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Inspection on 02/06/05 for Turret Villa Retirement Home

Also see our care home review for Turret Villa Retirement Home for more information

This inspection was carried out on 2nd June 2005.

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

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

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

What the care home does well

What has improved since the last inspection?

The Statement of Purpose has been reviewed and updated. The Manager makes regular checks of money held on behalf of residents. The Manager has almost completed work on the Registered Manager`s award.

What the care home could do better:

There needs to be a system for checking that records are updated when residents` needs change. This will ensure that all staff are made aware of changes to residents` needs. It also provides a basis for future assessments and information for reviewing care needs. A formal system should be introduced to seek residents` views on the service and to prepare an annual report on the findings.

CARE HOMES FOR OLDER PEOPLE Turret Villa Retirement Home Etal Road Tweedmouth Berwick Upon Tweed TD15 2EG Lead Inspector Anne Urwin Brown Unannounced 02 June 2005 14:00 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 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 B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 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 Mrs C R Kilmartin Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Michael Mordy CRH 35 Category(ies) of OP Old age (35) registration, with number of places Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are no conditions of registration. Date of last inspection Brief Description of the Service: Turret Villa is a detached property set in its own spacious 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 upon Tweed is only minutes by car or bus. Local bus services pass by the entrance to the Home and the train station at Berwick is easily accessible. Turret Villa has accommodation on the ground and first floor, but those living on the first floor must be able to use the stairs as there is no lift fitted. All rooms are well appointed with en-suite accommodation. Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out over half a day. It involved discussion with the Manager, four residents and four staff, inspection of records and a tour of the building. What the service does well: What has improved since the last inspection? Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 Page 6 The Statement of Purpose has been reviewed and updated. The Manager makes regular checks of money held on behalf of residents. The Manager has almost completed work on the Registered Manager’s award. 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. Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 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 standard(s) 1, 3, 6 Prospective residents have sufficient information to make an informed choice about where they live. Each resident has a full assessment carried out to ensure that the service will be able to meet his/her needs. The Home does not provide intermediate care. EVIDENCE: The Statement of Purpose has been rewritten since the last inspection and it provides detailed information about the service provided. Residents said that they had enough information about the service prior to coming to live at the Home. The Manager described an appropriate assessment process that is carried out by staff prior to a resident being admitted. Records showed that there is a detailed assessment of need. Residents confirmed that at the time of the admission staff were clear about their needs and wishes. Copies of Care Management assessments were also available in residents files for those people referred by the local authority. The Home does not provide intermediate care. Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 Page 9 Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 11 Care plans providing details of each resident’s health, personal and social care needs are in place. Staff promote and maintain residents’ health and ensure access to health care services to meet assessed needs. Policies and procedures are in place for dealing with medicines. Staff are aware of the need to treat residents with care, sensitivity and respect when they are dying. EVIDENCE: Three residents’ records were inspected. These provided information about each person’s care needs, although one plan needed to be updated. One resident who had recently been admitted to the Home did not have a full care plan. This resident’s assessment had been carried out and staff were able to confirm that they were aware of this person’s care needs. This resident said she was satisfied with the quality of care provided and the high level of support she had received since she was admitted to the Home. Other residents also said how satisfied they are with the support provided by staff. Records showed that residents receive a lot of support from local health care staff with all visits recorded. Residents said that they were satisfied with the support offered to meet their health care needs. Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 Page 11 Written guidance is in place for administration of medication. Arrangements for storing medicines is satisfactory. Staff training has been provided for all staff who hand out medication. Staff are aware of the written guidance for administering medication. Records were checked and these were in good order. The local pharmacist provides advice about the administration of medicines. The Manager was able to describe the arrangements in place for caring for residents who are dying. He reported that there is a good level of support from the local doctors, district nurses and other services. Staff were able to give appropriate examples of support provided to residents. Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 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 standard(s) 12, 13 Residents are satisfied with the flexibility of their routines for daily living and activities, which are appropriate to meet their social, cultural, religious and recreational interests and needs. Arrangements for residents to maintain contact with family/friends/representatives and local community are suited to individual residents’ needs. EVIDENCE: The Manager described how residents are asked about their expectations and preferences when they are admitted. Residents confirmed this. Records showed that residents’ social, religious, cultural and recreational interests and needs are identified. Residents said that staff supported them to make choices about their daily routines, meals and mealtimes, leisure and social activities. One residents said she had been very satisfied with the way in which staff supported her to make choices about her lifestyle. Staff were able to give examples of particular arrangements in place to support individuals, which took into account their particular needs and preferences. Visitors are able to visit at any reasonable time and evidence was available from the visitors book and from talking to residents that this is happening. The Manager described how transport is provided to help residents to keep in touch with relatives in other residential/nursing homes or living in the Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 Page 13 community. Written information is available for visitors. The Manager said that visitors are able to have meals with the resident if they wish. Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 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 standard(s) Residents are satisfied that their complaints will be taken seriously and acted upon. Residents feel safe and protected from abuse. EVIDENCE: Written guidance is available and each resident is given a copy of this. Staff confirmed that they are aware of the complaints procedure and could describe how they would help a resident to make a complaint. Residents confirmed that they felt satisfied that any concerns or complaints raised with the Manager or staff would be dealt with appropriately. They said they felt comfortable about speaking of any concerns to staff and the Manager. Records of complaints are kept and no complaints have been made since the last inspection. Three staff have recently completed abuse training. Written guidance is in place in the Home on the steps to be taken in the event of an allegation of abuse being made. A copy of Northumberland Social Services’ guidance is also available. Staff described what they would do in the event of a resident making an allegation of abuse. Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 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 standard(s) Residents live in a comfortable, safe and well-maintained Home. The Home is clean, tidy and hygienic. EVIDENCE: The Home is in a quiet residential area convenient for local shops and within a few minutes travelling distance of the centre of Berwick. The grounds are well kept and there is access at the front and rear of the building. A tour of the Home during the inspection confirmed the public areas are comfortably furnished, clean and well maintained. Evidence was available to confirm that a planned programme of maintenance and upgrading is in place. One room was being redecorated and re-carpeted before someone was admitted. Residents stated that they were very satisfied with their accommodation, particularly with having an en-suite toilet. They said that they felt the Home is very comfortable and well maintained. Turret Villa was clean, hygienic and free from offensive odours during the inspection. Written guidance is in place for Health and Safety and Infection Control. Following an Environmental Health Report in March the work Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 Page 16 identified has been done. Five staff have completed Infection Control training and two are about to start. A food hygiene assessment is completed every year by an external agency and a report is received. The laundry is well fitted and a new washing machine with a sluice facility has been installed since the last inspection. Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 30 Staffing is sufficient to meet the needs of the residents. Staff are trained and competent to do their jobs. EVIDENCE: Rotas showed that staffing is sufficient on each shift to meet the needs of the residents during the day. Two waking night staff are on duty during the night. There is always a senior member of staff on duty. The Manager stated that there is a very settled staff team who are experienced and skilled at meeting residents’ needs. Residents said that they are satisfied that there are sufficient staff to meet their needs and that staff have time to spend with them. They also said that staff were aware of their needs. Residents spoke highly of the Manager and his staff team giving examples of the good level of support that is offered. Records show that more than half of the staff group have completed recognised qualifications in care. The Manager said that regular training is provided in Moving and Handling, First Aid, Basic Food Hygiene and Protection of Vulnerable Adults. Records were available to confirm this. Staff said that they are encouraged to access training opportunities and that they receive regular updating training. Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 37, 38 Staff regularly ask residents about their views about the service, but there is not yet an effective quality monitoring system in place. Residents are protected by the accounting and financial procedures in the Home. The rights of individual residents are safeguarded by the Home’s record keeping, policies and procedures. Residents’ health, safety and welfare is promoted and protected. EVIDENCE: Staff were able to describe how they seek residents’ views about the service. Residents were able to give many examples about the particular arrangements in place to support their needs. There are regular residents’ meetings and minutes of meetings showed that residents feel able to put forward their views. There is no formal quality assurance system in place. Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 Page 19 Written guidance is in place for staff about holding money on residents’ behalf. Money is held for some residents. Samples of money were checked and found to balance with the records maintained. Copies of receipts are kept. Written guidance is in place that covers residents’ rights. Staff were able to confirm that they were aware of the need to safeguard residents’ rights and interests. Residents said that they were aware they could ask to see their records, but had not chosen to do so. All records apart from one care plan were up to date and in good order at the time of the inspection. Records show that the fire alarm and fire equipment is regularly tested and serviced. Three fire drills have been carried out since the last inspection. Staff said that they have regular fire training and records show that this is provided at appropriate intervals. Written guidance is available for Health and Safety. Staff confirmed that they were aware of this. First aid, fire, food hygiene, moving and handling training is regularly updated and records confirm this. Accident records are kept and evidence was available of regular monitoring. Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 4 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 3 x x 3 3 Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 Page 21 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 7 Regulation 15 Requirement Systems must be in place to ensure care plans are updated to reflect residents changing needs. A system must be introduced that regularly reviews the quality of care provided. Timescale for action 31.08.05 2. 33 24 30.09.05 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 Good Practice Recommendations Turret Villa Retirement Home B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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 B53-B03 S614 Turret Villa Retirement Home V225800 020605 Stage 4.doc Version 1.30 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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