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Inspection on 19/07/05 for Villarose

Also see our care home review for Villarose for more information

This inspection was carried out on 19th July 2005.

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

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

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

What the care home does well

This is a care home where residents are well looked after. The staff team work well together and show a good understanding of the needs of the residents in the home. The residents spoken to say that they were very happy and felt well cared for. One resident who was enjoying a period of respite care said `from what I have seen everyone one is treated well and receive first class treatment and care`. The atmosphere in the home is very relaxed and friendly. Visitors are made welcome and the visitors in the home at the time of the inspection confirmed that they have always been made to feel welcome and that you are not even through the door before you are offered refreshments. Meals are varied with an alternative available if required at each mealtime. Residents were pleased with the choice and variety. The home and grounds are maintained to a good standard, and residents live in comfortable surroundings.

What has improved since the last inspection?

Since the last inspection improvements have been made to the bathing facilities, the alterations, to the staircase has been completed and a chair lift is now in place. The main bathroom has been completely refurbished and now provides excellent facilities for residents of all abilities. The system of recording information on individual residents care plans has been reviewed and now clearly documents the needs of the residents and the assistance staff are required to provide. Care plans are now also being reviewed on a monthly basis. The homeowners are now near to completing the NVQ Level 4 qualification.

What the care home could do better:

The homeowners and staff work very hard to ensure that the needs of the residents are met, however they recognised that there is always room for improvement. Whilst care plans are now being reviewed on a monthly basis, none of the care plans were signed by the resident, the senior staff member stated that all reviews are carried out through discussion with the resident. The inspector advised that residents should sign the care plan stating their agreement to the completed document. Risk assessments must be in place for the use of cot sides. During the inspection it was noted that hazardous substances was being stored in the unlocked laundry room. The senior staff member was informed that all hazardous substances must be stored in accordance with the COSHH regulations.

CARE HOMES FOR OLDER PEOPLE Villarose 256 Clifton Drive South Lytham St Annes Lancashire FY8 1NE Lead Inspector Lillian McMullen Unannounced 19th July 2005 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. Villarose F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Villarose Address 256 Clifton Drive South Lytham St Annes Lancashire FY8 1NE 01253 711860 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Michael Garthwaite Mr Michael Garthwaite Care home only 15 Category(ies) of OP Old Age (15) registration, with number of places Villarose F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2005 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 `in-house` activity is encouraged and relatives and friends are made welcome at any time of the service user’s choice. Villarose F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of six hours and was carried out in conjunction with the inspection of its sister home Wentworth House. The inspector spoke with the senior staff and individual discussion also took place with two visitors and four residents. A number of records, including care records, and policies and procedures were also examined and a partial tour of the building took place. What the service does well: What has improved since the last inspection? Since the last inspection improvements have been made to the bathing facilities, the alterations, to the staircase has been completed and a chair lift is now in place. The main bathroom has been completely refurbished and now provides excellent facilities for residents of all abilities. The system of recording information on individual residents care plans has been reviewed and now clearly documents the needs of the residents and the assistance staff are required to provide. Care plans are now also being reviewed on a monthly basis. The homeowners are now near to completing the NVQ Level 4 qualification. Villarose F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 6 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 F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Villarose F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Prior to moving into the home, a full comprehensive assessment takes place, which ensures that needs can be met. EVIDENCE: The Inspector examined of the records of the last two residents to be admitted and found that in both cases a full assessment of needs had been carried out prior to admission, therefore ensuring that the home could meet the residents needs. The senior care assistant informed the Inspector that through discussion before admission with any prospective resident and their relative, they confirm verbally that the home can meet their assessed needs. Also on file was information from other sources such as hospital discharge information. One resident who had been admitted to Villa Rose for a period of respite care confirmed that he had been invited to view the home and meet the homeowner, he said “Maggie (homeowner) was wonderful and wanted to know what my needs were and my goodness every thing was ready when I arrived, I would have no hesitation coming back” Villarose F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 and 10 There is a good care planning process in place that details the care needs of the residents. These could be developed further to incorporate any social and cultural needs. EVIDENCE: Individual records are kept for each resident with a plan of care setting out in detail the action that needed to be taken by care staff to ensure all aspects of health and personal care needs of the residents were met. Significant events had been recorded and daily entries made setting out the care given. Evidence was seen to confirm that care plans are reviewed on a monthly basis the senior care assistant explained that all reviews are carried out in consultation with the individual. However the care plans were not signed by the resident and the inspector advised following the review the resident should be asked to sign their agreement to the care plan. Risk assessments accompany the care plan and are reviewed also on a monthly basis. However the inspector advised that risk assessments must be in place for the use of cot sides. The inspector advised that staff should sign the risk assessments once they have read and understood the content. Villarose F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 10 The health needs of the residents are monitored and daily diary entries provided evidence that health professionals are involved in the care and treatment of the residents. The visitors that were spoken to during the inspection explained that the resident they were visiting had complex health needs and said “we were present when the staff had to swing into action and it was really impressive”. One resident spoken to, explained that the district nurse visits her regularly and said if I am unwell the staff will call for the doctor. This resident also said, “the staff are a fine bunch and you could not ask for a better team”. Staff spoken to had a good understanding of the care needs of the residents and confirmed that they have good management support. The inspector observed staff assisting residents and was pleased to see they had good relationships with residents and carried out all tasks in a friendly and sensitive way. Villarose F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15 Social activities and meals are both well managed to suit the individual and group. Contact between residents and their families are encouraged to help them maintain relationships. EVIDENCE: There was two visitors in the home, who spoke to the inspector and said “that they can visit at anytime and that they are always made to feel welcome and offered refreshments. One said “you are not even through the door when you are asked if you would like biscuits with your tea”. A number of residents were spoken to and all confirmed that they are free to come and go as they please, staff spoken to informed the inspector that they quite often go out for a walk with the residents on a one to basis. Residents spoken with all said that their visitors are welcome at any time and often go out with them. A limited activity programme is in place, which includes bingo twice a week and walks out. The senior staff explained that they have tried other activities but the residents presently accommodated are not interested and prefer to read or watch television. Residents spoken to, confirmed that they were happy with what the home provided saying “we enjoy the quite life”. A number of residents said they enjoyed sitting in the garden when the weather is good. Villarose F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 12 A dedicated cook makes meals on the premises. Menus are based on providing a balanced and nutritional diet. The inspector was able to observe the choice offered at teatime and found it to be considerable with residents choosing what they want. This was further evidenced, as during the inspection a resident said she was hungry and the staff made her a cheese sandwich irrespective of her having eaten a good lunch. The cook was able to confirm she had information about residents with special diets and personal preferences. Meal times are set although flexible enough to accommodate preferences. The inspector ate a light lunch, during the inspection, which was appetizing and enjoyable. One resident stated, “ the staff know what I like”, and this was further evidenced when speaking to staff members, who commented on what residents like and don’t like at mealtimes. Villarose F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 13 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 Arrangements for complaints are handled well and taken seriously ensuring people feel listened to and protected. EVIDENCE: The home has a detailed complaints procedure, which is made available to all residents on admission. General discussion with the residents revealed that they were aware the home had a complaint procedure and said that if they were unhappy about their care they would know who to speak to. They were very positive about the care and treatment they receive and stated that they could speak to anyone of the staff or management if they had concerns. Villarose F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 14 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, 20,21 and 26 The planned maintenance and renewal programme for the redecoration and refurbishment of the home ensures that residents live in a comfortable and homely environment. EVIDENCE: Villa Rose is decorated and furnished to a good standard. The Inspector was pleased to see that a new bathroom has been created, this has improved the facilities available as the fittings and equipment are to a high specification and suitable for residents who have poor mobility and movement. Since the previous inspection a new staircase has been completed together with the installation of a new chair lift. The communal rooms were comfortable and furniture provided was appropriate to meet the needs of the residents. Residents spoken to confirmed that they are very happy with their personal accommodation and stated that they are able to bring with them items of a personal nature that make them feel at Villarose F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 15 home. Two residents also commented how nice the gardens were and how they have enjoyed sitting out during the good weather. The home is clean and free from offensive odours. The Inspector noted that cleaning materials had not been locked away and advised that all hazardous substances should be stored as per COSHH regulations. Villarose F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 16 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) EVIDENCE: Whilst none of the above standards were assessed at this inspection, adequate staff was on duty that had a good knowledge of the needs of the residents. Villarose F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 17 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) EVIDENCE: None of the above standards were assessed at this inspection. Villarose F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 18 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x x x x 2 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x x x x Villarose F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 19 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. 2. Standard 26 7 Regulation 23 15 Requirement all hazzardous substances should be stored as per COSHH Regulations. Risk assessments for the use of cot sides should form an integral part of the care plan. Timescale for action 25/7/05 30/8/05 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. 2. Refer to Standard 7 7 Good Practice Recommendations All care plans should be signed by the resident. Care plans should be developed to include social and cultural needs. Villarose F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Unit 1, Tustin Court Portway 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 F57 F09 S9787 Villarose V194947 190705 Stage 4.doc Version 1.40 Page 21 - 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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