Inspection on 01/09/06 for Villarose

This inspection was carried out on 1st September 2006.

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

Other inspections for this house

Villarose 04/01/06

Villarose 19/07/05

Villarose 18/01/05

Villarose 24/08/04

Villarose 11/11/02

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Villarose 256 Clifton Drive South Lytham St Annes Lancashire FY8 1NE Lead Inspector Phil McConnell Unannounced Inspection 09:30 1 September 2006 st 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 Villarose DS0000009787.V304134.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. Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Villarose Address 256 Clifton Drive South Lytham St Annes Lancashire FY8 1NE 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) 01253 711860 Mr Michael John Garthwaite Mrs Margaret Garthwaite Mr Michael John Garthwaite Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 2006 Brief Description of the Service: Villa Rose care home provides residential accommodation for up to 15 older people who do not require nursing care. The home is located in a predominantly residential area and in close proximity to the town centre and community services and resources. The home is in the main bungalow accommodation however a small number of bedrooms are located on the first floor of the building. Villa Rose is well maintained and furnished to a high standard in all communal areas of the home. Bedroom accommodation is comfortably furnished and reflects the needs and wishes of the individual occupant. A number of bedrooms provide an en-suite facility that supplements adequate communal facilities that are equipped with appropriate aids and equipment to address individual requirements. The external environment of the home provides landscaped garden areas that are easily accessible and furnished with garden furniture in the summer months. All service users are encouraged to remain as independent as possible and determine their chosen daily living pattern. Participation in community and ‘inhouse’ activity is encouraged and relatives and friends are made welcome at any time of the service users choice. The present rating of charging is between £324.50 and £400. Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The assimilation of information was used to assess the key standards that are identified in the National Minimum Standards, including: questionnaires from service users, the pre inspection questionnaire (completed by registered manager) and an unannounced inspection visit to the service. (Unfortunately no comment cards from service users’ relatives or GP’s were returned). During the visit to the home three service users files were examined, including the most recent person to go and live at Villarose and discussions took place with some of the service users throughout the day. There was the opportunity to observe the care provided to the service users and the interaction between them and the staff. The registered manager was available throughout the day and there was the opportunity to have conversations with other staff members including the homes cook and an advocate, from an advocacy agency. This person was in the process of visiting different residential homes in the area, in order to find the most suitable home for a person, that he was advocating for and he said, “I have visited between 30 to 40 homes and this is undoubtedly one of the best”. The homes policies, procedures and all other documentation including health and safety files and certificates were examined as well as a full tour of the home being carried out. What the service does well: What has improved since the last inspection? Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 6 All CRB checks are now carried out correctly, thereby helping to ensure that a robust and thorough recruitment process is maintained. Bed rail risk assessments are now part of an individuals care plan and other risk assessments regarding potential hazards including the control of substances hazardous to health (COSHH), have also been implemented as previously requested. Induction training is now being recorded for new employees and a training matrix has been developed, although this still needs further development. All regulation 37 notices are now forwarded to the Commission for Social Care and Inspection (CSCI). A formal supervision programme has commenced and senior staff have undergone supervisory skills training. 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. Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Intermediate care is not provided) “Quality in this outcome area is ‘Adequate’. This judgement has been made using available evidence including a visit to this service”. There was little evidence that pre admission assessments are carried out, although it was evident people are being well cared for. It is essential that assessments are completed, in order to ensure that peoples assessed needs are fully known. EVIDENCE: Three service users’ files were examined including the most recent person to come to live at Villarose and two of the files were very limited in information, especially with regards to pre-admission assessments. However, there were care plans in place, which contained appropriate and relevant information and guidance in order to provide care and support to individuals. In discussion with the manager it appears that assessments are carried out and the information is sometimes put straight into the individuals care plan. Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 9 One service user wrote in the questionnaire, “I had many visits from the home prior to admission”. The manager was informed that an assessment of needs must be completed prior to the person moving into the home and for the information to be documented appropriately, in order to ensure that a persons’ assessed needs are included in their care plan and that their needs are being adequately met. Service users’ files in general were a little disorganised and the manager gave an assurance that this issue would be addressed as soon as possible. Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. “Quality in this outcome area is ‘Adequate’. This judgement has been made using available evidence including a visit to this service”. Individuals’ health and personal care needs are catered for, helping to ensure that peoples’ wellbeing is promoted, monitored and maintained. Medication procedures are not satisfactorily practiced at the present time, this could cause potential risk or harm to service users. Equality, dignity and respect is actively and positively demonstrated in the way that care is provided. EVIDENCE: As previously mentioned service users’ care plans do contain appropriate and specific information, regarding personal and health care needs. It was also evidenced by a completed ‘medical visits chart’ that individuals are supported to attend any medical appointment whether it be to their GP, hospital appointment or any other appointment or consultation and it was Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 11 reported that the manager usually transports individuals to their appointments in his car. For the service users who are able to self medicate, there were signed contracts/agreements in place between them and the provider, confirming that individuals are responsible for taking their own medication. Highlighting that when possible, individuals are supported and enabled to be independent. The cupboard that is used for the storing of medication was seen to safe with correct recording procedures up to date and in place. In observation throughout the visit, service users were treated respectfully and with dignity and some comments received were, “its very good here, I am treated very well” and “the staff are all so very kind and are always smiling, which makes us feel very happy”. Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. “Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service”. The home provides a number of varied activities, promoting stimulation and motivation to service users. Visitors are made welcome to the home, demonstrating that relationships with family and friends are maintained and encouraged. The meals provided are wholesome and nutritious, with the food menus providing a balanced diet, helping to promote a healthy eating plan for all service users. EVIDENCE: The home employs an ‘activities person’ for 2 days a week and a number of varied activities take place throughout the week, including: exercise sessions, bingo, trips out, shopping trips and there is usually two annual visits to the theatre. There were books, magazines and daily newspapers also available, with some of the service users participating in a daily ‘word search’, which would help to stimulate people and create an interest. Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 13 The manger said that, “everyone has someone to take them out, either a relative or a visitor” and in discussion with some of the service users, it was commented that, “you can come and go as if it is your own home” “I am able to go out alone, but I know if I need help I only have to ask” and another person said, “I enjoy the outings and the bingo”. The home has an open house policy with visitors to the home being made welcome and service users are encouraged to maintain relationships with their families and friends. During the inspection / visit there was the opportunity to speak to a service users’ advocate who was looking for a suitable place for his client to live. This person said that he had just turned up at Villarose and he “was made very welcome, the staff are welcoming and open” and “a number of service users felt free to come up and speak to me, which was really good”. As previously mentioned this person said, “I have visited between 30 and 40 rest homes and I would definitely recommend Villarose”. There was a choice of menus available, which were seen to be nutritious, varied and appetising. Some of the comments regarding the food were: “I enjoy all of the meals, they are so varied. Always arrive on the table nice and hot and look very tempting” “ the meals are mainly very good” and in discussion with some of the staff, “It is a good varied diet, we try not to be too repetitive” and the homes cook said, “I am responsible for ordering all of the food and it is top notch”. The homes cook has many years of experience in care work and in catering and was aware of the different food items and preparations that maybe needed for someone of a different religion or culture, at the present time one of the service users has diabetes and the cook was very familiar with the procedures needed to provide for someone with diabetes. One of the service users said that, “last night I didn’t want to go downstairs and my tea was brought to my room” another said “I do like the fact that we can have whatever we want for tea”, demonstrating that mealtimes are flexible, with service users being encouraged to exercise choice and their wishes being catered for. Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. “Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service”. Thorough satisfactory policies and procedures are in place, helping to protect vulnerable people. Staff members are suitably and adequately trained, in order to manage any protection issues. EVIDENCE: The home had a comprehensive complaints policy and procedure in place, regarding the safeguarding and protection of vulnerable adults. There had been no complaints received since the last inspection. The service users, who were spoken with, knew whom they could speak to in the home if they had a complaint. They were also aware that the inspector for CSCI (commission for social care inspection) could be contacted if they chose to do so. One service user said, “I wouldn’t stay if I needed to complain about anything” and the questionnaires received from service users indicated that people are generally aware of the complaints procedure and how to complain if needed, with one person writing, “I would not know who to complain to, because I am always very happy here, so the question does not arise”. Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 15 There was a thorough policy in place to deal with a suspicion or allegation of abuse. The inspector spoke with staff members and they were fully aware of the procedures to follow, if there was any suspicion or alleged abuse and would be confident in the process, highlighting that staff had been trained in the protection of vulnerable people. Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 16 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 and 26. “Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service”. The home is clean, hygienic and well maintained, helping to ensure that people live and work in a safe, comfortable and pleasant environment. EVIDENCE: A full tour of the home was completed and throughout it was found to be of a good standard, it was clean, homely, fresh smelling, comfortable and hygienic with a fully equipped kitchen, which was bright, airy and fresh. The home was found to be generally well decorated, with service users’ bedrooms demonstrating their own personality, containing individual’s own personal possessions, including photographs, ornaments and items of furniture, helping to demonstrate that people are encouraged to bring their own belongings into the home, helping to maintain familiarity and identity. Some of the rooms are also ensuite. Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 17 Some of the comments received from service users included: “This is a very well run home” “The home is clean with no smells” and the service users’ questionnaires all indicated that the home is always ‘fresh and clean’. The home is well furnished, with good quality furniture in the spacious communal lounges and dining room. There was appropriate specialist equipment observed around the home, such as lifting hoists, a stair lift and walking frames, thereby helping to ensure that individual needs are catered for, whilst independence is promoted. The outside of the home was easily accessible to service users and the gardens were very neat, tidy and were maintained to a good standard. Overall the environment of the home was observed to be safe, comfortable, hygienic and well maintained. Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 18 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 and 30. “Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service”. The staff team have the necessary skills and experience to provide a good standard of care to vulnerable people. The home has a thorough recruitment process, which gives the confidence that service users are protected and safeguarded as much as possible. The training provided is satisfactory, helping to ensure that the service users are cared for and supported by well-trained staff. EVIDENCE: The staffing levels were examined and found to be adequate and satisfactory. Three staff files were examined, one of which was the most recent employee to join the staff team and all of the files contained the necessary information regarding experience, skills and training that individuals had received. Some of the staff were observed demonstrating a caring, sensitive, dignified and respectful approach, with service users responding positively and it was evident that good relationships existed between service users and the care staff and in talking to service users and with the comments in the Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 19 questionnaires, it was apparent that people feel safe, well cared for and protected. There was a thorough recruitment process in place, with staff files containing evidence that Criminal Record Bureau (CRB) checks had been carried out and staff are only employed on the satisfactory completion of these checks with two independent satisfactory references being obtained, thereby helping to ensure that service users are protected and safeguarded by having a robust recruitment and selection process. A partially completed training matrix was observed and although it was incomplete it was evident that the provider is committed to providing good quality training to staff. 90 of the staff have been successful in achieving the National Vocation Qualification Award in care (NVQ). Some of the other training that has been provided other than the mandatory courses, have included, dementia awareness, nutrition course, palliative care and some of the senior staff have had training in supervisory skills, which will help with the supervisions programme that is now underway, with staff being supervised approximately every 10 weeks. It was evident that the provider is committed to ensuring that staff are appropriately well trained, in order to provide a quality service to vulnerable people. Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 20 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 and 38. “Quality in this outcome area is ‘Good’. This judgement has been made using available evidence including a visit to this service”. The home is adequately managed, ensuring as much as possible that service users receive a satisfactory service. The financial arrangements for service users were thorough enough to ensure that individuals’ finances were protected. The procedure for the promotion of the health and safety of service users and staff needs to be improved. (Medication procedures and Legionella bacteria checks) This will help safeguard and protect individuals. EVIDENCE: The manager has over 17 years experience in care work and has managed Villarose for approximately 16 years. Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 21 He has relevant qualifications for the post of registered manager; including an NVQ level 4 in care management and has also had other relevant training including, a palliative care course, a medication course and a supervisory skills course. The comments regarding the management received from service users and staff were complimentary and positive, including “The management is really good, they are always on top of everything” another staff member said “They are always approachable and available”. Some of the comments from service users were, “The manager and all of the staff are very kind and pleasant, they make you feel at home” and another wrote, “This is a very well run home and I don’t have any problems”. The home has maintained the ‘Investors in People Award’ for the fifth successive year, Investors in People is a quality assurance-monitoring organisation. There were procedures in place, regarding service users’ finances, with appropriate and adequate records and receipts being kept, helping to ensure that people’s finances are safeguarded. There was an up to date health and safety policy, with corporate risk assessments, promoting the health, safety and independence of service users, however some concerns regarding medication were identified, (see Health and Personal Care section) which could potentially cause health and safety problems. The homes health and safety certificates were inspected and they were found to be up to date and in order, including: electric inspection, portable appliance testing, fire alarm, gas inspection and certificate for hoists. Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 22 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 23 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 OP3 Regulation 14 (1) (a) Requirement A pre admission assessment must be carried out before a service user is admitted to the home. Timescale for action 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations It is recommended that service users’ files contain far more information and are much better organised. Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Villarose DS0000009787.V304134.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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