Inspection on 20/04/05 for Valerie`s Rest Home

This inspection was carried out on 20th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Valerie`s Rest Home 14/08/08

Valerie`s Rest Home 24/07/06

Valerie`s Rest Home 27/09/05

Valerie`s Rest Home 07/10/04

Similar services:

St Vincents

Hamilton House

The Cotswold Home

Newbeech House

Winton House

Little Haven Nursing & Residential Home

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

CARE HOMES FOR OLDER PEOPLE VALERIES REST HOME 20 Ravenswood Avenue, Crowthorne Berkshire RG11 6AY Lead Inspector Yvonne Souden Unannouced 20 April 2005@ 10:00 hrs 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. VALERIES REST HOME H52-H01 60562 Valeries Rest Home V211085 200405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Valeries Rest Home Address 20 Ravenswood Ave Crowthorne Berkshire RG11 6AY 01344 761701 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) SES Care Homes Limited Annette Chuter Care Home 17 Category(ies) of Older Person ( OP ) registration, with number of places VALERIES REST HOME H52-H01 60562 Valeries Rest Home V211085 200405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7th& 8th October 2004 Brief Description of the Service: Valeries Care Home is a large detached victorian house set within a private residential road in the village of Crowthorne and provides care and accommodation for up to seventeen people aged sixty-five or over. There are local shops nearby and public transport is available. The home has thirteen single bedrooms (five have an en-suite) and two double bedrooms. The rooms are arranged over two floors, and a passenger lift is available. The buiding is not suitable for service users who are wheelchair dependant due to some premises restriction. There is a large victorian conservatory that leads from the main dining area and is used as the main lounge. The conservatory/lounge looks out on to a landscaped back garden where seating is provided. VALERIES REST HOME H52-H01 60562 Valeries Rest Home V211085 200405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a Wednesday from 10:00 to 18:30 by one inspector. About 70 of the inspection was spent talking to service users individually and in groups, talking to staff, management and a visitor to the home and general observation of care practice; the rest of the time was spent assessing the environment, care plans and other records. 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 contacting your local CSCI office. VALERIES REST HOME H52-H01 60562 Valeries Rest Home V211085 200405 Stage 4.doc Version 1.30 Page 6 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 VALERIES REST HOME H52-H01 60562 Valeries Rest Home V211085 200405 Stage 4.doc Version 1.30 Page 7 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, & 5 The homes Statement of Purpose and Service Users Guide does not ensure service users and their representatives are fully informed. The home ensures the needs of the service user is fully assessed prior to their admission, and service users and their representatives have opportunity to assess whether the home can meet their needs prior to a permanent placement being agreed. EVIDENCE: The homes Statement of Purpose and Service Users Guide has been reviewed following requirements made at the previous inspection however, they do not detail their complaint procedure and the service users guide is typed in small text, is not brief and is not readily available to the service user; when asked service users were not aware of the provision of a service users guide. Staff, service users and a relative of service user spoke of service user health and social care assessments and visits to the home prior to admission, and documentation seen supports assessment undertaken by the by the registered manager and where applicable by the service users care manager. VALERIES REST HOME H52-H01 60562 Valeries Rest Home V211085 200405 Stage 4.doc Version 1.30 Page 8 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 & 9 The home has a dedicated staff team who are fully aware of the needs of the service user and associated risk however, individual service user risks are not documented and this could pose a risk in itself to the service user. Despite systems and training in place complacent monitoring increases the risk of mistakes being made in the administration of service users medication. EVIDENCE: Individual service user care plans are in place; the manager recognises that improvements could be made to improve the format and has registered to attend a care-planning course. Staff spoken to have an awareness of the needs of the service users and associated risk. Service users spoken to say, “staff are very good to us” and a relative of a service user said, “staff can always tell you how she is and what she needs”. There was no individual service user risk assessment in place. Medication is administered from a monitored dosage system and PRN, controlled drugs and liquid medication are packaged separately as dispensed by the pharmacist. A controlled drug record did not match stock in place and there was no audit trail for PRN medication. Nine staff has attended a structured medication course and those who have not, have received in-house training. The home has a medication policy but does not have a copy of the Royal Pharmaceutical Society care home medication guidelines. VALERIES REST HOME H52-H01 60562 Valeries Rest Home V211085 200405 Stage 4.doc Version 1.30 Page 9 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 & 15 A nutritionally balanced and attractively presented menu offers no alternative choice; this does not consider the preferences and individuality of the service user. There is a general contentment of lifestyle amongst the service users, however information on local community events, and a programme of activities within the home is not available to promote service user participation. EVIDENCE: Service users said, “we play bingo and quiz games, and staff call out the numbers, some of us go to the daycentre on the Tuesday afternoon, and we have the vicar, hairdresser and chiropodist who visit, we also have the television if we want”. A service user said “I would like to do more activities but I can’t due to my mobility, but I am happy with what is available, and we do have regular resident meetings”. Minutes of resident meetings gave detail of service user involvement in decisions around activities and menu planning however there is no structured plan of recreational activities or a notice board to ensure service users are informed. The menu plan did not detail an alternative choice to that of the main, but did offer a varied and nutritionally balanced diet. Service users said, “The food is very nice” and in response to a question on an alternative choice, “you have what is put in front of you, which is nice, but it would be nice to have a choice. VALERIES REST HOME H52-H01 60562 Valeries Rest Home V211085 200405 Stage 4.doc Version 1.30 Page 10 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) 16 & 18 The home takes complaints seriously and documents all concerns voiced by the service user; service users feel listened too. The home does not ensure availability of their complaint procedure or that it is in a suitable format for the service user. Service users are protected from abuse. EVIDENCE: Service users and a visitor complemented the home on the services provided and confirmed that they had no complaints. A logbook details four informal complaints made since the last inspection, but is not clear whether the complaints were substantiated or give full detail of action and outcome. The homes complaint procedure does not fully detail stages, contact names and timescales and is not readily available in a format suitable to the service users. Records show that staff have received abuse awareness training and that the home has appropriate policies and procedures on the protection of vulnerable adults. When asked some staff were uncertain about what they would do if they suspected or witnessed abuse other than to report this to a senior member of staff. VALERIES REST HOME H52-H01 60562 Valeries Rest Home V211085 200405 Stage 4.doc Version 1.30 Page 11 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) 19 Pleasant comfortable and homely surroundings that is warm and welcoming with safety measures in place. EVIDENCE: The home was tidy, clean, fresh and comfortably furnished, and routine repair was being carried out on the day of the inspection. The attractive landscaped garden was accessable to the service users with seating provided. The Royal Berkshire Fire & Rescue Service carried out an inspection of the premises on the 31st March 2005 and forwarded a copy of their report to the Commission for Social Care Inspection. The report details fire safety deficiencies and gave the compliance date of 30/07/05. The fire officer has visited the home since this date and the home is working towards complying with requirements made. VALERIES REST HOME H52-H01 60562 Valeries Rest Home V211085 200405 Stage 4.doc Version 1.30 Page 12 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 & 29 Service users are protected by the homes recruitment policy and staff numbers are sufficient to meet the needs of the service users. EVIDENCE: The home accommodates up to seventeen service users and staff numbers were observed to be sufficient to meet the needs of the fifteen service users who were in residence on the day of the inspection. The home has increased staff cover at night. Records show the manager has followed the homes recruitment procedure and is awaiting return of CRB disclosures and 2nd references; a new application showed gaps within the employment history and the manager is aware that this needs to be explored before a position of employment is agreed. The manager has recently completed an audit of existing staff files to ensure they obtain all necessary information as required at the previous inspection. VALERIES REST HOME H52-H01 60562 Valeries Rest Home V211085 200405 Stage 4.doc Version 1.30 Page 13 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) 36 & 38 Staff receive supervision and receive mandatory training to ensure safe working practice but, infection control and fire safety is jeopardised. EVIDENCE: Staff have a skill profile that details mandatory and specialist training received with plan of action to close any gaps. Water, fridge, freezer and food temperatures are maintained to ensure safety. Toiletries and sponges were observed in the communal bathrooms and there was no pedal on the clinical waste bin that had to be opened by hand. A clothesline was observed over the boiler and if used could pose a risk of fire. Fire safety inspection has taken place and requirements were made; the home is working with the fire officer to comply with requirements made. The manager confirmed she would take advice from the fire authority with respect to clothesline over boiler. VALERIES REST HOME H52-H01 60562 Valeries Rest Home V211085 200405 Stage 4.doc Version 1.30 Page 14 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 1 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x 2 x x x x x 3 x 1 VALERIES REST HOME H52-H01 60562 Valeries Rest Home V211085 200405 Stage 4.doc Version 1.30 Page 15 yes 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 1 Regulation 4 Requirement The Statement of Purpose (SOP) must contain information as detailed in Schedule 1 of the National Minimum Standards Care Homes Regulations. The updated copy of the SOP must be sent to the Commision for Social Care Inspection. (Timescale 07/02/05 not met) The Service Users Guide (SUG) must be in a suitable format and accessable to the servic user. A copy of the SUG must be sent to the Commission for Social Care Inspection. (Timescale of 07/02/05 not met) Indavidual service user risk assessment must be developed and attached to the service user plan, detailing risk and action plan to minimise risk. An audit trail on PRN medication must be implemented and followed on each delivery of service users PRN medication. Management must undertake an investigation of missing medication and put a plan of action in place to ensure records match stock in place to ensure the safety of the service users. Timescale for action 20/06/05 2. 1 5 20/06/05 3. 7 13.4© 20/05/05 4. 9 13.2 20/05/05 5. 9 13.2 20/05/05 VALERIES REST HOME H52-H01 60562 Valeries Rest Home V211085 200405 Stage 4.doc Version 1.30 Page 16 6. 16 sch 4.11 7. 16 22 8. 38 13.4 9. 38 13.3 10. 38 13.3 The homes complaint logbook must clearly document the complaint made, action taken and outcome. The complaint procedure must be in a suitable format giving clear guidance of stages, contact numbers and timescales, and must be accessable to the service user. The home must not use the clothesline that hangs over the boiler until they have taken advice from their fire safety officer. The practice of using communal tioletries or storing service users personal toiletries and sponges together within the communal bathrooms must stop so as to promote infection control. The home must promote infection control with the provision of a clinical waste bin that can be operated by a foot pedal. 20/05/05 20/05/05 20/04/05 20/04/05 20/05/05 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 9 Good Practice Recommendations A copy of the on the administration and control of medicines in a care home by the Royal Pharmaceutical Society of Great Britain, should be obtained and management/staff who administer medication should be familiar with the document. A programme of forthcoming activites/outings should be available to the service user, and a notice board in place to ensure service users are informed. The home should incorporate into their menu plan an alternative choice to that of the main, and keep a record of the service users choice. H52-H01 60562 Valeries Rest Home V211085 200405 Stage 4.doc Version 1.30 Page 17 2. 3. 12 15 VALERIES REST HOME Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Reading RG7 4SA 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 VALERIES REST HOME H52-H01 60562 Valeries Rest Home V211085 200405 Stage 4.doc Version 1.30 Page 18 - 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!