their skills and independence in a way that is safe and achievable. Residents are provided with detailed written day and night risk assessments as part of the care planning process, which are regularly reviewed and updated. The home’s Statement of Purpose contains information on confidentiality and a very comprehensive
Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 12 confidentiality policy has been recently written and forms part of the staff ongoing training. The home has regular residents’ meetings where the residents are involved in decisions regarding life in the home. The residents I spoke with said that the manager and staff encourage them to make decisions and support them to achieve what they want. Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. Residents are encouraged to develop their self-care skills and take part in a variety of activities in and out of the home and the activities are individual to enable the residents to lead a fulfilling lifestyle. Management and staff are judged by the house rules and daily routines, which respects individual privacy, individuality and dignity. EVIDENCE: The evidence from the residents care plans and daily records demonstrate how they are encouraged to develop their skills and independence with individual goals set for each resident. Opportunities both internally and externally exist for personal development and independence training for appropriate paid work, meaningful occupation and for integration into community life and leisure activities Residents are supported individually to go out in the local community. Family contact is encouraged and some of the residents spend time away from the home on family visits. The residents confirmed that they had suitable opportunities to participate in the local community and confirmed that they enjoyed a range of suitable leisure activities such as holidays, clubs and trips out. Residents said that there
Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 14 was a big improvement in the food they receive and that they are offered choice at all times. The residents are enjoying shopping and participation in the kitchen. Suitable records are kept of meals provided. Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21. The manager and staff provide appropriate personal and healthcare support, which deals with issues of ageing, illness and death. Policies, procedures and practices regarding medication are appropriate ensuring any risk to the residents is minimal. EVIDENCE: Several of the residents are well into their seventies and their physical and mental health is deteriorating. The resident’s records contain appropriate information outlining how resident’s physical and mental health care needs are met. There are also suitable records regarding appointments in the community with healthcare professionals. The residents told me that they felt they received appropriate support regarding their health care needs. The manager who has experience in other care sectors is very caring and outlined appropriate approaches to the care of one resident who was quite ill on the day of the inspection. Medication is well managed but all staff should refer to the index when medication has not been given. Some staff has received training in the safe handling of medication. This needs to be extended to all staff that handles
Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 16 medication on behalf of residents. There is a suitable policy regarding the storage and administration of medication. Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. The home has suitable complaints and adult protection policies available to ensure that the residents are free from harm. EVIDENCE: The home has appropriate complaints and adult protection procedures. A summary of the complaints procedure is incorporated in the Service User Guide. A copy of this is displayed on the notice board and copies have been given to residents and their relatives. The manager has produced a written policy for the protection of vulnerable adults from abuse. The policy and procedure is unique to Station Villa and does not represent the corporate approach. Staff are provided with guidance and training as part of their induction and ongoing training. Access to external, multi-agency training has been arranged and will be taking place soon. A review of the money held in safekeeping should take place and individual savings accounts should be put in place to accrue interest for the residents.. Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,29 and 30. Big improvements to the interior and exterior of the home have taken place to improve the services and facilities for the residents. The manager must draw up an action plan and make an assessment of the premises so that dependent residents can have the specialist equipment they require to maximise their independence. The home was clean and tidy throughout which makes for a cosy and comfortable home for the residents. EVIDENCE: There has have been a major financial investment by the company to improve the service s and facilities for all the residents that live at Station Villa. The following list whilst not exhaustive demonstrates their commitment to providing a high standard of accommodation. New carpets, new furniture, redecoration both internally and externally, new equipment bedrooms have been redecorated and refurnished. I discussed the dependency of several of the residents who are deteriorating both physically and mentally. The manager has carried out detailed assessments and invited other professionals to give their assessments of the individuals and the premises. It is recommended that an action plan is drawn up by the manager, which identifies those areas, and equipment that would be essential to make life easier for those residents. The
Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 19 home was clean and tidy throughout and staff are provided with protective equipment with regard to maintaining hygiene in the home. Training is also provided in infection control. Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33 and 34. Staffing ratios have been increased to meet the needs of the residents. Individual staff portfolios have been set up so that residents can feel assured that the staff have been appropriately vetted and recruited. EVIDENCE: Staff roles and responsibilities are clear but whilst they have access to a range of training courses there is little evidence that the training provided has led on to NVQ level 2 training. This means that the home falls short of the 50 requirement that staff in the home should achieve level 2 by April 2005. There was evidence to support fair, safe and effective recruitment and selection of staff in the home. I spent time discussing POVA first checks that must be carried out before the member of staff can commence employment. The manager has Internet Connection and a trial check took place on the day of the inspection. New systems will have to be set up to carry this out instead of sending the CRB form to head office. Staff are well supported and supervised by the manager. The residents said that they like the staff and they were nice to them. Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42. Further work is required to upgrade the arrangements in place to protect and promote the health, safety and welfare of residents. EVIDENCE: The manager maintains some records of the testing of equipment and servicing documentation. These should be further expanded to comply with her responsibility under health and safety checks and monitoring, e.g. testing of monthly emergency lighting. fire risk assessment, servicing of gas and the testing of all electrical equipment. Whilst the manager has compiled new policies and procedures, which were very informative, they need to evidence the corporate approach, which is the desired approach by the company. Contact with the fire authority regarding fire risk assessments and emergency lighting should be carried out forthwith. Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X 1 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 2 3 3 X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Station Villa Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000063182.V250748.R01.S.doc Version 5.0 Page 23 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 Standard YA24 Regulation 23(2)(n) Requirement An action must be drawn up to detail the environmental adaptations and disability equipment that must be provided to those residents whose dependency levels increase. An action plan must be drawn up to detail how 50 of the staff can achieve NVQ level 2 by the recommended time. Contact with the fire department regarding fire risk assessment plans, emergency lighting and compliance with Electricity At Work Regulations must be carried out. Timescale for action 30/04/06 2 YA32 18 30/04/06 3 YA42 23 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No.
Station Villa Refer to Good Practice Recommendations
DS0000063182.V250748.R01.S.doc Version 5.0 Page 24 1 1 Standard YA23 YA34 It is recommended that individual savings accounts should be opened and interest accrued for the residents POVA First checks should be carried out before staff can commence employment. Station Villa DS0000063182.V250748.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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