CARE HOMES FOR OLDER PEOPLE
Villarose 256 Clifton Drive South Lytham St Annes Lancashire FY8 1NE Lead Inspector
Mrs Lillian McMullen Unannounced Inspection 10:30 4 January 2006
th 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.V260368.R01.S.doc Version 5.1 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.V260368.R01.S.doc Version 5.1 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.V260368.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th July 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 users choice. Villarose DS0000009787.V260368.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place over a period of six hours and was carried out in conjunction with the inspection of its sister home Wentworth House which is situated across the road from Villa Rose. The inspector spoke with the homeowners and individual discussion also took place with four staff members and the cook. In addition, discussion also took place with a number of residents within a group setting. A number of records, including staff recruitment and medication records were examined. What the service does well: What has improved since the last inspection?
The homeowners have now both completed the NVQ Level 4 qualification. Care plans, are now being signed by the resident. Locks have now been fitted to the laundry room to ensure that COSHH products are safely stored and the safety of residents is maintained.
Villarose DS0000009787.V260368.R01.S.doc Version 5.1 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 DS0000009787.V260368.R01.S.doc Version 5.1 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.V260368.R01.S.doc Version 5.1 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): EVIDENCE: All of the above core standards were assessed at the previous inspection. Villarose DS0000009787.V260368.R01.S.doc Version 5.1 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 the following standard(s): 9 A good medication policy is in place however this is not being consistently followed. EVIDENCE: The medication policy has been amended in line with the advice provided by the Pharmacist Inspector at a previous inspection. Staff spoken to confirmed that they had received training in the safe administration of medication. However some procedures are not following good practice. The inspector noted that a system of secondary dispensing medication was being adopted. Tablets were being left in named pots for administration later in the day. This system is not acceptable and increases the risks of mistakes occurring. All medication must be dispensed directly from the pharmacist container and signed for at the point of administration by the staff member. Examination of the medication records revealed some dose omissions, in that, it was evident that the medication had been administered but not signed for by the staff member. Therefore medication procedures must be reviewed to ensure they adhere to current legislation and accepted good practice.
Villarose DS0000009787.V260368.R01.S.doc Version 5.1 Page 10 A number of residents take charge of there own medication and locked facilities are provided in resident’s bedrooms for safe storage. The homeowners was advised that any resident wishing to and is able to retain responsibility for their own medication should be asked to sign a disclaimer agreeing to keep all medicines safely locked when not in use. All medication is stored safely in secure locked cupboards to which only senior staff has access to the keys. Villarose DS0000009787.V260368.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: All of the above standards were assessed at the previous inspection. Villarose DS0000009787.V260368.R01.S.doc Version 5.1 Page 12 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): 18 Residents are protected by a robust policies and procedures that enable concerns to be raised and responded to and to protect residents from abuse. EVIDENCE: The home has an abuse policy in place, which includes guidance on whistle blowing, abuse by residents and advice for staff regarding challenging behaviour. This policy is easily accessible by staff and is compliant with the D.O.H. guidance ‘No Secrets’. Villarose DS0000009787.V260368.R01.S.doc Version 5.1 Page 13 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): EVIDENCE: All of the above standards were assessed at the previous inspection. Villarose DS0000009787.V260368.R01.S.doc Version 5.1 Page 14 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 Staffing levels are satisfactory to meet the needs of the residents. Policies and procedures for the recruitment of staff are in place. Induction training should be appropriately recorded. EVIDENCE: Observation of the staff rota revealed that adequate staff are on duty to meet the needs of the residents. Staff spoken to stated that time is available to spend time with residents and that the routines of the home can be flexible. There is a policy in place in respect of staff recruitment, which is adhered to by the homeowners. Evidence of all required checks was viewed on file including references and verification of identity. Criminal Records Bureau checks were examined it was noted that a cook who had recently commenced employment had not been referred to the Criminal Record Bureau prior to her employment. The homeowners were advised that current legislation states that all staff must be police checked prior to them commencing employment irrespective of the length of time of any previous police checks. The homeowners were also advised that all overseas staff must be cleared through the Criminal Record Bureau as an addition to any police clearances obtained from their country of origin. It was pleasing to note that with the exception of the appointment of a cook there have been no further staff changes since the previous inspection. The inspector spoke with the cook who confirmed that she had worked for three
Villarose DS0000009787.V260368.R01.S.doc Version 5.1 Page 15 days prior to taking up her duties in order that she could receive induction training. At present this induction training is not recorded and the homeowners were asked to develop a checklist that records the training provided which once completed should be signed by the new staff member and the person providing the training. The inspector also provided some advice and a copy of The Skills for Care induction standards. Individual records of training were viewed which confirmed mandatory training was in place, however these records should be extended to record other internal and external training undertaken. The homeowners were also advised to develop an up to date training matrix to be able to identify collectively the skills and knowledge of the staff team at any given time and to identify when training updates are required. Staff confirmed during discussions that they are actively encouraged to access training. One member of staff said “we get plenty of support from the homeowners and are kept up to date with training courses that are appropriate to our work”. It is to the credit of the homeowners and the staff that good progress has been made with the numbers of staff that have achieved an NVQ qualification. Nine of the ten staff has achieved an NVQ level 2 or equivalent. This standard has now been exceeded with well over 50 of the staff group now being appropriately qualified. Annual appraisals have been introduced and staff spoken to confirmed that they found the appraisal forum to be useful in discussing their role and identifying future training needs. The inspector now hopes that the appraisal system will develop into regular supervision. Villarose DS0000009787.V260368.R01.S.doc Version 5.1 Page 16 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): 31,33,35,36 and 38 Resident’s finances are protected. Systems need to be put into place to reduce the risk of legionella. Risk assessments need to be put into place for all safe working practices. EVIDENCE: Staff members were very positive in their comments about the homeowners and the support they provide. One staff member stated, “the homeowners are always available, they are approachable, supportive and helpful”. The quality of the service provided is closely monitored and this is evidenced as the home has achieved the Investor in People award for two consecutive periods of time. Formal supervision was discussed with the homeowners and it is their intention to introduce this once all the staff has received their annual appraisal.
Villarose DS0000009787.V260368.R01.S.doc Version 5.1 Page 17 Inspections of records for residents were comprehensive, well written and up to date. Records of money being handled by the homeowner for residents were up to date, explaining the reason for any expenditure and the balance of the money that was being retained. The inspector advised that a second signature in the form of a witness should be obtained for any expenditure of resident’s money. The homeowners are very conscious of health and safety and have good policies in place. A health and safety inspection was carried out by the Health and Safety Executive employed by Fylde Borough Council on the 13th October 2005, the homeowner stated that the inspection had been very positive with one requirement made to have systems in place to reduce the risk of legionella disease, a further recommendation was made to introduce risk assessments in relation to COSHH products. The inspector discussed the need to have risk assessments in place for all areas that could be a potential hazard, in particular to the use of cot sides and safe working practices. The inspector advised that a critical view should be taken of the whole environment and work practices and risk assessments developed that should then be read and signed by the whole staff group. Records provided evidence that regular fire drills take place and fire safety equipment is checked regularly. Staff do receive training in mandatory subjects, however due to the lack of a training matrix it was difficult to establish if all staff had current certificates. The inspector provided advise as to the training that should be provided and informed the homeowner that a named first aider must be on duty at all times. A training matrix should be in place and the inspector recommended that this be kept up to date in order to assess and evaluate what training has taken place and when refresher courses are due. Whilst a number of documents were examined that confirmed equipment is service as per manufactures recommendations, some safety certificates could not be located. The homeowner was asked to complete and forward the pre inspection questionnaire in order to provide evidence to confirm that all equipment is maintained and serviced at appropriate intervals and that safety certificates are in place. The homeowners was reminded that that all significant events including the death of a resident must be reported to The Commission for Social Care Inspection. Villarose DS0000009787.V260368.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Villarose DS0000009787.V260368.R01.S.doc Version 5.1 Page 19 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Risk assessments for the use of cot sides should form an integral part of the care plan.(not met from previous inspection) A system must be put into place in order that the risk of Legionella is minimised. All induction training must be recorded. The system of secondary dispensing of medication must cease. Regulation 37 notices must be forwarded to the Commission for Social Care Inspection. All staff must be referred to the Criminal Record Bureau for clearance prior to employment, this also refers to the oversees staff. Medication must be signed for at the point of administration. Risk assessments for all potential hazards including the use of COSHH products should be in place. Timescale for action 31/01/06 2. 3 4 5 6 OP38 OP30 OP9 OP33 OP29 23 18 18 37 19 31/01/06 31/01/06 04/01/06 04/01/06 04/01/06 7 8 OP9 OP38 17 23 04/01/06 31/01/06 Villarose DS0000009787.V260368.R01.S.doc Version 5.1 Page 20 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 4 Refer to Standard OP28 OP36 OP9 OP38 Good Practice Recommendations A training matrix should be developed in order that a up to date record is maintained of all training undertaken by the staff group. Formal staff supervision should be in place. Residents who self medicate should be asked to sign a disclaimer agreeing to accept responsibility for the safe storage of their medication. Evidence should be forwarded to the Commission for Social Care Inspection to confirm that all maintenance and safety checks are in place. Villarose DS0000009787.V260368.R01.S.doc Version 5.1 Page 21 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
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