CARE HOMES FOR OLDER PEOPLE
The Village Care Home Hylton Bank South Hylton Sunderland SR4 0LL Lead Inspector
Mr Clifford Renwick Announced Inspection 23rd November 2005 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 The Village Care Home DS0000015760.V251225.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 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. The Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service The Village Care Home Address Hylton Bank South Hylton Sunderland SR4 0LL 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) 0191 534 2676 0191 534 1427 The Village Care Home Limited Miss Tracey McCully Care Home 40 Category(ies) of Dementia (8), Mental disorder, excluding registration, with number learning disability or dementia (9), Old age, not of places falling within any other category (40), Physical disability over 65 years of age (6) The Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The service may from time to time admit persons between the ages of 60 and 65 years of age. 24th November 2004 Date of last inspection Brief Description of the Service: The Village Care Home provides personal care for 40 older people over the age of 65 years, some of who may have dementia or mental health needs. It does not provide nursing care and any health needs are dealt with by the Community Nursing Services.Registration includes 6 places for people with a physical disability and as such has designated rooms on the ground floor, which offer easy access to the outside grounds.The house is detached Victorian in construction and two storeys high, with bedrooms being on both ground and first floors. Each floor has a variety of lounge and dining areas. In addition to this there is a large conservatory area on the ground floor, which is also a designated smoking area.The upper floor has a sun terrace, which overlooks a patio area. The interior furnishings of the home are in keeping with the period of the house and due to its age many of the rooms are unique in design and layout.The home is sited on the main road into South Hylton Village, which is close to the metro station, enabling easy access to Sunderland city centre as well as Newcastle and Gateshead.There are some small shops in the village, which include a post office, chemist and general dealers, as well as a social club, all of which are in walking distance of the home.A local bus service can be accessed to the city centre and surrounding areas. The Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection took place over 7 hours. Prior to the inspection a questionnaire was sent to the manager in order to obtain updated information about the home. This was returned to the commission with copies of the staffing rotas and also the menus. In addition to this comment cards were made available to service users and their families so that they could offer a view on the services being provided. The inspection focused upon on most areas of the building, which included communal areas and residents bedrooms. A sample of resident’s records was inspected. The inspector was able to chat with some of the residents, to observe life in the home and share the lunchtime meal. Health and safety records were examined and this included the fire logbook and the accident book. Records that also related to staff training and recruitment were examined. The judgements made are based on the evidence available to the inspector on the day of the inspection. What the service does well:
A total of 13 questionnaires were returned from residents and their families and these said that they never had to make a complaint about the service. They also said that staff make you feel welcome when visiting the home. Families also commented that staff keep them informed about all aspects of the residents care in the home and if there are any significant changes. Observations made confirmed that there is a good rapport between staff and residents. In discussion with the family of one resident they said that they are very satisfied with the care. Residents also said that they too were satisfied with the care being provided. The Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 Page 6 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 Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 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 The Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 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): 3, 4 The admissions process ensures that prospective resident’s needs are assessed prior to being offered a place in the home. This helps to ensure that residents are offered the right type of care if they are admitted into the home. EVIDENCE: Comprehensive assessments are obtained from social services in respect of a prospective resident. In addition to this the homes staff also carry out their own assessment of individual needs. This also includes a social assessment in which staff obtain information from residents families. A moving and handling assessment is carried out in conjunction with all other assessments and the information is collated into a care plan. Of the two most recent admissions, the home had confirmed in writing to one of the residents that their needs could be met. The social assessment is a useful document and discussion was held with the manager as to how this could be developed further in order to assist staff with the care process. This would be of benefit for those residents who have dementia type illnesses.
The Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 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 measures staff take to support the health and personal care needs of residents are now being recorded in the individual plan of care. This ensures that staff are able to consistently meet residents assessed needs. EVIDENCE: Examination of 4 residents files confirmed that an individual plan of care is in place and these have been designed to meet individual assessed needs. Appropriate monitoring charts are also in use. The care plans are improving development and the manager confirmed that this would continue with all staff being involved. This will ensure that staff have a good understanding of the care plans and also help them to be consistent. Discussion was held with the manager about the use of certain terminology in the care plans and how this could have a negative impact if used. The manager was receptive to the advice that was offered. Good records are available which confirmed that residents are able to access all services provided by the NHS. A good relationship exists between the home and the local GP surgeries and also the community nurses who visit the home. A resident who took ill during the inspection and required the assistance of the paramedics was cared for in a positive manner by the staff. The staff responded quickly and professionally to the situation. And also ensured that a member of staff accompanied the resident to the hospital.
The Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 Page 10 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): 12, 13, 14 There are no restrictions on visiting the home, which ensures that residents are able to maintain contact with their relatives and friends. The residents are able to follow their daily lifestyles which satisfies their social and religious needs, however, there are limited opportunities for social activities and very little for the residents to do in the home. This restricts the resident’s ability to lead stimulating and fulfilling lifestyles. EVIDENCE: Good contact is maintained between residents and their relatives who are able to visit the home at any time. A policy on visiting the home is available and this outlines how there are no restrictions on visiting times. Families are able to take the residents out and this is supported by staff. An activities list is on display but discussion held with the manager and residents confirmed that this needs to be updated, as it does not accurately reflect what is happening currently. The manager is actively trying to recruit an activities coordinator. At present one of the homes administrators is allocated to carry out 2 hours of activities with the residents. There have been no recent outside activities due to the colder weather. Residents said that they are able to choose how they spend their day and follow their own routines. A number of residents prefer to spend part of the day in their room where they have their own televisions and other equipment. One resident has additional television channels and also a good supply of videos and only comes out of their room at mealtimes.
The Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 Page 11 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): 18 Robust policies and procedures are in place, which ensure that residents are protected from abuse. EVIDENCE: The home has a set of policies and procedures in place which are based on the local authority guidelines in offering protection to vulnerable adults. The manager has recently had cause to use the procedures and called a strategy meeting with social services. Staff are familiar with what constitutes abuse and are also aware of the need to make an alert if there are any concerns about abuse of residents. The Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 Page 12 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): 19, 26 The home is clean, warm and well maintained offering residents a homely and safe environment in which to live. Some refurbishment works have taken place but there are still some outstanding works from the last inspection that need to be addressed. EVIDENCE: All areas of the premises were viewed which included resident’s bedrooms and communal areas. A number of bedrooms have been decorated and items of furniture have been replaced. Some communal lounges have been decorated and this has brightened up these rooms making them a pleasant area to sit in. Appropriate equipment is now in place in the laundry room for the laundering of resident’s clothes. Work has been carried out to the lighting in the hallways to improve illumination but there still some wall lights on the ground floor corridor that are not working. The manager confirmed that this is being sorted out. The Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 Page 13 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, 30 The deployment and number of staff on all shifts ensures that at all times residents are supported by an experienced group of staff. Record keeping in respect of new staff employed in the home is robust and sufficient information is obtained to ensure that resident’s are protected. The staff team receive regular training appropriate to the work. This means that resident’s needs, can be effectively met. EVIDENCE: Copies of staffing rotas received prior to the inspection confirmed that staffing levels are sufficient to meet the needs of all residents. Discussion with the manager and examination of staffing files confirmed that staff do not commence work until all of the required checks have taken place. There is an annual training plan, which confirms what training is to be provided in 2006 for all staff. Eighteen staff members have achieved NVQ Level 2 and for those staff without this qualification training in NVQ Level 2 will commence in January 2006. Some staff are currently undergoing an 8 week distance learning course in health and safety. Once completed additional staff will also undergo the same level of training. Most staff completed the 12 week distance learning course on dementia care. Staff confirmed that they had found this course useful in their work. The manager stated that all newly employed staff would be undergoing this course in 2006. The Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 Page 14 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): 31, 35, 38 The manager ensures that all staff have guidance and support so that resident’s needs can be most effectively met. The arrangements for the handling of resident’s personal allowances ensures they are not at risk of being financially disadvantaged. The arrangements to ensure that the health, safety and welfare of resident’s and staff are in place and are effective. EVIDENCE: The manager and the deputy are undergoing NVQ Level 4 in care, which they have almost completed. The manager plays an active part in the home and on occasions has worked shifts alongside the staff covering for staff absences. The manager has developed a good staff team in all areas and this has resulted in a positive atmosphere in the home. Records which are used for resident’s personal allowances were examined and were satisfactory.
The Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 Page 15 A formal fire risk assessment is being developed for each bedroom and this is linked into a control measure sheet. This demonstrates the actions that staff must take in the event of a fire. The manager is continuing to develop these and on completion will be seeking additional advice from the fire officer. Good records are maintained of fire drills and fire instructions for staff. Though it is advisable to ensure that all dates of training are entered into the fire logbook as well as the book currently in use. Records are available that confirm new staff receive fire instruction training as part of their induction. Hot water temperatures are taken on a regular basis and recorded. This ensures that residents are not subjected to risks while bathing and that hot water is being provided at the recommended temperatures. As previously stated in this report a number of staff are undergoing health and safety training. Good records of accidents are kept which show not only the accident but also the action taken and the outcome. The Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 Page 16 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 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 3 The Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 Page 17 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 2 Standard OP7 OP12 Regulation 15 (1) 16 (2) (m) Requirement The care plans for each resident must continue to be developed as advised during the inspection. The manager must ensure that residents are consulted about their social interests and activities. A programme of activities must then be implemented. A maintenance plan showing how the outstanding decorative works to the premises are to be addressed. Must be submitted to the commission. A record must be kept in the fire logbook which confirms that new staff receives 2 periods of fire instruction training in the first month of employment. A date of all fire drills and fire instruction must be kept in the fire logbook. Timescale for action 30/04/06 31/01/06 3 OP19 23 (2) (b) (d) 31/12/05 4 OP38 23 (4) (e) 23/11/05 5 OP38 23 (4) (e) 23/11/05 The Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 Page 18 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 OP7 Good Practice Recommendations Consideration should be given to developing a written social profile of each resident as part of the care plan. The Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 The Village Care Home DS0000015760.V251225.R01.S.doc Version 5.0 Page 20 - 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!
