Inspection on 11/07/06 for Valley View Residential Home

This inspection was carried out on 11th July 2006.

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

Valley View Residential Home 25/07/07

Valley View Residential Home 07/10/05

Valley View Residential Home 26/05/05

Valley View Residential Home 28/09/04

Valley View Residential Home 20/05/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Valley View Residential Home Burn Road Winlaton Blaydon Tyne & Wear NE21 6DY Lead Inspector Gillian McCabe Key Unannounced Inspection 11th & 25th July 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 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. Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Valley View Residential Home Address Burn Road Winlaton Blaydon Tyne & Wear NE21 6DY 0191 414 0752 NO FAX 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) Valley View Residential Homes Limited Care Home 44 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (44), of places Physical disability over 65 years of age (4), Sensory impairment (2) Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th October 2005 Brief Description of the Service: Valley View provides personal care for up to forty-four older persons, with care staff available at all times over the twenty-four hour period. Nursing care is not provided at the home. The building is a two-storey, the first floor being accessed by stairs and a passenger lift. Car parking is available to the front of the home. A large grassed area is available to the rear of the building, which is not yet fully landscaped. Valley view is situated in a semi-rural area on the outskirts of Winlaton Village, close to the shops, bus route and local amenities. However access to the Home from Blaydon is at the top of a steep bank. Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over two days in July 2006 and was a scheduled unannounced inspection. The inspection included a separate look at the pre-inspection questionnaire (completed by the manager), and comment cards received from relatives before the inspection. The judgements made are based on the evidence available to the inspector during the inspection. A tour of the building took place, and a sample of staffing and residents’ records were inspected. Residents, staff, the registered provider, the manager and deputy manager and visitors were spoken with, and the inspector took a meal with residents on the first floor. What the service does well: What has improved since the last inspection? Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 6 A number of improvements have been made to the home since the last inspection. An activities coordinator has been recruited to the home to plan and participate in activities, with residents. The way staff are recruited to the home ensures that appropriate pre employment checks, such as two references and criminal records checks, are undertaken prior to an offer of employment being confirmed. Care plans have improved however, they still only provide a basic framework of information. Some plans are not sufficiently detailed to inform staff how to support people with their individual needs. The manager has taken advice with regards to improving the environment to help to meet the needs of people with dementia. Soft furnishings and new pictures have also been purchased which brighten the home up. The garden area has also been re developed and now provides a pleasant additional space for residents to enjoy in the summer months. A ramp is in place to allow easy access for residents who have a physical disability. New garden benches have been purchased and a summerhouse has been built for residents to use. The garden also has the benefit of colourful plants, which compliment the design What they could do better: Contracts did give details of the homes fees however the fees stated were out of date. The contract did not give details of period of notice that is given, should there be an increase in a person’s fee. Regular checks are not carried out as part of medication procedures and quality monitoring, these checks are vital to ensure any errors are highlighted and put right straight away. This will ensure the safety of residents at the home. There have been some improvements to the care planning system since the previous inspection however care plan records need more attention so that all staff know exactly how to help people in the right way. These should also show how and whether residents have been involved. Risk assessments are not in place for all identified areas of risk. Importantly, quality assurance checks need to more accurately reflect the areas audited, such as the quality of furnishings, and the manager should provide training or additional guidance to those staff undertaking quality checks. One bathroom on the ground floor has a window that requires a blind to be fitted to preserve the privacy of those using these rooms. Accidents are recorded in the homes accident book however the manager has failed to report any serious accidents/illness or deaths to CSCI (Commission for Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 7 Social Care Inspection) this is a requirement under Regulation 37 of the Care Standards Act. Time was spent talking with the manager about Regulation 37 and what is required. An Immediate requirement Form was left at the home to tell the Owner that arrangements must be made to put these matters right. Time was also spent talking with the manager about reporting to CSCI Commission for Social Care Inspection under Regulation 26. No reports have been received since May 2005. An Immediate requirement Form was left at the home to tell the Owner that arrangements must be made to put these matters right. 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. Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 8 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 Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 9 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): 2,3 & 6 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. All prospective residents’ needs are assessed prior to the person being offered a place. This helps to ensure that residents are offered the right type of care and no one is admitted inappropriately. The home does not provide intermediate care EVIDENCE: The home has a detailed Statement of Purpose/Service User Guide, which is made available to prospective residents and their families when they are considering moving into the home. The Statement of Purpose sets out the homes aims and objectives, services and facilities available, and the type of care the home intends to provide. This information along with a visit to the home helps prospective residents and their families to make an informed choice about the suitability of Valley View. The Statement of Purpose/ Service User Guide does not include details of the homes fees. The document also had information that was out of date. The Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 10 manager confirmed that all prospective residents receive a copy of the homes Statement of Purpose and a member of staff will usually discuss any issues or concerns in relation to it. The Statement of Purpose/Service User Guide may not be accessible for people who have difficulty reading written words. Time was spent talking with the deputy manager about reviewing the document and ensuring it is available in accessible formats. As part of the homes pre admission procedure, the home usually receives an assessment for each prospective resident from the persons Care Manager prior to admission. This information is looked at by the manager to determine if the home can meet the person’s needs. The manager also carries out an additional pre admission assessment prior to the prospective resident moving in. The purpose of the assessment is to gather information to determine if the home can meet the person’s needs. As part of the case tracking exercise, three residents files were sampled and all contained pre admission assessments, which were signed by the individual concerned and/or their representative. All files sampled also contained care management assessments. All residents have a copy of the homes contract/statement of terms and condition in their files, however not all contracts have been signed by residents or their representative, this is important as a persons signature confirms that each person is in agreement with the homes terms and conditions. Contracts did give details of the homes fees however the fees stated were out of date. The contract did not give details of period of notice that is given, should there be an increase in a person’s fee. This information is important and needs to be up to date at all times to ensure residents are aware of what they need to pay. The homes administrator confirmed that new contracts had been forwarded to residents and/or their representatives showing new fees. Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The manager and staff have made some developments with individual care plans to ensure resident’s needs are met however, care plans do not provide sufficient information about a person care needs to ensure independence is maintained and support is given to continue a full and valued lifestyle. Residents have good regular access to health professionals to ensure healthcare is promoted. Some medication arrangements are not managed appropriately to promote the health and well being of residents. Residents are treated with respect and dignity and privacy is upheld in the home. Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 12 EVIDENCE: The Deputy Manager has worked hard on developing individual care plans in the home since the previous inspection however, they only provide a basic framework of information. Some plans are not sufficiently detailed to inform staff how to support people with their individual needs. One person’s file contained old care plan records that are no longer relevant. Two residents, one who has pressure care needs and one who has hearing impairment did not have a care plan in place to instruct staff how support should be given. Care plans do not demonstrate how residents are involved in formulating and evaluating their plans. Risk assessments are not in place for all identified areas of risk. Care plans are reviewed on a monthly basis however, specific information is not recorded regarding a persons changing needs. For example, ‘no change in this area’ does not tell the reader how the person has progressed. Phrases such as “full assistance” and “dress appropriately” do not guide staff in the specific times and type of support that is needed. Care plan records need more attention so that all staff know exactly how to help people in the right way. The manager and staff strive to ensure that all residents’ healthcare needs are met. The home continues to support residents to access various healthcare professionals. Records show details of visits to G.P, Opticians and Hospital. Two residents who have support needs in relation to a particular medical condition have regular visits from the district nursing service. The deputy manager confirmed that verbal guidance had been given from district nursing service, about the type of care and support that staff need to give for each person however detailed written plans are not in place to ensure that this condition is managed effectively in the home. A sample audit of the homes medication system was carried out and medication practices generally ensure that residents are assisted to take their medication in a manner, which promotes their health and well being. However some practices in relation to storage, administration and recording of medicines does not ensure the safekeeping and management of medicines in the Home. Medication is handled and administered by senior care staff in the home; all staff have completed training in Safe Handling of Medicines to ensure competence when dealing with medicines. A monitored dosage system is used, whereby the dispensing pharmacist supplies medication in individual blister packs. Printed ‘medication administration records’ are also supplied by the pharmacist giving details of medication prescribed and dosage. Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 13 One medication administration record had recording errors, medication had been given but not signed for in one instance, one sheet did not detail the correct amount of drugs held by the home, whilst another sheet did not detail clearly what certain recordings such as the letter ‘F’ stood for. The home does not have comprehensive descriptions of medication currently prescribed for each resident along with any side effects or contra indications that may occur as a result of taking such medication. A sample of staff signatures that are responsible for administering medication was not available. Records of weekly audits carried out as part of quality monitoring were not available during inspection. The home has controlled drugs in stock, which are recorded in a controlled drugs register and administered by two members of staff in accordance with regulations. However one persons controlled drugs had more tablets stored than it was stated in the Controlled Drugs Log. The Deputy manager confirmed that this person’s medication showed an overstock as extra medication had been brought into the home when the person went home for a weekend stay. The Deputy Manager was instructed to carry out regular audits of the homes medication stock, staff practice and of the records kept in this regard and to take prompt action to address any new problems found. An Immediate Requirement notice was left at the home to tell the Owner that arrangements must be made to address these issues immediately. Staff ensure residents are treated with respect and support is given sensitively and discreetly. Assistance with personal care is carried out in the privacy of a person’s room or bathroom. One resident confirmed that staff knock on their bedroom door before entering. Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before a visit to the service. Residents are able to follow their own daily routines, to a certain degree, which satisfy their social, cultural and religious needs. Friendships with people outside and inside the home are encouraged and resident’s family members are welcomed to visit the home at any reasonable time. This helps to prevent social isolation. Staff encourage residents to take control and make choice in their lives, which helps to promote independence. Residents are offered a variety of wholesome and nutritious meals in comfortable and pleasant surroundings, which can promote health and wellbeing. Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 15 EVIDENCE: Residents are encouraged to follow their daily routines however staffing shortages at present limit what residents can do regarding their daily routines. Relatives and visitors are welcome at any reasonable time throughout the day and evening. A lot of residents have visiting relatives on a regular basis. Visitors will usually meet with their relatives in the privacy of their own room or in the homes lounges or dining room. One relative spoken with prior to the site visit was happy with the overall care of her relative however concerns were raised about staffing shortages in the home. Since the previous inspection, the home has appointed an activities coordinator to plan and participate in activities with residents each day. The coordinator is employed to work four hours each day Monday to Friday. The coordinator plans activities on a weekly basis with residents via an informal meeting and once the activities are chosen the coordinator will display them in a weekly activity plan. Time was spent talking about developing the activities plan for people with dementia and for people who may have difficulty reading written words, thus, ensuring the plan is accessible for all residents. Activities enjoyed by residents include bingo, flower arranging, gardening trips visiting the local pub and village and excursions to places of interest. A notice board in both lounges displayed pictures of a recent excursion enjoyed by residents to Marsden Grotto. There are plans for more excursions and a BBQ over the summer period, weather permitting. The home does not have the benefit of its own transport however residents use a local hired mini bus for excursions when necessary. Residents were observed taking part in a still life painting session of a bowl of fruit, finished pictures are going to be put into frames at the residents request. Some residents were also participating in a sing a long during the inspection. Lunchtime was observed where choices of two meals were available. The majority of residents spoken with said that meals provided in the home ‘were alright’. One resident said “menus are ok” and another resident said, “The meals are very nice”. When asked about the choice of meals on offer some residents said they did not know what the choices were, some residents said you did not get a choice and some residents said you could have what you like. Meals are freshly prepared by the cook on a daily basis. Fruit and vegetables are encouraged in meal choices to ensure a healthy diet is maintained. The lunchtime meal was well presented and looked sufficient in quantity. The majority of residents continue to choose to have their meals in the dining room however, a couple of residents prefer to have their meals in the comfort Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 16 of their own rooms. One member of Staff served the meals from a ‘hot lock’ trolley and the homes activities coordinator gave assistance with serving meals. There were some practice issues observed during lunchtime, which limit residents’ independence, choice and dignity. For example, tea was served with milk already added. This is institutional practice and meant that residents were not able to choose the quantity of milk they wanted, sugar was not available for residents on the first floor. Staff were unable to sit with the residents, due to staff shortages, leaving some residents without the support they needed to eat their meal. Staff shortages at present are limiting the amount of support care staff can provide, which can leave residents at risk. Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 17 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 &18 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before a visit to the service. Residents and relatives have information about how to make a complaint and are confident that any complaints will be acted upon immediately. All Staff are aware of the POVA (Protection Of Vulnerable Adults procedure). However, not all staff has received training in protection of vulnerable adult procedures. EVIDENCE: The home has the complaints procedure in place giving details of who to contact should anyone want to make a complaint. Details of the process and how any complaints will be dealt with are also documented in the procedure. Residents spoken with during the inspection confirmed that they would tell the manager or the staff if they had any concerns or complaints. One complaint has been received since the previous inspection. The complaint related to the home meeting an individuals healthcare needs. An inspection of healthcare records was carried out and records indicated that the home had acted accordingly, and contacted relevant healthcare professionals when the person needed medical assistance. The manager confirmed that emergency assistance is called immediately in matters when medical assistance is needed urgently. The manager confirmed that the majority of the staff team have received training in Protection of Vulnerable Adults procedures. The home still does not Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 18 have a copy of the Vulnerable Adult policies and procedures for staff to access however, the manager has contacted Gateshead’s Protection Of Vulnerable Adults trainer and the home should receive a copy of the procedures in the very near future. The home has a whistle blowing policy, which sets out the values and principles that underpin the homes approach to whistle blowing. Staff spoken with during the inspection showed an awareness of the procedure to follow in the event of an alert. Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is clean safe and warm offering residents a homely and safe environment in which to live. EVIDENCE: A number of improvements have been made to the home since the last inspection. A walk in fridge has been purchased for the kitchen providing a bigger space for cold storage. The manager has taken advice with regards to improving the environment to help to meet the needs of people with dementia. For example, by purchasing plain carpets, which are all one colour and placing names of streets (chosen by residents) in the corridors. This home looks very nice as a result of the new carpets and the improvements are very beneficial for people with dementia. Adding pictures of named street that residents may be familiar with, could further develop the corridors. Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 20 Soft furnishings and new pictures have also been purchased which brighten the home up. Overall the home is pleasantly decorated and residents are happy with the furnishings. The garden area has also been re developed and now provides a pleasant additional space for residents to enjoy in the summer months. A ramp is in place to allow easy access for residents who have a physical disability. New garden benches have been purchased and a summerhouse has been built for residents to use. The garden also has the benefit of colourful plants, which compliment the garden design. Comments about the new garden design were again, very positive. The Registered Provider takes responsibility for carrying out all areas of maintenance in the home. All individual bedrooms have en suites and are nicely decorated and reflect residents’ individual taste. The pipework in residents en suites are exposed, which could pose a risk to residents’ safety. Some wardrobes in the home are not fitted with an anti topple. The Registered Provider has started to address these issues. Hot water temperatures are tested on a monthly basis however some recordings of water temperatures were shown to be too high. The Registered Provider took immediate action to rectify this and ensure water temperatures are safe. Although works are carried out as part of ongoing maintenance within the home the Registered Provider does not have a maintenance plan. The Registered Provider needs to develop a maintenance plan for the home and a copy forwarded to Commission for Social Care Inspection. This will ensure areas of maintenance throughout the home are highlighted, followed up and monitored on a regular basis. Some areas of the corridors in the home are very dark when the lights are switched off. Time was spent talking with the manager and the Registered Provider about ensuring lighting levels in the home remain consistent. There is a slight ramp in one corridor on the ground floor. No signs are displayed to alert people that this slight ramp is there. This may present a risk for people when mobilising. One bathroom on the ground floor has a window that requires a blind to be fitted to preserve the privacy of those using this room. The notice boards in both the downstairs and first floor lounge were blank, and therefore offered no information to visitors or residents. Time was spent talking with the manager and the activities coordinator about the kind of information that could be displayed. Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 21 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Staffing levels are not adequate to allow residents needs to be met effectively. Residents are protected by the home’s recruitment procedures, which are implemented to a good standard. This can help ensure that unsuitable candidates do not gain employment in the home. Members of staff receive regular training opportunities that ensure service users are appropriately supported and protected. Most updates and refresher are up to date courses. EVIDENCE: On the first day of inspection 41 residents were accommodated. The manager, deputy manager, two senior care staff and three care staff were on duty. The homes rota shows there are at times insufficient numbers of staff on duty throughout the day and night, to ensure residents are fully supported with their needs. The rota does not easily identify members of staff designation; time was spent talking with the deputy manager about how to address this. The home has a well-established team of staff who work well together and are knowledgeable about residents needs. Fourteen members of staff are qualified up to NVQ level two, and five care staff have been successful in achieving an NVQ level three. Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 22 The majority of care staff have completed mandatory training such as First Aid, Moving and Handling, Infection control, Fire Safety and Food Hygiene however, there are a number of staff who have not competed this training (although the manager has been trying to secure places). This kind of training is vital to ensure residents are supported and protected properly and staff are competent and confident in their roles. A training matrix was not available during this inspection, which made it difficult to assess training needs and training completed. The home has a recruitment policy in place outlining the values and principles the home adopts regarding recruitment. The manager uses application forms, interview references and all necessary Criminal Records Bureau checks and clearances before employing any new staff. This helps to ensure that only suitable staff are employed to support the people who live here. Three staff files all held the necessary employment checks in place. Residents comments received about the care staff at the home include “The staff are very nice people and friendly” “They are very good” “The staff will always help you” Staff spoken with confirmed that they usually have informal supervisions with the manager or the deputy. The manager and deputy are also available on a daily basis for advice or to discuss any issues or concerns. Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 23 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): 31,33,35,38 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The acting manager is experienced in her role however, she has yet to complete her application to be registered as a manager with Commission for Social Care Inspection. Good procedures are in place to ensure that residents’ financial interests are safeguarded. The health, safety and welfare of residents is generally promoted and protected. Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager has been employed at Valley View for a number of years now and has been carrying out the role of manager since last year. The manager of the Home is not yet registered with the Commission for Social Care Inspection and is to make an application to go through a Fit Person Interview to enable her to become the Registered Manager. The manager and deputy manager are available each day and their time is usually spent addressing the many management and administrative tasks involved in running the home. The homes rota includes sufficient domestic and catering staff to ensure that the home’s premises and catering services meets the needs of the people who live here. Staff and residents confirmed that the manager is very approachable and supportive and commented that they enjoy working at the home. Financial records are accurate with two signatures being obtained for all transactions. Receipts are kept as evidence of monies spent on behalf of residents. Money is kept in a secure facility in the home; however, very small amounts of are kept there. The manager has developed a quality assurance audit around measuring quality in the home. The manager confirmed that quality assurance checks are carried out as part of quality monitoring however, evidence of all quality audits carried out were not available during the inspection. As part of the quality assurance process the manger also seeks the view of residents and their relatives. This is carried out by sending out annual questionnaires however, evidence of what is done when the information is received is not clear. Comments from the questionnaires include “Valley View provides a first class service and all staff are a credit to their profession”. “Very happy with the service you give”. “I think the laundry could be improved. A lot of my relatives clothes have gone missing and she has acquired other peoples” Quality assurance audits are important as they help to identify and changes that may be needed to the service. Fire training, drills and checks are up to date promotes the safety and welfare of residents. One bedroom where Oxygen is being used did not display appropriate signage to alert staff residents and visitors. Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 25 Appropriate signage is not displayed in the kitchen to alert staff of any extreme water temperatures necessary for infection control. Accidents are recorded in the homes accident book however the manager has failed to report any serious accidents/illness, deaths to CSCI (Commission for Social Care Inspection) this is a requirement under Regulation 37 of the Care Standards Act. Time was spent talking with the manager about Regulation 37 and what is required. An Immediate Requirement notice was left at the home to tell the Owner that arrangements must be made to address these issues immediately. Time was also spent talking with the deputy manager and the Registered Provider about reporting to CSCI Commission for Social Care Inspection under Regulation 26. An Immediate Requirement notice was left at the home to tell the Owner that arrangements must be made to address these issues immediately. Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 26 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 1 28 1 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 27 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 OP1 Regulation 5(1)(b) Requirement Timescale for action 30/11/06 2. OP7 15 Contracts need to include details of fees payable and be signed by person or representative. Period of notice of any fee increase should be included in the contract. Care plans must reflect the 30/10/06 current needs of the resident and how they are to be met. (Previous timescale of 31/9/05 not met) Care plan evaluations need to tell the reader how the person has progressed. Residents at risk of falls must receive a comprehensive assessment from relevant healthcare professionals. Residents must have comprehensive plans in place for any medical conditions. Medication must be managed as required in legislation and good practice guidance. 30/10/06 15/09/06 3. 4. OP7 OP7 14 13(1)(b) 5. 5. OP7 OP9 13(1)(b) 13(2) 30/08/06 19/08/06 6. OP9 13(2) Details of medication, any side 19/08/06 effects or contra indications must be available alongside individual DS0000007382.V299115.R01.S.doc Version 5.2 Page 28 Valley View Residential Home 7. 8. OP18 OP18 13(6) 13(6) medical administration sheets. All staff must have completed training in POVA procedures. Local guidelines for the Protection of Vulnerable Adults procedures must be available in the Home. (TIMESCALE OF 30/11/05 NOT MET) Exposed pipe work in en suites must be boxed in All freestanding furniture in the home must be fitted with an anti topple device. Lighting levels in the home must remain consistent at all times The home must provide a maintenance plan and forward a copy to Commission for Social Care Inspection The registered person shall ensure that at all times suitably qualified, competent and experienced staff are working at the care home in such numbers as appropriate for the health and welfare of residents. Arrangements must be made for remaining staff to receive mandatory training. All staff working with people with dementia must attend appropriate training to enable them to understand and meet their needs. TIMESCALE OF 28/02/06 NOT MET) The homes quality assurance system must be developed further to include records of audits carried out in the home. Formal supervisions for all staff must be carried out at least six times per year. DS0000007382.V299115.R01.S.doc 30/09/06 30/09/06 9. 10. 11. 12. OP19 OP19 OP19 OP19 13(4)(a) 13(4)(a) 23(2)(p) 16 & 23 15/09/06 30/08/06 19/08/06 30/11/06 13. OP27 18(1)(a) 30/09/06 14. OP27 18(1)(a) 30/10/06 15. OP27 18 30/10/06 16. OP33 24 30/11/06 17. OP37 18(2) 30/10/06 Valley View Residential Home Version 5.2 Page 29 16. OP37 26(1) The Registered Person shall 30/09/06 supply to the Commission for Social Care Inspection a report in accordance of this regulation. The Registered Manager shall give notice to the Commission for Social Care Inspection without delay of the occurrence of events under this regulation. 19/08/06 17. OP37 37(1) 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. 2. 3. Refer to Standard OP15 OP27 OP29 Good Practice Recommendations A review of mealtime arrangements should be carried out to address the issues identified in the body of this report. Care staff should not be performing laundry duties to enable them to fulfil their role as carers. An interview template should be developed to standardise the recruitment process and ensure equal opportunities are fulfilled. The manager should be located in an office of their own to enable them to conduct their management duties and to meet with people in private. 4. OP31 Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 30 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 Valley View Residential Home DS0000007382.V299115.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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