We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

Transcription

1 Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Eastbourne Villa 21 Eastbourne Road, Hornsea, HU18 1QS Tel: Date of Inspection: 23 July 2014 Date of Publication: August 2014 We inspected the following standards as part of a routine inspection. This is what we found: Care and welfare of people who use services Safeguarding people who use services from abuse Requirements relating to workers Staffing Supporting workers Assessing and monitoring the quality of service provision Records Met this standard Met this standard Met this standard Action needed Action needed Action needed Action needed Inspection Report Eastbourne Villa August

2 Details about this location Registered Provider Registered Manager Overview of the service Type of service Regulated activity Mr & Mrs G Hart Mrs Phyllis Irene Poole Eastbourne Villa is a care home that provides accommodation and personal care for older people, including those with dementia related conditions. The home is situated in Hornsea, a seaside town in the East Riding of Yorkshire. It is close to the sea front and to the town centre. A new extension has recently been completed and everyone is accommodated in a single room. Some bedrooms have en-suite facilities. Care home service without nursing Accommodation for persons who require nursing or personal care Inspection Report Eastbourne Villa August

3 Contents When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'. Summary of this inspection: Page Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 What we have told the provider to do 7 More information about the provider 7 Our judgements for each standard inspected: Care and welfare of people who use services 8 Safeguarding people who use services from abuse 10 Requirements relating to workers 11 Staffing 12 Supporting workers 14 Assessing and monitoring the quality of service provision 16 Records 18 Information primarily for the provider: Action we have told the provider to take 19 About CQC Inspections 21 How we define our judgements 22 Glossary of terms we use in this report 24 Contact us 26 Inspection Report Eastbourne Villa August

4 Summary of this inspection Why we carried out this inspection This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection. This was an unannounced inspection. How we carried out this inspection We looked at the personal care or treatment records of people who use the service, carried out a visit on 23 July 2014, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with staff and reviewed information sent to us by other authorities. What people told us and what we found Our inspection team was made up of one inspector. We gathered evidence against the outcomes we inspected to help answer the five key questions: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? We looked at a range of records, spoke with the manager, five members of staff and five people who used the service. We also observed the interactions between staff and people living at Eastbourne Villa. If you want to see the evidence supporting our summary please read the full report. Is the service safe? People were treated with respect and dignity by the staff. People told us they were listened to and that they felt safe. Staff understood their role in safeguarding the people they supported. CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. At the time of our inspection they had no DoLs in place. The home had policies and procedures in relation to the Deprivation of Liberty Safeguards but not for the Mental Capacity Act and only five out of 16 staff had received Mental Capacity Act training, three of which were in There was no system in place to make sure that manager and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This increased the risk of harm to people and failed to ensure that lessons were learned from mistakes. The home did not have a complaints policy. Safe recruitment procedures ensured that people were protected from unsuitable staff. Is the service effective? Inspection Report Eastbourne Villa August

5 People's health and care needs were assessed and however it was not recorded that these were reviewed. Some monthly reviews were dated December Body maps were in place but these were not fully dated, for example one person's said 20/7 but no year was added. Daily records such as fluid charts, turning charts and daily events charts were completed but the column that said date and time, only the date was added. People's care plans provided information on the care they needed but they were not person centred. There was very little information about a person's life history, their likes or dislikes. Records of activity and social recordings were not completed, therefore it looked like the last time someone had quality time spent with them was August Is the service caring? People were supported by kind and attentive staff. We saw that staff engaged with people in a positive way and showed respect, kindness and gave people gentle encouragement. Staff we spoke with demonstrated a good understand of the people they cared for and were able to tell us how they tried to recognise and meet people's individual needs. Staff told us they were looking forward to starting the distance learning dementia training. Is the service responsive? People who used the service said they knew how to make a complaint if needed. We asked to see the complaints file, there was one complaint registered. The manager told us that any verbal complaints or little complaints such as clothes going missing were not recorded. There was information on the walls to say how someone could make a complaint, although this needed updating. This meant people were at risk of not having their concerns and needs properly taken into account. Staff we spoke to had a good understanding of how to raise concerns and felt able to raise these with the manager. Two people who used the service had seen the dietician and been diagnosed as clinically malnourished. One person was in May 2014 and had not been weighed since and one person was diagnosed on the 11th June 2014 but was not weighed again until the 8th July We spoke with the manager regarding this and the first person was not weighed due to mobility reasons and needing special scales, the manager had been in contact with the dietician about this, although this was not recorded. The second person was due to the decision to weigh them monthly rather than weekly. We have asked the manager to put something in place immediately regarding this. In one person's care file it stated they liked to see the chiropodist regularly, there were no records of any visits to see the chiropodist. Whilst we looked at the finance records we saw evidence of payment to a chiropodist. We asked a member of staff to find this record in the professional visits log, this was not recorded. One person had not received a diabetic eye screening test since January We spoke to the manager about this and there was a legitimate reason, this had not been recorded. Is the service well-led? We looked at the finance records for seven people and found that there were discrepancies with one of them, there was 1.10 less money than recorded. We spoke Inspection Report Eastbourne Villa August

6 with the manager about this and she was going to investigate. The service did not have any records of quality assurance systems in place. Therefore the registered manager was not protecting the people who used the service and others against the risks of inappropriate or unsafe care and treatment. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance and record keeping. People who used the service had the opportunity to attend meetings. Topics discussed were mainly food and the choice, likes and dislikes. Staff also attended regular meetings where they discussed holidays, a recent local authority inspection, and completion of records along with handwriting. At the latest meeting they discussed staff cut backs, fees and rotas. The manager also said she puts a monthly newsletter in with their pay, this covered any updates, changes, relevant news and inspections that had taken place. The manager said she was planning on setting up relative's meetings. Survey/questionnaires had been sent out to all relatives with a few responses. Staff had also completed one and the majority of the comments were they enjoyed working at Eastbourne Villa but the décor needed updating, they would like more activities and there were not enough staff. We discussed with the manager about how they were going to address these concerns. One member of staff explained that they were key worker for a person that used the service. This person loves gardening and had totally transformed the back garden. They said they often took this person to garden centres, at least once a week. We questioned how this left the staff in the home, as there was only two staff on duty at any one time. The person said she could only do this on her day off. Eastbourne Villa was badly in need of redecorating, paper was coming off the walls, walls were half painted and then left, paint was coming off window seals leaving bare wood and carpets needed cleaning. Many areas looked like they could do with a thorough clean; the manager said it was difficult as they had one cleaner who worked for two hours a day. It was then left for the two members of staff to clean, do laundry, provide all meals after the cook went home at 1pm and care for the people who used the service. There were also a clear lack of any activities taking place; we have asked the manager to look into this. What people told us. People who used the service said, "Staff are nice, all helpful and pleasant," and "Staff are brilliant and will do anything for me," and "I feel safe, I have no worries." Staff we spoke with said, "Staff interacts well on a personal level, they know the residents really well," and "I feel supported and my manager is very supportive," and "There is never a single day I do not want to come to work." One member of staff said "I love the residents; the manager is great I just wish the owners would support more." You can see our judgements on the front page of this report. Inspection Report Eastbourne Villa August

7 What we have told the provider to do We have asked the provider to send us a report by 12 August 2014, setting out the action they will take to meet the standards. We will check to make sure that this action is taken. Where providers are not meeting essential standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service (and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take. More information about the provider Please see our website for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases we use in the report. Inspection Report Eastbourne Villa August

8 Our judgements for each standard inspected Care and welfare of people who use services Met this standard People should get safe and appropriate care that meets their needs and supports their rights Our judgement The provider was meeting this standard. Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. Reasons for our judgement During the inspection we sat in communal areas so that we could see both staff and people who used the service. Some of the people who used the service lived with a dementia and other conditions which made it difficult for them to express their opinions or recall recent events. Because of this, we observed the way staff and people interacted. We saw that staff treated people kindly and explained what was happening when they assisted people. We saw that people were encouraged to mobilise independently (when possible) and that staff assisted people with personal care throughout our visit. For example, staff assisted or prompted people to go to the toilet. We saw that staff treated people with dignity and respect. The staff we spoke with knew people well and were able to explain how they met people's needs. For example, how they ensured that people received regular baths or showers and had their continence needs met. At the time of our inspection there were 11 people who used the service. During our visit we reviewed four peoples care records. People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. We found the care plans had a lot of information about the care that was needed and how this care was provided. This information was not regularly reviewed, so any possible changes were not reflected in the care plans. Some monthly reviews were dated December The manager did complete three monthly reviews on the care plans but the monthly reviews were lacking. The manager showed us a care plan where needs had changed and these had been updated on the three monthly review, unfortunately there was no evidence recorded that staff had been made aware of these changes, acknowledged or even read them. The care plans needed to be more person centred, to include likes, dislikes and preferences as well as the person who used the service's life history, this is particularly important when providing care to people with dementia as it helps people to understand, Inspection Report Eastbourne Villa August

9 value and respect the person. The manager said this was something she was aware of and was planning on updating all the care plans. The care records had no index at the front to direct the reader to each section. The care record contained a photograph of the person who used the service along with name and preferred name and personal information. The care records included risk assessments. There was no evidence that these risk assessments had been reviewed since March Two people who used the service had seen the dietician and been diagnosed as clinically malnourished. One person was in May 2014 and had not been weighed since and one person was diagnosed on the 11th June 2014 but was not weighed again until the 8th July We spoke with the manager regarding this and the first person was not weighed due to mobility reasons and needing special scales, the manager had been in contact with the dietician about this, although this was not recorded. The second person was due to the decision to weigh them monthly rather than weekly. We have asked the manager to put something in place immediately regarding this. Daily records such as fluid charts, turning charts and daily events charts were completed but the column that said date and time, only the date was added. Records of activity and social recordings were not completed, therefore it looked like the last time someone had quality time spent with them was August Eastbourne Villa did not employ an activities coordinator; the care workers provided the activities. Staff we spoke with knew what each individual person enjoyed doing such as gardening, knitting and singing. One staff member told us they like to sing with the people who used the service. One member of staff explained how they were key worker for a person that used the service. This person loves gardening and had totally transformed the back garden. They said they often take this person to garden centres, at least once a week. We questioned how this left the staff in the home, as there was only two staff on duty at any one time. The person said she could only do this on her day off. We observed staff sitting and chatting to residents if they had a spare five minutes. People who used the service said "Staff are nice, all helpful and pleasant," and "Staff are brilliant and will do anything for me." Inspection Report Eastbourne Villa August

10 Safeguarding people who use services from abuse Met this standard People should be protected from abuse and staff should respect their human rights Our judgement The provider was meeting this standard. We found that systems were in place to minimise the risks of people using the service from being harmed, and to report alleged abuse, but some improvements are needed. Reasons for our judgement CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The home had proper policies and procedures in relation to Deprivation of Liberty Safeguards but not for the Mental Capacity Act. Staff had not received training in relation to these topics although they had received training on the safeguarding of vulnerable adults and had an understanding of the actions to take. During our inspection we observed staff interacting with people who used the service. We saw people were happy to speak with staff and be in their company. We saw the provider had a safeguarding policy and procedure in place. We could not see any information on display about raising concerns. This meant staff and people living at Eastbourne Villa did not have easy access to guidance on what to do if they had concerns about a person's wellbeing. We spoke with three staff who worked in the home; they were all familiar with safeguarding procedures and aware of what constituted abuse. The staff described clearly what action they would take in the event of a safeguarding matter coming to their attention. They were also clear about their roles and responsibilities in this area. The staff all told us they had completed training about safeguarding adults and we saw records which confirmed this. One person we spoke with who used the service said "I feel safe, I have no worries." We saw the finance records for people who used the service, we found that there were discrepancies with one of them; there was 1.10 less money than recorded. We spoke with the manager about this and she was going to investigate. Inspection Report Eastbourne Villa August

11 Requirements relating to workers Met this standard People should be cared for by staff who are properly qualified and able to do their job Our judgement The provider was meeting this standard. People were cared for, or supported by, suitably qualified, skilled and experienced staff. Reasons for our judgement The people who used the service we spoke with were complimentary about the staff who worked at the home. Comments made to us about the staff included, "Staff are nice, all helpful and pleasant," and "Staff are brilliant and will do anything for me," During our visit we observed staff interacting with people in kind and appropriate ways, suggesting that staff were familiar with people's needs. The manager explained to us how all new staff go through a formal recruitment process, which included completing an application form, attending an interview and undertaking recruitment checks, such as obtaining two written references and Disclosure and Baring Service (DBS) checks. The manager has recently updated the application form. During our visit we looked at the recruitment records for three staff one of whom was recently recruited. The records showed that staff had been through a formal recruitment process, including an application form, interview, obtaining the required recruitment checks, such as DBS checks and references, and had undertaken an induction training programme. The provider may wish to note that there were no interview records on the files we looked at, or a letter on each file inviting the applicant to a formal interview. We asked the manager about this and they confirmed that they did not currently keep interview records, although they were able to show us a blank copy of interview questions. Staff we spoke with said "All staff are really good, they keep everyone informed of changes and we get a good handover after days off," and "Staff interact really well on a personal level, they know the residents really well." Inspection Report Eastbourne Villa August

12 Staffing Action needed There should be enough members of staff to keep people safe and meet their health and welfare needs Our judgement The provider was not meeting this standard. There were not sufficient numbers of suitably qualified, skilled and experienced staff to safeguard the health, welfare and safety of service users and staff. We have judged that this has a minor impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report. Reasons for our judgement At the time of our inspection there were 11 people using the service. On arrival it was the managers day off and the deputy managers day off and a senior carer was in charge. The service employed four senior carers in total and six carers, and on the day of our visit there were two carers on duty. The service employed one domestic who worked two hours a day, from about seven thirty am, after that it was down to the two carers on duty to clean the home. The service employed one cook who worked seven thirty till about one pm, then it was down to the two carers on duty to cook. The service did not employ laundry staff and we were told that responsibility for laundry tasks was done by the carers, if the domestic did not get all the laundry finished in their two hours. The home did not employ a handyman, the owner managed any maintenance duties. On the day of the inspection the senior carer on duty and in charge, contacted the manager on their day off and they came in at one thirty, the senior carer and the two carers on duty in the morning, then left, leaving the manager and two carers for the afternoon. During our visit we observed the supervision people received from staff. We saw that staff were in the main always present in the main communal lounge area, where most people spent time. There were times that the two staff on duty had to attend to someone who needed two to one care. At the time of our visit there were five people who needed two to one care. This meant that staff were not on hand and able to support and safeguard people. We spoke with the manager regarding this and they said that staff informed them if they were to be away supporting someone and they could be away for half an hour at a time, the manager would then sit in the lounge. The manager finished at five pm and night staff came in at eight pm leaving three hours with only two members of staff. This meant if staff were supporting people who needed two to one support then there were no other staff available for the other 10 number of people using the service. At the time of our inspection the manager was trying to arrange some evening support. Eastbourne Villa was badly in need of redecorating, paper was coming off the walls, walls were half painted and then left, paint was coming off window seals leaving bare wood and Inspection Report Eastbourne Villa August

13 carpets needed cleaning. Many areas looked like they could do with a thorough clean; the manager said it was difficult as they had one cleaner who worked for two hours a day. It was then left for the two members of staff to clean, do laundry, provide all meals after the cook went home at 1pm and care for the people who used the service. Eastbourne Villa did not employ an activity coordinator and there were also a clear lack of any activities taking place, staff knew what people liked to do and told us they try to do activities 'if they have time.' Staff were using their days off to take people who used the service on outings, we have asked the manager to look into this. Inspection Report Eastbourne Villa August

14 Supporting workers Action needed Staff should be properly trained and supervised, and have the chance to develop and improve their skills Our judgement The provider was not meeting this standard. People were cared from by staff that were not supported to deliver care and treatment safely and to an appropriate standard. We have judged that this has a minor impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report. Reasons for our judgement There were 16 staff working at Eastbourne Villa, one member of staff had a degree in social work, five had NVQ level 3 and eight had NVQ level 2. We asked to see supervisions and appraisals for the 16 staff working at Eastbourne Villa; the manager had none to show us. This had also been highlighted by a recent local authority inspection and the manager had dates in the diary next week to start the supervisions. Staff also attended regular meetings where they discussed holidays, a recent local authority inspection, and completion of records along with handwriting. At the latest meeting they discussed staff cut backs, fees and rotas. No records were in place to show if staff had read and understood staff meeting minutes. This meant we did not know if staff that had been unable to attend their staff meeting had been informed of any changes which affected them. The manager also said she puts a monthly newsletter in with their pay, this covered any updates, changes, relevant news and inspections that had taken place. Staff had completed questionnaires and the majority of the comments were they enjoyed working at Eastbourne Villa but the décor needed updating, they would like more activities and there were not enough staff. We discussed how the service was going to address this with the manager. We looked at the training matrix for all 16 staff employed at the home. We found that training was up to date for eight staff for fire safety, none for first aid but this was booked in for July 2014, 12 for food safety, no staff had up to date health and safety training, eight staff had medication training, 12 staff had, infection prevention and control training, nine staff had manual handling training and two staff equality and diversity training. We found that some mandatory training was not up to date. Five staff had completed Mental Capacity Act training but three of them were in 2012 and no staff had completed Inspection Report Eastbourne Villa August

15 Deprivation of Liberties Safeguards training. Safeguarding training had been completed by 14 staff. This meant that not all staff had the knowledge they needed to understand whether someone had the capacity to make a decision or how to identify possible abuse and the procedures which needed to be followed. A small majority of staff had carried out further training which was specific to the needs of people. This included diabetes and Parkinson's. Dementia training had been arranged for all staff via distance learning, the manager said they were waiting for the books. Staff we spoke with felt very much supported by their manager. Inspection Report Eastbourne Villa August

16 Assessing and monitoring the quality of service provision Action needed The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care Our judgement The provider was not meeting this standard. The provider had no effective system to regularly assess and monitor the quality of service that people receive. We have judged that this has a minor impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report. Reasons for our judgement The manager told us that at the time of our visit they did not have any systems in place to assess and monitor the quality of the service that people received. Therefore there was no evidence to show Eastbourne Villa was protecting the people who used the service against risks of inappropriate or unsafe care. There was no system in place to make sure that manager and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This increased the risk of harm to people and fails to ensure that lessons are learned from mistakes. People who used the service said they knew how to make a complaint if needed. We asked to see the complaints file, there was one complaint registered. The manager told us that any verbal complaints or little complaints such as clothes going missing were not recorded. There was information on the walls to say how someone could make a complaint, although this needed updating. This meant people were at risk of not having their concerns and needs properly taken into account. There was no evidence that the provider conducted regulation 10 visits or had any kind of management reporting tool. There was no evidence of other audits, such as health and safety audits and risk assessments to ensure the service continues to monitor its effectiveness and to assist with continuous improvement. There was no evidence of infection control audits, cleaning audits, room check audits. We asked the manager how they know cleaning tasks had taken place, we were told that staff signed a form in the laundry each day, we looked at this and it was blank. Survey/questionnaires had been sent out to all relatives with a few responses. Staff had also completed a questionnaire and the majority of the comments were they enjoyed working at Eastbourne Villa but the décor needed updating, they would like more activities and there were not enough staff. We discussed with the manager about how they were going to address this. Inspection Report Eastbourne Villa August

17 The manager had a list of jobs that needed doing around the home, the home have no maintenance staff and rely on the owner to do the jobs required. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to learning from incidents and events and to identify, assess and monitor the quality of the service and manage risks relating to the health, welfare and safety of people who used the service. Inspection Report Eastbourne Villa August

18 Records Action needed People's personal records, including medical records, should be accurate and kept safe and confidential Our judgement The provider was not meeting this standard. Eastbourne Villa did not have any recording systems in place to assess and monitor the quality of the service. No records were kept in relation to the management of the service and there were gaps in the recording of information in the care files. We have judged that this has a minor impact on people who use the service, and have told the provider to take action. Please see the 'Action' section within this report. Reasons for our judgement People's health and care needs were assessed and however it was not recorded that these were reviewed. Some monthly reviews were dated December Body maps were in place but these were not fully dated, for example one person's said 20/7 but no year was added. Daily records such as fluid charts, turning charts and daily events charts were completed but the column that said date and time, only the date was added. Records of activity and social recordings were not completed, therefore it looked like the last time someone had quality time spent with them was last August In one person's care file it stated they liked to see the chiropodist regularly, there were no records of any visits to see the chiropodist. Whilst we looked at the finance records we saw evidence of payment to a chiropodist. We asked a member of staff to find this record in the professional visits log, this was not recorded. One person had not received a diabetic eye screening test since January We spoke to the manager about this and there was a legitimate reason, this had not been recorded. The home had no policies in place for behaviour that challenges, Mental Capacity Act and complaints. Any audits the manager had completed were just a paragraph of observations on a piece of paper, no dates, actions or learning's. Care files for people who used the service were stored securely in the nurse's office and could be located promptly. Inspection Report Eastbourne Villa August

19 This section is primarily information for the provider Action we have told the provider to take Compliance actions The table below shows the essential standards of quality and safety that were not being met. The provider must send CQC a report that says what action they are going to take to meet these essential standards. Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 22 HSCA 2008 (Regulated Activities) Regulations 2010 Staffing How the regulation was not being met: Regulation 22 There were not sufficient, suitably qualified and experienced staff to ensure the health, safety and welfare of service users. Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 23 HSCA 2008 (Regulated Activities) Regulations 2010 Supporting workers How the regulation was not being met: Regulation 23 (1) (a) (b). Appraisals were not up to date for all staff. Supervision had not been carried out at the frequency specified by the provider. Mandatory training for health and safety, first aid, the Mental Capacity Act and Depravation of Liberties safeguarding was not up to date for most of the staff team. Inspection Report Eastbourne Villa August

20 This section is primarily information for the provider Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 10 HSCA 2008 (Regulated Activities) Regulations 2010 Assessing and monitoring the quality of service provision How the regulation was not being met: Regulation 10 (1) (a) (b). There were no systems in place to monitor the quality of service provision, therefore there was nothing to show that Eastbourne Villa were protecting the people who used the service against risks of inappropriate or unsafe care. Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 20 HSCA 2008 (Regulated Activities) Regulations 2010 Records How the regulation was not being met: Regulation 20 (1) (a) and (b). The registered person must ensure that people who used the service are protected against the risks of unsafe or inappropriate care and treatment arising from a lack of proper information about them. This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations The provider's report should be sent to us by 12 August CQC should be informed when compliance actions are complete. We will check to make sure that action has been taken to meet the standards and will report on our judgements. Inspection Report Eastbourne Villa August

21 About CQC inspections We are the regulator of health and social care in England. All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website. Inspection Report Eastbourne Villa August

22 How we define our judgements The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected. Met this standard This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made. Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete. Enforcement action taken If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people. Inspection Report Eastbourne Villa August

23 How we define our judgements (continued) Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact. Minor impact - people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. Moderate impact - people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. Major impact - people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards. Inspection Report Eastbourne Villa August

24 Glossary of terms we use in this report Essential standard The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are: Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20) Regulated activity These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided. Inspection Report Eastbourne Villa August

25 Glossary of terms we use in this report (continued) (Registered) Provider There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'. Regulations We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations Responsive inspection This is carried out at any time in relation to identified concerns. Routine inspection This is planned and could occur at any time. We sometimes describe this as a scheduled inspection. Themed inspection This is targeted to look at specific standards, sectors or types of care. Inspection Report Eastbourne Villa August

26 Contact us Phone: Write to us at: Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Website: Copyright Copyright (2011) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Inspection Report Eastbourne Villa August