Inspection on 26/01/06 for West Villa Ltd

This inspection was carried out on 26th January 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 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

West Villa Ltd 04/06/07

West Villa Ltd 21/12/06

West Villa Ltd 27/06/05

West Villa Ltd 16/11/04

West Villa Ltd 26/08/04

West Villa Ltd 24/03/04

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

CARE HOMES FOR OLDER PEOPLE West Villa Ltd 73 Batley Road Wakefield West Yorks WF2 0AB Lead Inspector Gillian Walsh Unannounced Inspection 26th January 2006 09:45 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 West Villa Ltd DS0000006226.V253825.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. West Villa Ltd DS0000006226.V253825.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service West Villa Ltd Address 73 Batley Road Wakefield West Yorks WF2 0AB 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) 01924 377328 01924 291795 Mr Jones Mrs Jones Mrs Judith Jones Care Home 32 Category(ies) of Dementia - over 65 years of age (32), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (32), Old age, not falling within any other category (32) West Villa Ltd DS0000006226.V253825.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. To provide care for one named person under 65 years with physical disabilities (PD) Two named persons under 65 years One named person under 65 years with a mental disorder. Date of last inspection 27th June 2005 Brief Description of the Service: West Villa is registered to provide personal care and accommodation for up to 32 older people who may also have mental health problems. The home is set back in its own grounds in Alverthorpe on the outskirts of Wakefield. It is on a main bus route and close to local amenities. There is a large walled garden with well established trees and shrubs. There are three large lounges and a large dining room and conservatory which overlooks the garden. All rooms are single occupancy, 22 having an en suite facility. There are communal toilets and bathrooms within close proximity to communal areas. West Villa Ltd DS0000006226.V253825.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 made on 26th January 2005. Only a small number of standards were assessed on this occasion as most key standards were assessed as met on the previous unannounced visit. Time was spent talking with residents, walking around the home and speaking with staff and management. The inspector would like to thank residents and staff for their time, assistance and hospitality during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Discussion took place with staff and management about how care plan files could be better organised to ensure that documentation is available to evidence that all residents’ needs and preferences are considered and that appropriate assessments are made and demonstrated through the care planning process. The home’s manager and staff demonstrated an eagerness to make improvements in this area. West Villa Ltd DS0000006226.V253825.R01.S.doc Version 5.1 Page 6 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. West Villa Ltd DS0000006226.V253825.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 West Villa Ltd DS0000006226.V253825.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 key standards in this section were assessed at the last inspection and were found to be met. West Villa Ltd DS0000006226.V253825.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): 7 and 9. Not all of the residents’ needs are considered within the current care planning documentation. This could result in some needs being overlooked. Residents are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Since the last inspection the documentation included in care plan files has been reviewed. Positively, the files now include short-term care plans for more acute problems such as pressure sores, chest infections etc. Unfortunately, as part of this review, some of the useful information such as pen pictures and care plans covering areas of need as defined in the activities of daily living have been removed. This has resulted in information about individuals’ personal preferences regarding their lifestyles and social and recreational needs no longer being available. Discussion took place with the manager and staff about what information should be included in the files and what could be kept separately to the main care plans. West Villa Ltd DS0000006226.V253825.R01.S.doc Version 5.1 Page 10 Risk assessments are being completed but some of the ones seen were out of date and no longer relevant. Assessments such as Waterlows and nutritional assessments are being completed although the information from these is not always being used to formulate an appropriate care plan. For example, the weight chart for one person indicated a steady weight loss over a period of five months but a care plan had not been devised to say how this problem was to be addressed to prevent further weight loss. Daily records are generally good and reflect how residents have spent their time and what interventions they have received. Policies and procedures for the receipt, storage, administration and disposal of medications ensure that a safe system is maintained at the home. West Villa Ltd DS0000006226.V253825.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): 12 and 15. Residents are happy with the lifestyle they experience at the home. Residents enjoy wholesome and appealing meals and are provided with enough choice to meet their needs. EVIDENCE: All of the residents spoken with said that they were happy with their lifestyles at the home and had plenty to do with their time. Activities are carried out on a daily basis by care staff which most of the residents spoken with said they enjoyed. One resident said that they preferred to stay in their room but was happy with their television, magazines and visits from family. Menus are in place at the home which are rotated on a three weekly basis. All of the residents spoken with said that they were very happy with the food provided at the home and that they had plenty of choice available to them. West Villa Ltd DS0000006226.V253825.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): EVIDENCE: Both standards in this section were assessed at the last inspection and were found to be met. West Villa Ltd DS0000006226.V253825.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): 19. Residents live in a safe, well maintained environment. EVIDENCE: Generally the home is well maintained and redecoration is completed on an “as required” or rolling programme schedule. One bedroom was identified as in need of redecoration but this was already known to the manager. West Villa Ltd DS0000006226.V253825.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): 29. Systems in place at the home ensure that residents are supported and protected by the recruitment policy and practices. EVIDENCE: All of the staff files seen contained all of the documentation required by regulation to, as far as reasonably possible, ensure the protection of residents. West Villa Ltd DS0000006226.V253825.R01.S.doc Version 5.1 Page 15 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): 33 and 35. Quality monitoring is in place to ensure that the home is run in the best interests of residents. Procedures are in place to ensure that residents’ financial interests are safeguarded. EVIDENCE: Staff at the home carry out weekly quality checks for the environment and care procedures, a sample of these was seen. Quality monitoring is done on an annual basis using questionnaires for staff, residents, visitors and professionals visiting the home. Information gained through this procedure is put together in a booklet and an action plan is formulated. West Villa Ltd DS0000006226.V253825.R01.S.doc Version 5.1 Page 16 Procedures and documentation relating to small amounts of residents’ personal allowances kept, at their request, in the home’s safe were checked. All of the balances and documentation checked were correct. West Villa Ltd DS0000006226.V253825.R01.S.doc Version 5.1 Page 17 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 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X X West Villa Ltd DS0000006226.V253825.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations Care plans should be reviewed to provide detail of how resident’s needs, including social, recreational and psychological needs should be met. West Villa Ltd DS0000006226.V253825.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 West Villa Ltd DS0000006226.V253825.R01.S.doc Version 5.1 Page 20 - 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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