Inspection on 11/11/05 for Turret Villa Retirement Home

This inspection was carried out on 11th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Turret Villa Retirement Home 09/07/09

Turret Villa Retirement Home 10/05/07

Turret Villa Retirement Home 02/06/05

Turret Villa Retirement Home 26/10/04

Turret Villa Retirement Home 24/05/04

Similar services:

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

The Gardens Care Home

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

CARE HOMES FOR OLDER PEOPLE Turret Villa Retirement Home Etal Road Tweedmouth Berwick-upon-tweed Northumberland TD15 2EG Lead Inspector Anne Urwin Brown Announced Inspection 11th November 2005 09:00 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 Turret Villa Retirement Home DS0000000614.V249404.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. Turret Villa Retirement Home DS0000000614.V249404.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Turret Villa Retirement Home Address Etal Road Tweedmouth Berwick-upon-tweed Northumberland TD15 2EG 01289 330808 01289 330467 turret.villa@virgin.net 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) Mrs C R Kilmartin Mr D E Kilmartin Mr Michael Mordy Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Turret Villa Retirement Home DS0000000614.V249404.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd June 2005 Brief Description of the Service: Turret Villa is a large detached property set in its own grounds in Tweedmouth, Berwick upon Tweed. The home was previously a hotel and has been extended to accommodate up to thirty-five elderly people. The home is near to local shops and Berwick can be reached by car or bus in minutes. Bus services pass by the entrance to the home and the main line train station is in Berwick a few minutes away. Turret Villa has bedroom accommodation on the ground and first floor, but there is no lift fitted. All rooms are well appointed with en-suite accommodation. Turret Villa Retirement Home DS0000000614.V249404.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection involved talking to the manager, eleven residents and six staff, a tour of the building and inspection of records. Questionnaires were available for residents and relatives prior to the inspection and there was about a fifty per cent take up of these. The questionnaires showed that residents and relatives were very satisfied with the quality of the service provided. What the service does well: 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 Turret Villa Retirement Home DS0000000614.V249404.R01.S.doc Version 5.0 Page 6 contacting your local CSCI office. Turret Villa Retirement Home DS0000000614.V249404.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 Turret Villa Retirement Home DS0000000614.V249404.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): 4, 5 Residents and their representatives know that the home they enter will meet their needs. Prospective residents, their relatives and friends have an opportunity to visit the home and assess the quality, facilities and suitability of the home. Individual arrangements are made to suit each person and these vary from a short visit to a short stay to ensure that the prospective resident is able to make an informed choice. EVIDENCE: Records show that residents’ needs are identified and appropriate arrangements put in place to meet them. Residents said that specialist services are provided to suit their individual needs and this was confirmed in individual records. They also said that staff knew about their needs when they came to live in the home. Evidence was available to confirm that staff have the skills and experience to provide appropriate care to the residents living at Turret Villa. The manager described how arrangements for visiting the home before admission are flexible to suit individuals. Prospective residents and their relatives or representatives can visit the home at any time and can make Turret Villa Retirement Home DS0000000614.V249404.R01.S.doc Version 5.0 Page 9 additional visits. Some people have stayed for a weekend or a week or more before making up their mind. Residents confirmed that they were encouraged to visit and told that they could stay for a short time before making up their mind. They said staff were very understanding that it was a big decision and were supportive if they wanted more time to make up their mind. Turret Villa Retirement Home DS0000000614.V249404.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): 7, 10 Residents’ health, personal and social care needs are set out in an individual plan of care. Residents confirmed that they are treated with respect and that their right to privacy is upheld. EVIDENCE: The care planning system has been reviewed since the last inspection and all staff are involved in providing information for residents’ plans. Each resident’s plan has been reviewed and the new format introduced. Each person’s needs, goals and information about how the goals and needs are met are available in a simple format. This is a significant improvement on the last care plans, which did not contain so much detail. The manager confirmed that residents are involved in preparing care plans as they supply a lot of the information available. Written guidance is in place relating to privacy and dignity. None of the residents shares a room. The need to respect privacy and dignity of residents is part of the staff induction training. During the inspection staff treated residents with respect and they showed a good understanding of the need to respect individuals’ privacy. Residents confirmed that the staff treat them respectfully and do respect their privacy. Evidence was available from records Turret Villa Retirement Home DS0000000614.V249404.R01.S.doc Version 5.0 Page 11 and discussion with staff that they had dealt sensitively with an issue involving the behaviour of a resident. Appropriate support was sought from the mental health team, including the day hospital, psychologist and Community Psychiatric Nurse. One resident said that staff are sensitive and have time to spend with us. She said that staff have good memories and always remember what your preferences are. Turret Villa Retirement Home DS0000000614.V249404.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): 14, 15 Residents are helped to exercise choice and control over their lives. The food served is wholesome, appealing and provides a balanced diet. Mealtimes can be arranged to suit individual choice and residents can choose where they have their meals. EVIDENCE: One resident said that there was a lot of freedom to make choices. Others said they could make choices about their daily routines and activities. The manager confirmed that it is the home’s policy to encourage residents to manage their own finances for as long as they are able. Residents confirmed that they were able to bring in personal possessions from their previous homes. Bedrooms show evidence of this. Residents confirmed that they could access their personal records if they wanted to, but almost all of them said they did not want to. The manager confirmed that residents can be assisted to access an advocate who will act in their best interests. Records of the food provided are kept and were available for inspection. These showed a good variety of food is provided. Residents said that they were very satisfied with the quality of food provided. They said that they were able to request alternatives if they did not like the food served. One resident said that staff remember what you like and dislike and she did not have to keep reminding them. The dining room is well furnished and most residents take Turret Villa Retirement Home DS0000000614.V249404.R01.S.doc Version 5.0 Page 13 their lunch and evening meal there. Most residents have chosen to have breakfast served in their rooms. Special diets are provided. Records confirmed that Food Hygiene training is regularly updated and that staff involved in the preparation and servicing of food hold an up to date certificate. Turret Villa Retirement Home DS0000000614.V249404.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): 16 Residents, their relatives and friends are satisfied that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: Written guidance is in place for dealing with complaints. Two complaints have been made since the last inspection and these have been satisfactorily resolved. Staff were aware of how to assist a resident to make a complaint. Residents said that they felt able to raise issues or make a complaint to any member of staff. One resident said she was impressed by the way the manager always had time to speak with her and with other residents, he never said he was too busy. She said he always makes time for us. Turret Villa Retirement Home DS0000000614.V249404.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): 20, 21, 22, 23, 24, 25 Residents have access to safe and comfortable indoor and outdoor communal facilities. Each bedroom has its own en-suite facilities of a toilet and wash hand basin. There are an appropriate number of bathrooms that are appropriately equipped. Residents have the specialist equipment they require to maximise their independence. Residents’ rooms suit their needs. Each person has his or her own bedroom that is well furnished and safe. Residents have their own personal possessions around them. Resident live in safe and comfortable surroundings. EVIDENCE: The home is well furnished and decorated throughout. There are three sitting areas not including the entrance hall. These areas are comfortably furnished and well decorated. The dining room is spacious and well furnished. The gardens are accessible and residents said they regularly go out for a walk round the garden. Seating is available in the garden. Some trees need to have some branches removed and one will be felled. Appropriate plans are in place to cordon these off while work is in progress. Residents said they are very happy with the facilities provided at the home. Turret Villa Retirement Home DS0000000614.V249404.R01.S.doc Version 5.0 Page 16 Each bedroom has an en-suite toilet and wash hand basin. Toilets are accessible and appropriate aids are available to meet individual residents’ needs. From individual records it was possible to confirm that appropriate assessments are undertaken to identify the need for specialist equipment. The home provides hoists, grab rails and other aids suited to residents’ needs. Bathrooms and toilets are fitted with appropriate aids. There is a call system point in each room. Each resident has their own room and rooms are above the minimum size. Residents’ rooms are comfortably furnished and well equipped. Residents are encouraged to bring in personal possessions and rooms showed evidence of this. Residents are given a key to their rooms unless their risk assessment suggests this would not be safe. Lockable storage is available in each room. Each resident’s room has a window that can be opened. Central heating is fitted throughout the home and the temperature of radiators can be adjusted. Radiator guards are fitted. Lighting is appropriate throughout the building and emergency lighting is provided. Arrangements for water storage are satisfactory and appropriate checks are carried out. Thermostatic controls are fitted on all hot water outlets. An independent health and safety audit is carried out annually and records confirm that all areas meet current requirements. The local health and safety officer visited shortly before this inspection and provided a satisfactory report after his inspection. Turret Villa Retirement Home DS0000000614.V249404.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): 27, 28, 29 Residents’ needs are met by an appropriate number of staff who are experienced and trained in caring for elderly people. Residents are in safe hands at all times. Residents are supported and protected by the home’s recruitment policies and practice. EVIDENCE: The staff rota showed that appropriate numbers of staff are available during the day and night. At least three staff are on duty each shift. There is a senior member of staff on duty at all times. Staff said that there were enough staff to cover the rota. Existing staff work extra hours to cover sickness and annual leave. Two waking care staff are on duty at night. Residents said that they felt there were sufficient staff to meet their needs and that staff always made time to spend with them. No staff under twenty-one years are employed. Sufficient domestic staff are employed. A programme of staff training in care is in place. Sixty-five per cent of the staff have completed qualifications in care. Three staff will start a training course in care in the New Year. No agency staff are employed in the home. Written guidance is in place for the recruitment of staff. Inspection of staff files confirmed that two written references and appropriate checks are carried out before a new member of staff starts work. Staff receive a statement of terms and conditions of employment. Staff have access to the code of conduct and practice set by the General Social Care Council. Turret Villa Retirement Home DS0000000614.V249404.R01.S.doc Version 5.0 Page 18 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, 32, 35, 36, 38 The residents live in a home that is run and managed by a person who is fit to be in charge, of good character and is able to discharge his responsibilities fully. Residents benefit from the management approach that creates an open, positive and inclusive atmosphere. Residents’ financial interests are safeguarded. Staff are not all receiving supervision at appropriate intervals, although they confirmed that the management team provides a good level of informal support. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The manager is a qualified nurse with a lot of experience of caring for older people. He is currently completed the Registered Manager Award. Records show that he undertakes appropriate updating training. A written job description is in place for the manager. There are clear lines of accountability within the home and the manager meets regularly with the owner. Turret Villa Retirement Home DS0000000614.V249404.R01.S.doc Version 5.0 Page 19 Staff confirmed that there is clear direction and leadership in the home. They said that they felt able to raise issues or put forward their views about the service. Staff said there are regular meetings and an open agenda. Residents said that they feel satisfied that the manager always makes time for them and “never appears to be too busy to listen to us”. Written guidance is in place for dealing with residents’ money. Records are kept of any money held on behalf of residents. Receipts are kept for any transactions. Samples of the money held for residents were checked and these corresponded with the money held. Each resident has lockable storage in his/her room to keep valuables or money safe. All new staff receive appropriate induction training and records confirm this. Some staff have not received regular supervision and the manager said that this matter is being given priority. Staff said they feel well supported by the senior staff group who provide a good level of informal supervision. Staff have regular training in moving and handling, first aid, fire safety, food hygiene and infection control and records confirm this. Written guidance is in place for Health and Safety and Infection Control. Control of Substances Hazardous to Health is also the subject of written policies and procedures. A health and safety audit is carried out annually by an external organisation and a positive report was available for inspection. The local council’s Health and Safety Officer visited the home shortly before this inspection and was very satisfied with arrangements in place. The home’s management is to be commended for the attention given to maintaining a safe environment. Fire records are kept in an appropriate form. Records relating to fire alarm and equipment tests and servicing were in good order. The staff receive fire training at regular intervals. Turret Villa Retirement Home DS0000000614.V249404.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X 4 4 3 3 4 3 X STAFFING Standard No Score 27 3 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 2 X 3 Turret Villa Retirement Home DS0000000614.V249404.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP36 Regulation 18 Requirement Arrangements must be in place for the provision of regular staff supervision. Timescale for action 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Turret Villa Retirement Home DS0000000614.V249404.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Turret Villa Retirement Home DS0000000614.V249404.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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