Inspection on 27/06/05 for West Villa Ltd

This inspection was carried out on 27th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 26/01/06

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 73 Batley Road Wakefield WF2 0AB Lead Inspector Gillian Walsh Unannounced 27 June 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. West Villa J51J01_s6226_West Villa_v235389_270605.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service West Villa Address 73 Batley Road Wakefield WF2 0AB 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) 01924 377328 01924 291795 Mr and Mrs Jones Mrs Judith Jones Care Home 32 Category(ies) of Mental Disorder - over 65 - 32 places registration, with number Dementia - over 65 - 32 places of places Old age - 32 places West Villa J51J01_s6226_West Villa_v235389_270605.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 16.11.04 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, 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 J51J01_s6226_West Villa_v235389_270605.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection made on 27th June 2005 over five hours. Time was spent looking around the home, talking with residents and staff and looking at documentation. The inspector would like to thank residents and staff for their openness and time and assistance during the visit. What the service does well: What has improved since the last inspection? 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. West Villa J51J01_s6226_West Villa_v235389_270605.doc Version 1.40 Page 6 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 West Villa J51J01_s6226_West Villa_v235389_270605.doc Version 1.40 Page 7 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) 2, 3, 4 and 5 The home’s admission procedure ensures that residents are not admitted to the home without a full assessment of their needs being done and residents have had opportunity to visit the home before making the decision to move in. Standard 6 is not applicable as the home does not provide intermediate care. EVIDENCE: All new residents are issued with a statement of terms and conditions on admission and copies of these were seen on resident’s files. The registered person said that all potential residents are assessed by one of the senior staff to ensure that their needs can be met at the home. The potential resident and their family are also encouraged to visit the home before making the decision to move in. An offer of placement is then confirmed by letter to the potential resident or their next of kin. West Villa J51J01_s6226_West Villa_v235389_270605.doc Version 1.40 Page 8 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 Individual care plans are in place but do not include sufficient detail of residents more acute needs such as pressure area care. Resident’s health care needs are met. Residents feel that they are treated with respect. EVIDENCE: The registered person said that care plan files were being revised to make them more user friendly. An example of this was seen and appeared to be well laid out and included good information. One of the residents is having problems with pressure areas and the district nurse has been involved in their treatment. The pressure areas are in need of, and are receiving, ongoing attention and observation from the home’s staff but there was not a care plan available to outline what staff should be doing to maintain and promote healthy tissue. There was also no mention in this resident’s care plan of recent weight loss. Plans of care for resident’s needs in relation to activities of daily living are in place and provide good information. Some discussion took place about how West Villa J51J01_s6226_West Villa_v235389_270605.doc Version 1.40 Page 9 staff could further improve the care planning process by including more detail about residents personal preferences and likes and dislikes. Evidence was available in care plan files to show that resident’s are referred to appropriate professionals as required to ensure that their health care needs are met. All of the residents who spoke with the inspector said that staff were kind and respectful. One person said that staff did not always knock on the bedroom door before entering but they didn’t mind this. The inspector observed this whilst speaking to a resident in their bedroom and a care assistant entered the room without knocking and made no apology for interrupting the conversation. Another person said that staff could not be better in their approach and that their need for privacy was always respected. West Villa J51J01_s6226_West Villa_v235389_270605.doc Version 1.40 Page 10 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) 13 and 14 Residents maintain contact with families and friends as they wish and are encouraged and supported to make decisions about their lifestyle. EVIDENCE: One resident said that their family visit every day and another said that their family come whenever they can and are always made welcome at the home. Another resident said that on nice days their family take them out on short trips. One resident said that they were able to make choices about how they spent their time, what time they got up and went to bed, what they ate and where they chose to take their meals. On the day of the inspection residents were being asked if they would like to eat their lunch in the garden to enjoy the nice weather. One resident said that they had done this the previous day and was glad that staff had encouraged them to join in as they found it very enjoyable. Time was spent with one person who chooses not to join other residents in the communal areas and stays in their room all the time. This person said that staff were supportive of their choice to stay in their room and made sure that they had everything they needed for their comfort. West Villa J51J01_s6226_West Villa_v235389_270605.doc Version 1.40 Page 11 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 and 18 Residents are confident that any concerns or complaints they have will be listened to and acted upon. Staff training and the home’s policies ensure that residents are protected from abuse. EVIDENCE: The complaints procedure is available within the service user guide and on notice boards around the home. One resident said that staff would always listen to any concerns they may have and that the registered person would always sort things out for them if they had a problem. Staff said that they would always report any suspicion of abuse to the registered person but were a little unclear on what actions they should take within Wakefield council’s adult protection procedures. The registered person is familiar with the procedure and further training has been organised for staff on this subject. West Villa J51J01_s6226_West Villa_v235389_270605.doc Version 1.40 Page 12 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) 20, 21, 22, 23, 24, 25 and 26 Residents live in a safe, well-maintained and comfortable home with facilities in place to meet their needs. EVIDENCE: Time was spent touring the home with staff. Communal areas were homely, comfortable, clean and tidy. The garden appeared well kept and provided a nice place for residents to sit and enjoy the good weather. One of the upstairs bathrooms was being used to store things in and a member of staff said that they didn’t use that room as all the residents had their baths downstairs. The inspector questioned this as the bathroom was near to several resident’s bedrooms and may be a more appropriate room for them to use. The care assistant and later the registered person said that there was no reason other than habit why all residents bathed downstairs and said that the room would be cleared and residents would be offered the choice of using the room. Some toilet and bathroom doors do not have appropriate signage and some do not have engaged/vacant indicators. West Villa J51J01_s6226_West Villa_v235389_270605.doc Version 1.40 Page 13 All of the resident’s bedrooms seen were clean and tidy and had been personalised to provide the resident with very comfortable private space. Some bedrooms were in need of call bell extensions to ensure that the resident could reach the bell. Two bedroom doors did not have locks but the registered person said that these were on order. All of the residents who spoke with the inspector said that they were very happy with their bedrooms and with the environment in general. West Villa J51J01_s6226_West Villa_v235389_270605.doc Version 1.40 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 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 and 30 Residents are cared for by appropriately trained staff, available in sufficient numbers to meet with their needs. EVIDENCE: None of the residents who spoke with the inspector felt that there were insufficient numbers of staff available staff to meet their needs. All shifts are covered by a senior carer and the inspector was told that a staff member trained in first aid is available on each shift. Training is ongoing at the home and training plans have been developed. West Villa J51J01_s6226_West Villa_v235389_270605.doc Version 1.40 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 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) 31, 32 and 38 Residents have faith in the abilities of the home’s manager. The health, safety and welfare of residents and staff are protected. EVIDENCE: The registered person is a registered nurse who owns and manages the home. Several of the residents spoke very highly of her and one person said that they have complete confidence in her. The registered person is supported by senior care staff, each of who have specific roles in the day to day management of the home. Health and safety files including fire drills and training, hoist, lift, gas and water supply and delivery records were checked and were up to date. West Villa J51J01_s6226_West Villa_v235389_270605.doc Version 1.40 Page 16 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION x 3 2 3 3 2 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x x x x 3 West Villa J51J01_s6226_West Villa_v235389_270605.doc Version 1.40 Page 17 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 Regulation None 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. 2. 3. 4. 5. 6. Refer to Standard OP7 OP10 OP18 OP21 OP21 OP24 Good Practice Recommendations Care plans should give better detail of residents of how residents acute needs should be met. Care staff should be reminded to knock on residents bedroom doors berore entering. Training in protection of vulnerable adults should continue to ensure that all staff Residents should have the choice of which bathroom they wish to use and bathrooms should be kept clear of clutter. Toilet and bathroom doors should have appropriate signage and engaged/vacant indicators. Extension leads for call bells should be provided in bedrooms where required by the resident. West Villa J51J01_s6226_West Villa_v235389_270605.doc Version 1.40 Page 18 Commission for Social Care Inspection 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 J51J01_s6226_West Villa_v235389_270605.doc Version 1.40 Page 19 - 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. 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