Inspection on 21/04/05 for Vivian House

This inspection was carried out on 21st April 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.

Other inspections for this house

Vivian House 03/05/07

Vivian House 04/10/06

Vivian House 21/09/05

Vivian House 21/09/04

Vivian House 14/04/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE VIVIAN HOUSE Brunswick Street Morley LEEDS LS27 9DL Lead Inspector Graham Drye Unannounced 21 April 2005 10-00 am 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. VIVIAN HOUSE Version 1.10 Page 3 SERVICE INFORMATION Name of service VIVIAN HOUSE Address Brunswick Street 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) 0113 2530309 W & S Red Rose Healthcare Limited CRH 21 Category(ies) of PC registration, with number of places VIVIAN HOUSE Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 10 October 04 Brief Description of the Service: Vivian House is a large detached property set in its own grounds. Over a period, the house has had a 2-storey extension added. It is situated on the outskirts of Morley, but within easy reach of all the amenities in the centre of Morley, there is convenient for bus service to surrounding areas. The home provides care for 21 elderly service users who require residential care by virtue of old age. Accommodation is provided on 2 floors, which are serviced by a lift, there is also a stair lift available in the older part of the building. There are 19 single bedrooms and 1shared bedroom. Bathing and toilet facilities are available on all floors, and 4 of the single bedrooms have an en-suit toilet. The ground floor also contains a choice of sitting area and a large dining room, which overlooks gardens to the front of the building. VIVIAN HOUSE Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first visit for this inspection year 2005/6. The inspection was unannounced with the next inspection being announced. The inspection took place over the morning and early afternoon of 5th April 2005. It focused on issues outstanding from the last inspection, records, the premises and discussions with service users. A total of 5 service users were spoken with during the inspection. Three were detailed discussions relating to their care plans. Brief discussion did take place with the staff regarding general issues relating to the home. The home continues to benefit from the day-to-day involvement of the registered person who is keen to ensure that the service users maximise their quality of life. It was clear from this inspection that the staff team value the service users and are keen to develop a service user led model of care. Assistance when given was discreet and reflected the service users need and ability. The staff practices clearly acknowledge the service users rights to privacy. Service users spoken to stated they were happy with their lifestyle. What the service does well: What has improved since the last inspection? There has been some refurbishment of the communal area’s and re carpeting of the ground floor corridor area’s. The kitchen cuboards have been upgraded. VIVIAN HOUSE Version 1.10 Page 6 The manager has reorganised the some of the care documentation. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. VIVIAN HOUSE Version 1.10 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 VIVIAN HOUSE Version 1.10 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) 3,6 the home has a comprhensive admission procedure. Service users are encouraged to make an informed choice about the home through visits to look round. The home ensures that it can meet the needs of prospective residents before they are admitted. EVIDENCE: All the service users have a care plan which, is generated from the initial assessment undertaken by the manager or based upon the “Easy Care” information package provided by the referring authority. Currently the home does not provide intermediate care. VIVIAN HOUSE Version 1.10 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) 7,8,9,10 It was evident from the records that where appropriate the service user was involved in the development of the care plan. There was also supporting evidence of family/carer involvement. Each service user has a comprehensive care plan that sets out their individual needs in a clear and consise way it identifies the manner in which the care is delivered. The plans are dated and signed and there are dates set for the review of the individual plans. The care plans reflect good ongoing involvement of other professionals including community nurses. Care plans seen clearly indicated that specialist equipment was provided on a as needed basis. However, the staff do not consistently use the available documentation to make appropriate entries to reflect the of care. All the service users are registered with a local doctor, regular hearing and sight tests take place. The drugs storage and records and found them to be well organised. Currently none of the service users manage their own medication although the manager said that following assessment service users would be encouraged to self medicate if it was safe to do so. VIVIAN HOUSE Version 1.10 Page 10 It was very evident from observation that the staff teams interaction with the service users reflected the service users rights to privacy and dignity these areas are reflected in the care plans. EVIDENCE: VIVIAN HOUSE Version 1.10 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) 12,13,14,15.The inspector was involved in a meal at the home. Social stimulation in the home is not provided in an organised manner. Service users are enabled and encouraged to continue links with their friends and family and to exercise choice and control over their lives. EVIDENCE: The social needs of the service users are well documented. The home has a well equipped activities room, however, the social needs are not met by the staff team in an organised manner. There needs to be a more evidence of the staff team meeting social needs regularly. At the time of the inspection the inspector notedf that the service users had been involved in making items to celebrate St Georges day. The manager said that the home did not have any service users from ethnic minorities but if this happened in the future would alwaysmake sure that their individual cultural needs are met and religious dates are appropriately celebrated. Since the last inspection the seating in the dining room has been reorganised into smaller groups which makes meal times more of a social occasion. This allows for greater socialisation between service users. The main meal of the day was relaxed and informal. Staff support when provided reflected the individual service user,s dignity and needs. VIVIAN HOUSE Version 1.10 Page 12 The inspector spoke with a number of visitors. They said that they were able to visit at any reasonable time. Service users said that they were enabled to visit the local shops with staff support. Currently one service user manages their own finances, the manager said that the service users are assessed as to their ability to manage areas of self care, including medication and personal finances. This is evidenced in individual service users files. The service users complimented the quality of the food. However. The management do not provide a menu, this was discussed with the manager who was advised to produce a menu which offers a choice to the service users. The meal seen was provided in a relaxed and informal way staff support when provided reflected the individuals dignity. Large handled cutlery and other equipment was available to make sure that service users remained independent. VIVIAN HOUSE Version 1.10 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) 16,18 complaints are handled in a positive manner with appropriate action taken. The home has produced a Adult abuse policy which links to local policy/procedures. Service users are protected and feel safe in the home. EVIDENCE: The home has a comprehensive complaints procedure. Service users and families spoken with said that they knew how to raise concerns. One complaint was received by CSCI over the past year alleging poor care practice. This complaint was, not substantiated. The home, were able to provide records of appropriate actions being provided by both the staff team and community nurses, which rebutted the allegation. Feedback was provided to the complainant. The Adult Abuse procedure meets the current standards and reflects local policy. VIVIAN HOUSE Version 1.10 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) Service users are living in a safe and well-maintained home, which is suitable for their needs. The home is clean and tidy. EVIDENCE: Since the last inspection the home has continued with their programme of redecoration and some refurbishment. Some new seating has been provided, and new carpets have been fitted in some areas. There has also been some upgrade of the kitchen cuboards. All hot water outlets are regulated and exposed hot water pipes are guarded. Attempts have been made to make the bathrooms more inviting. Service users are encouraged to personalise their own rooms. All rooms have door locks. VIVIAN HOUSE Version 1.10 Page 15 At the time of the inspection there were no malodours present. Ancillary staff have had COSHH training. VIVIAN HOUSE Version 1.10 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) 27,29,30.The recruitment procedure meets the standards and provides safeguards to the people living in the home.Deployment of staff is appropriate to meet the needs of the service users EVIDENCE: There is a very stable staff team at the home. Staff files examined show that all the necessary recruitment checks including Criminal records Bureau and Protection of Vunerable Adults checks are carried out and all the required documentation was available. There are no staff under the age of 18 and none of the senior staff are under 21. Service users said that the staff were very caring and always appeared to have time to spend “just to chat”. Rotas showed which staff were on duty at any particular time of the day. Currently 5 members of staff hold NVQ level 2. Four other members of staff are undertaking the qualification. Two members of staff hold NVQ level 3. At the time of the inspection staff were undertaking “Moving and Handling” training. VIVIAN HOUSE Version 1.10 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( 31,32,33,35,38) Good lines of communication have been established at the home. The views of staff and service users are sought. EVIDENCE: The manager adopts an open door policy. The service user’s families said that the manager and proprietor make time available for them and that they were very open in their responses. This approach creates a relaxed and homely atmosphere. The inspector discussed with the manager the need to identify on the rota the hours when she is working in a management role. Inspection of the fire records showed that regular fire drills take place. Staff confirmed that they had been involved in fire practices. Fire extinguishers are regularly checked. Currently one service user manages their own finances, the manager said that this is an area they are keen to promote and is part of the initial assessment. VIVIAN HOUSE Version 1.10 Page 18 For the majority of service users the family manage the finances including the service users personal allowance, which is paid by the referring authority direct to the family. Staff records were examined and it was found that there were some gaps in the records of staff employed before the current manager and proprietor took over the running of the home. However, for the most recent appointments to the home their records have all the required documentation and checks. VIVIAN HOUSE Version 1.10 Page 19 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. Where there is no score against a standard it has not been looked at during this inspection. 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 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 Standard No 16 17 18 Score 3 3 3 2 3 3 x 3 x x 3 VIVIAN HOUSE Version 1.10 Page 20 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 12 Regulation 16(2)(m) Requirement The registered person shall given the size of the care home and the number and needs of the service users enable them to engage in local, social and community activities. Timescale for action 1.08.05 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 31 Good Practice Recommendations Care staff should ensure that the care required by the service user plan is consistently recorded. senior staff need to evidence oversight of the recording systems. The manager should ensure that the rota reflect the times she is undertaking careor management roles. VIVIAN HOUSE Version 1.10 Page 21 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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 VIVIAN HOUSE Version 1.10 Page 22 - 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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