CARE HOMES FOR OLDER PEOPLE
The Village Care Home Hylton Bank South Hylton Sunderland SR4 0LL Lead Inspector
Mr Clifford Renwick Unannounced Inspection 10:00 25 May, 1 June & 28th July 2005
th 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.V254499.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.V254499.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.V254499.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. 24.11.04 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.V254499.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 13 hours and over a three-day period in order to monitor works identified on the first day that required action. The first day of the inspection focused upon on all areas of the building and all areas with the exception of two bedrooms were viewed. 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 log boo and the accident book. The judgements made are based on the evidence available to the inspector over the three days of the inspection. What the service does well: What has improved since the last inspection?
The Statement of Purpose and service user guide is now completed and available to all prospective residents in order to offer them information about the service provided in the home. Social activities both in and outside of the home have increased and residents stated that they had enjoyed the outings to Beamish museum and also to see the musical show. Catering services and how the meals are served have continued to be improved and the home offers a good service in this area. Risk assessments have continued to be developed and fire evacuation procedures, which also take into account resident’s bedrooms, are much
The Village Care Home DS0000015760.V254499.R01.S.doc Version 5.0 Page 6 improved. This has resulted in staff having a clearer understanding of what to do in the event of a fire or the alarm sounding. The manager has also continued to develop quality assurance systems. Decoration has taken place in the large dining room and conservatory and new carpets have been provided and several bedrooms have been decorated. Lighting has been improved in resident’s bedrooms by fitting new shades and stronger light bulbs. 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.V254499.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.V254499.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): A range of information is available which enables residents to make a fully informed choice about where they would like to live. Each resident is issued with a copy of their terms and conditions of residence and this informs them of the services to be to be provided in the home. The admissions process ensures that resident’s needs are assessed prior to care being offered. This helps to ensure that residents are offered the right type of care at the home. EVIDENCE: Discussion with the manager confirmed that all prospective residents are issued with a copy of the Statement of Purpose and a copy is also to be made available in each residents bedroom once the manager has included additional information about the menus provided in the home. Three residents were awaiting their relative to sign the contracts on their behalf and as they live out of the area this meant that there had been a delay in obtaining their signature agreeing to the terms and conditions. Examination of case files confirmed that an assessment of needs is carried out before a decision is made to admit a resident into the home. This ensures that appropriate information has been collated to assist in the development of the care plan. It was positive to note that assessments included how a resident
The Village Care Home DS0000015760.V254499.R01.S.doc Version 5.0 Page 9 preferred to be addressed and also to see that risk assessments were being developed as part of the ongoing developments in the home. The Village Care Home DS0000015760.V254499.R01.S.doc Version 5.0 Page 10 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): Residents care plans are in place, but do not fully reflect their observed needs. This can limit the guidance available to staff regarding care practice and consistency. The homes procedures for storing and administering medication are sufficiently robust to safeguard residents. Residents right to privacy is respected, and their right to be treated with respect was fully promoted, which supports their general well being. EVIDENCE: Care plans are in place and have been developed since the last inspection and now incorporate risk assessments. They are more understandable in their new format. In discussion with the manager it was confirmed that care plans would continue to be developed, as they are still not specific in how staff are to meet individual needs. One incident, which was observed and related to a resident who as a result of dementia attempts to climb out of the ground floor window, needs to be addressed in the care plan as well as by use of a risk assessment. The manager was aware of the issues around this incident and was able to offer a description of how staff deals with this. Observations made confirmed that staff administers medication appropriately and satisfactory records of administration are also maintained.
The Village Care Home DS0000015760.V254499.R01.S.doc Version 5.0 Page 11 Discussion held with residents confirmed that staff are always respectful towards them and always knock on their door before entering the room. They confirmed that staff speaks to them by their chosen form of address and this is also recorded in the residents assessment document. Observations made confirmed that staff had a nice manner with residents and also their families and this made for a pleasant atmosphere throughout both visits The Village Care Home DS0000015760.V254499.R01.S.doc Version 5.0 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): Residents are offered the opportunity of participating in a range of leisure and social activities enabling them to lead active and fulfilled lives. Residents are offered and receive a varied, wholesome, nutritious and well-presented menu. This can contribute to their general health and wellbeing. EVIDENCE: The hairdresser was in the home on the day of the inspection and this was a big event for the residents as the hairdresser who is from Thailand also carried out head and neck massages as part of the service. Residents also confirmed that they can and do visit their own hairdresser. Discussions held with residents confirmed that activities had increased since the last inspection and five of them had recently been line dancing to the local club and this was to be a regular weekly event. The manager has increased the hours allocated to activities in order to try and recruit someone for this post, which in the past has proven to be very difficult. Staff are carrying out the current level of activities with residents. One carer has been on a course relating to activities and there may be a chance for this person to take on board the role of activities coordinator. A keep fit course has started and will run for 12 weeks and is carried out by an external trainer. The course was described as being chair exercises for mature people and will involve 15 – 25 residents.
The Village Care Home DS0000015760.V254499.R01.S.doc Version 5.0 Page 13 A structured daily timetable of activities is on display and this was under revision as some activities were not popular. Discussion held with the manager confirmed that discussion had been held with residents and as a result they were going to develop more tactile activities which will involve colouring books and bubble making. A trip to the customs house has been arranged to see a musical show entitled “memory lane” and 6 service users had been on a trip to Beamish open air museum. Lunch was taken with service users and this was a pleasant experience. As is usual food was nicely presented, of good quality and quantity and piping hot. Tables were nicely set out and hot and cold drinks were available throughout the meal. Where residents required support to eat their meal this was provided by staff in a relaxed and unhurried manner. The Village Care Home DS0000015760.V254499.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home has a satisfactory complaints system. Complaints are handled appropriately and the outcomes used to improve the service. EVIDENCE: Complaints sheets are in use and these are used to record any complaints that are made or any concerns that are expressed. A record is then maintained of the actions taken and also the outcome and whether people are satisfied with the outcome. Discussions held with residents confirmed that they had no complaints and if they did they stated that staff would deal with them satisfactorily. The Village Care Home DS0000015760.V254499.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home is generally clean and warm offering residents a homely environment in which to live. However, there were a number of maintenance issues, which need to be addressed, which could compromise the health and safety of the residents. Resident’s bedrooms, communal areas and bathing/WC facilities are accessible to meet service users’ mobility needs though a number of these rooms are in need of refurbishment. EVIDENCE: All rooms with the exception of 2 bedrooms were viewed and this confirmed that a number of issues relating to decoration, lighting, bathing facilities, laundry equipment and the condition of bedroom furniture needed to be addressed by the owner and manager. The laundry room has had a new floor laid but the room requires decorating. There are commercial drying facilities but insufficient washing facilities for a home of this size with one commercial washing machine being out of order and apparently beyond repair. There is a domestic washing machine that staff can use but this is ineffective for the amount of laundry that is dealt with in the home.
The Village Care Home DS0000015760.V254499.R01.S.doc Version 5.0 Page 16 A shower cubicle in one bathroom was described, as being beyond repair and this is not appropriate, as all bathing facilities must be kept in good working order. A detailed list of the matters relating to the premises, which includes the shower facilities and also the laundry equipment, has been issued to the owner and the manager. As part of the inspection a monitoring visit was carried out in July and this confirmed that works are being addressed in a number of these areas. The conservatory has been decorated and the manager confirmed that specialist cleaning of the windows is to be carried out. The large ground floor dining room has been decorated and new carpets have been fitted in corridors. The front entrance to the home has been decorated and also several bedrooms. The Village Care Home DS0000015760.V254499.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The deployment and number of staff on all shifts ensures that at all times service users are supported by an experienced group of staff. Although this is only possible due to staff picking up extra shifts and also with the manager and deputy manager working as part of the care team. Staff recruitment practice does not protect service users and record keeping in respect of new staff employed in the home, is not robust and does not offer sufficient information to ensure that service users are protected. A well-trained staff team meets the resident’s needs. EVIDENCE: Examination of rotas confirmed that the home is providing adequate staffing levels. However due to staff sickness, annual leave and people working their notice the manager and deputy manager are working care shifts in order to maintain safe staffing levels. The rotas do not always show the designated role of staff so at times it can be confusing to establish who is doing what. There are currently 4 care vacancies and these hours are being covered by existing staff picking up extra shifts as well as some of the catering staff doing care shifts. Though this is maintaining staffing standards at the moment it cannot be maintained over a longer term and the manager and owner need to be more proactive in looking at a long-term solution to the staffing issues. Discussion with the manager confirmed that all vacancies are being advertised and the owner is also exploring the possibility of recruiting staff from overseas. Recruitment records for one person who has commenced work in the home were not satisfactory as there was a gap in employment which had not been fully explored and a current criminal record bureau check was not carried out.
The Village Care Home DS0000015760.V254499.R01.S.doc Version 5.0 Page 18 With the manager relying upon information from a criminal record bureau check carried out by a previous employer. All staff have an individual training plan which sets out what training they have undertaken and 9 staff have recently completed a 12 week training course on dementia which has provided them with an understanding of this illness so that they can adequately meet the needs of all of the residents living in the home. The training plan does not show future training planned for the staff team. The Village Care Home DS0000015760.V254499.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The manager offers clear leadership and direction to the staff so that they can consistently meet the needs of residents. The manager seeks views of the residents in order that they can contribute to the development of the service. The resident’s health and safety is promoted by a well managed home. However, there are some areas of potential risk to resident’s safety that need to be addressed. EVIDENCE: The manager plays an active role in the home and as a result of staff shortages continues to work along side staff in order to ensure that residents are offered a consistent service. Though this is commendable it has had an impact on the manager having insufficient time to develop records systems such as care plans. The manager is aware of this and has attempted to develop a number of the records systems in the home. A quality assurance policy and procedure has been implemented and this requires some further development in order to demonstrate which aspects of the service is to be quality assured.
The Village Care Home DS0000015760.V254499.R01.S.doc Version 5.0 Page 20 The manager has also developed a questionnaire for use by residents and their relatives in order to seek their views on the service. A health and safety audit checklist has been developed and this now needs to be implemented. Hot water temperatures are checked weekly and charts are kept in order to ensure that hot water is provided at a safe temperature. Accident records are satisfactorily maintained and give a good description of the actions taken and also the outcome. Records of fire drills and fire instruction with staff are kept in accordance with the guidance in the fire logbook and a member of staff has been delegated to deal with staff fire training and the regular tests of equipment. Following discussion with the manager and the issue of an immediate requirement sheet the fire evacuation procedure for the home was revised to include the actions to take in the event of a fire. The manager confirmed that a fire risk assessment has also been carried out for each bedroom and identifies any risk areas that staff need to be aware of as part of the general health and safety procedures within the home. The Village Care Home DS0000015760.V254499.R01.S.doc Version 5.0 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 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X X X 3 X 3 X STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 3 The Village Care Home DS0000015760.V254499.R01.S.doc Version 5.0 Page 22 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 OP7 Regulation 15 Requirement Residents care plans must continue to be developed as discussed during the inspection.These must also include risk assessments in order to ensure that staff are consistent in their actions. Outstanding since 24/11/04. All matters relating to the premises and as detailed within the letter must be addressed. Rotas which show the designated role of staff must be available at all times. The manager must ensure that staff do not commence work in the home until all documentation as required by regulation has been obtained. Outstanding since 24/11/04. An annual staff training plan must be developed. Timescale for action 31/12/05 2 3 4 OP19 OP27 OP29 23 18(1)(a) 7,9, 19 Schedule 2 30/09/05 28/07/05 28/07/05 5 OP30 18c(1) 31/12/05 The Village Care Home DS0000015760.V254499.R01.S.doc Version 5.0 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. Refer to Standard Good Practice Recommendations The Village Care Home DS0000015760.V254499.R01.S.doc Version 5.0 Page 24 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.V254499.R01.S.doc Version 5.0 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!
