Inspection on 08/05/06 for Holwell Villa

This inspection was carried out on 8th May 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

Holwell Villa 20/08/08

Holwell Villa 11/10/07

Holwell Villa 20/12/05

Holwell Villa 20/09/05

Holwell Villa 08/11/04

Holwell Villa 07/07/04

Holwell Villa 12/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Holwell Villa Holwell Villa 119 New Road Brixham Devon TQ5 8BY Lead Inspector Judy Cooper Unannounced Inspection 10:00 8th May 2006 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 Holwell Villa DS0000018373.V290341.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. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Holwell Villa Address Holwell Villa 119 New Road Brixham Devon TQ5 8BY 01803 854103 01803 859669 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) Mr Ronald Frank Marlow Mrs Barbara June Marlow Christina Marie Thomas Burridge Care Home 17 Category(ies) of Dementia - over 65 years of age (17), Old age, registration, with number not falling within any other category (17), of places Physical disability over 65 years of age (17) Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Females may be admitted from the age of 60 Date of last inspection 20th December 2005 Brief Description of the Service: Holwell Villa offers accommodation with personal care to older people (60/65 ), older people with physical disability and older people with dementia. It is registered to provide a service for up to 17 service users both male and female. The manager also accepts day care service users (maximum of two, when the home has the capacity to do this). The home is laid out over 3 levels and has a passenger lift connecting the ground, first and second floors. With regard to private accommodation, there are 11 single bedrooms (2 of which have en suite facilities) and 3 double bedrooms (2 of which also have en suite facilities). In terms of communal space, Holwell Villa has a lounge and a dining room as well as a front garden and rear patio with seating. There are also communal bathrooms and toilets throughout the home, including a recently adapted walkin shower room. The building itself is a large detached property located within walking distance of Brixham town centre with its range of shops and amenities. Recent upgrading to the front of the property has resulted in an increased parking area and overall easier accessibility. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit took place on Monday 8th May between 10.00a.m and 5.00 p.m. Opportunity was taken to observe the general overall care given to current residents. The care provided for three residents was also followed in specific detail, from the time they were admitted to the home, which involved checking that all elements of their identified care needs were being met appropriately. A tour the premises, examination of some records and policies, discussions with the manager, residents (that were able to converse) and staff, as well as one visitor to the home, also formed part of this inspection, whilst staff on duty were observed, in the course of undertaking their daily duties. Other information about the home, including the receipt of several completed questionnaires from residents (with help), staff, and other interested parties, has provided further feedback as to how the home performs, and the majority of this collated information has been used in the writing of this report. All required core standards were inspected during the course of this inspection. What the service does well: The manager continues to ensure that an “open door” policy is in place, which allows residents, staff and residents’ families/carers the ability to speak openly and easily, which helps all concerned, deliver the appropriate care. A very relaxed, family atmosphere also continues to be maintained within the home, for which the manager and staff should be commended. The manager and staff continue to provide very individual care for the residents, some of whom are unable to communicate their needs. The manager and staff are aware of this and ensure the care provided matches the residents’ needs and personal preferences as far as they are able to ascertain. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 6 The manager continues to maintain a small but regular “hands on” role within the home to ensure she is aware of the residents’ needs and is therefore aware of how the staff can best meet these needs. One of the home’s main strengths remains the way that the staff maintains the residents’ dignity and their rights to make personal choices. Due to the category of the resident group that continue to be cared for at Holwell Villa (i.e. many residents suffer from advanced dementia), it means that staff need to take time and use good observational skills to determine what a resident may be trying to communicate, and this skill continues to be an integral part of the staffs’ role within the home. It is to the owners’ and manger’s credit that previously issued requirements have now been met, whilst a few minor shortfalls only were identified at this inspection which resulted in some good practice recommendations. What has improved since the last inspection? The home’s environment continues to be upgraded to ensure that the accommodation meets the required standards and provides a comfortable and safe environment for the residents living at Holwell Villa. This has included new carpeting to the second floor stairs and landing. The home’s kitchen has also very recently been refurbished and upgraded, which allows the home’s catering staff to be better able to produce quality meals in a more user friendly environment, which meets the requirements/recommendations of the local Environmental Health Department. Improved links have also been initiated with the local Environmental Health Department to ensure that the home’s catering staff undertake food handling and preparation in the safest and most appropriate way using the recently introduced “Safer Food—Better Business” principles, thereby fully safeguarding residents in this area. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 7 The front driveway of the home has been extended to provide easier access and increased parking availability. There have been plans, submitted, to allow the home to knock two smaller toilets into one larger one and to create another easy access toilet both on the ground floor. The plans also include the creation of a small office area sited within the main home. This will allow some records etc to be stored and therefore make them more easily accessible to the staff. The manager has increased the staffing levels in the mornings by one carer to ensure that residents’ needs can be fully met at all times. What they could do better: All residents and/or their advocates, including those that have been at the home for lengthy periods of time should be given a copy of the home’s service user guide and issued with a home’s own contract. This is to ensure all residents are treated equally, as currently only more recent admissions have been issued with this documentation. In the event that the CRB disclosure has not yet been received back and subsequently approved, before the staff member needs to commence work, a named supervisor should be appointed to work with the staff member until such times as the disclosure is received back. This then should be formally recorded. This is to ensure all residents remain protected at all times. The contract for the general assistant should fully detail the fact that personal care is not part of this post holder’s duties. As this post is currently occupied by a seventeen year old, it is important that she is made formally, as well as informally, aware that providing personal care is not a part of her job role as she would not be able to do so in any case until she is eighteen years of age. The owners and manager should provide a more formal document to record their good quality auditing processes. Although they regularly take place, this is not formally documented and therefore does not always allow a true picture to be easily identified regarding the time and effort taken in this area in ensuring those residents’ needs and lives inform the way the home operates. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 8 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. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 9 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 Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 10 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): 3 (Some aspects of standards 1/2 were discussed but not inspected in detail) The quality in this outcome area is good. The admission process continues to be well managed and new residents are given clear information regarding the service prior to admission so that they, and/or their relatives/advocate, can make an informed decision. EVIDENCE: Since the last inspection the home has admitted four new residents (one of which is a respite resident and one who has since passed away). Two of the new residents were talked with/observed during the inspection, which included the resident on a respite placement. Following discussion with the manager, and observing documentation in relation to the admission process, it could be concluded that their admissions had been undertaken in such a manner as to allow them and/or their families/ advocate to be aware of what services the home could offer. The manager had visited the residents, whenever possible prior, to admission and there was detailed evidence of in-depth pre admission assessments and liaisons with other professionals that had been undertaken at this point. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 11 In one instance regarding a husband and wife placement, a pre-admission visit had not been possible due to the immediacy of the placements, however there was close communication with the couple’s care manager to ensure the placements were in order. The respite resident was already well known to the home, having already attended regularly for day care for some time, but it was pleasing to note that a detailed assessment and subsequent care plan was already in operation for this client. This ensured that the emergency respite admission, for this same client, could be provided with the manager already having full details of care needed. The prospective residents and/or their families had been given access to necessary information including the home’s statement of purpose. Up to date and relevant contracts were in place for all of the residents, which included Social Service contracts as well as them, or their representatives, having been given a copy of the home’s own contract. A feedback questionnaire, received back from a care manager who has been involved with some resident placements at Holwell Villa, stated that she felt very confident that the manager and her team would be able to identify anyone they would be unable to care for which, therefore, would ensure that residents would not then need to be moved further to a more appropriate setting. However, some residents and/or their families/advocate had not received an individual copy of the home’s statement of purpose/service user guide or a copy of the home’s own contract due to these residents having been at the home prior to the new manager taking over. She had only issued this documentation to admissions following her appointment and consequently previous admissions had not been issued with this documentation. The manager will now rectify this and ensure all residents and/or their families/advocate receive the same information about the home and what it can offer as all newer admissions. The home does not provide an intermediate care service. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 12 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): 7,8,9,10 The quality in this outcome area is good. All residents are looked after well in respect of their health and personal care needs. Residents’ privacy and dignity is upheld and their life style choices respected. EVIDENCE: The care plans inspected related to the residents whose admission procedure was previously inspected. The care plans were very concise and detailed and contained all relevant information appertaining to providing for the individual residents care, including any medical needs of the resident, as well as any visits made by District Nurses, G.P’s or any other health professionals. Care plans are regularly reviewed with the residents and/or their families/advocate. It was pleasing to further note that the care plan inspected, in respect of the one resident who had been at the home for a substantial period of time, had been regularly reviewed and only recently completely re-done to reflect the resident’s changing needs. The manager and staff liaise with other professionals as required including District Nurses, community psychiatric nurses, continence advisor etc. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 13 Appropriate handling and lifting devices were in evidence including a mobile hoist and handling equipment, which it was noted was being used appropriately by the staff when transferring a resident from her easy chair to a wheelchair. The staff’s daily written records were particularly professional being concise and in-depth which provided a good understanding of what care had been needed/given throughout the day/night to each individual resident. Those residents able to verbally feedback their feelings were again very positive about the care received, saying that they felt well looked after and that the staff treated them well and were very kind to them. Others were again noted as being treated by the staff with kindness and due regard for the maintenance of their dignity and rights to individuality. Such evidence that supported this was noting the gentle way that staff spoke to residents, taking into account their individual levels of ability, all residents being nicely dressed, clean and well presented. A feedback card from a care manager stated the following: “The manager and her staff are extremely skilled with the client group, respecting individuality of needs. She has excellent knowledge of all of her clients and liaises with me closely. She also supports the carers exceptionally well” Medications were well managed and securely stored. A small fridge is provided for the storage of eye drops etc. The manager has recently changed over to new supplying pharmacist. The new pharmacist visited the home in January this year and concluded everything to be in order(report seen), whilst the medication cupboard and medication records were inspected at this inspection and found to be satisfactory. All staff that administer medication have received training in the same, which ensures residents are protected in respect of receiving their medications appropriately. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 14 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): 12,13,14,15 The quality in this outcome area is excellent. Residents continue to enjoy a peaceful, pleasant yet varied life at the home, with visitors encouraged and links encouraged and maintained with the local community. Various informal activities are made available with new activities also tried out to help vary residents’ life at the home. Varied and good meals continue to be provided. EVIDENCE: The home continues to operate an open visiting policy and the visitor’s book evidenced that the residents continue to have many visitors at varying times throughout the day. One visitor spoken with confirmed that he visited daily throughout the week and was always made welcome. It was noted that a cup of tea was immediately brought to the visitor and the staff were friendly yet respectful. Staff continue to undertake activities with residents both individually and as a group on a daily informal basis. This can involve in house activities, which are changed regularly to meet the residents’ needs/desires each day, and, Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 15 residents also benefit from being taken out on an individual basis to the local town or places of interest when staff time and weather allow. On the day of inspection some residents had enjoyed listening to music and being together in the communal lounge. The atmosphere is very much a friendly, family atmosphere and the mentally frail residents living at Holwell Villa benefit from this, being noticeably relaxed and calm within the lounge’s environment and with the staff. Residents continue to be encouraged to express their individuality as far as possible and to this end one resident continues to have her pet cat with her and anther married couple their two cats and pet bird. Any resident that wishes to smoke is able to do so in a designated area of the home under staff supervision (if assessed as necessary). Currently one gentleman, continues to enjoy being able to freely smoke his pipe. Evidence to particularly support the fact that the manager ensures that residents individual interests are maintained was noted by the fact that a small safe plastic greenhouse has been purchased to allow those residents that wish to participate in gardening the opportunity to do so. Some of the residents are planning to go to the garden centre to choose some plants etc to grow in the greenhouse. The home’s cook has been at the home for a number of years and is very familiar with the residents’ individual needs, likes and dislikes. It was noted on the day of inspection that a new menu plan was being put into operation. This had been previously drawn up with the residents and had tried to encompass some new ideas. On the day of inspection the meal served was a broccoli and cheese bake with vegetables, followed by bread and butter pudding. As this was a new meal for the residents the cook was very keen for feedback and took on board any comments. It was pleasing to note the level of involvement that the residents were encouraged to have and the way staff tried to get them to express opinions etc. The key worker was available to help communicate with one resident who has difficulty with speech. The key worker understands the resident and was able to allow the resident the opportunity of expressing himself. Choice at mealtimes is always offered and time was given, for those able to, to choose what they wanted. For others unable to do this, staff made the best choice they could on the resident’s behalf, taking into account personal knowledge and understanding of the resident concerned. Any support required in helping with feeding is provided in a discreet manner and with due regard for other residents feelings. One resident who is diabetic, continues to enjoy her meals, with the cook aware of the need to monitor her diet. The routines within the home remain very flexible to ensure that residents can choose how they spend their time. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 16 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): 16,17 The quality in this outcome area is good. Arrangements for protecting residents and responding to their concerns are satisfactory. EVIDENCE: The home’s complaint policy remains centrally displayed and is also contained within the home’s statement of purpose. Some residents spoken with said they “soon complain if anything was wrong”, “would speak to the manager or her deputy” etc. Others were not always able to verbally express that they knew how to complain. However, the manager does all she can to make the complaints information clearly available to anyone visiting the home and all staff receive up to date training in the home’s vulnerable adult policies. As the external trainer providing this training no longer is operating training in this area the manager has made arrangements for an external trainer to undertake this required training within the home. Three returned questionnaires received back from staff members evidenced that they were aware of the adult protection procedures operating within the home. The home has not received any complaints either internally or externally within the twelve months prior to this inspection. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 17 Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 18 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): 19,26 The quality in this outcome area is good. Additional upgrading of the home’s environment has resulted in Holwell Villa presenting overall as comfortable, clean and well maintained whilst providing a safe standard of accommodation for the residents. EVIDENCE: The tour of the home confirmed that the upgrading of the home continues to take place. The home’s kitchen has been recently been re-fitted and re-decorated. This has resulted in a pleasant and very functional large kitchen area to work in. Other upgrading has included the provision of new carpeting to the second floor stairs and landing. Residents’ bedrooms throughout the home have been personalised as desired and residents can bring in personal items with them if they wish to. The manager stated that the home would provide a suitable lock if requested by a resident, but they are not provided as standard on admission. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 19 The lounge and dining areas provide adequate space and are well appointed. Plans are in hand to create further lounge and dining areas by the erection of large conservatory at the front of the house. Plans are also in hand to create a larger more easily accessed toilet, knock two smaller toilets into one and create a small office space on the ground floor of the home. The management maintains the day to day home’s fire precautions in line with the requirements of the local fire department. The fire department last visited on the 19/2/06 and the home is complying with the requirements of the fire department. The home presented, as very clean with no odours present at all, for which the staff at the home should be commended for. The home maintains suitable infection control measures, including staff training, which protects residents from the spread of any infections. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality in this outcome area is good. The home’s recruitment programme is robust and protects residents by the appointment of suitable staff. Staff at the home are well trained and supported, and employed in sufficient numbers to meet the residents’ needs at all times. EVIDENCE: On the day of inspection there were seventeen residents in the home and one day care client. Staffing rotas inspected evidenced that there is sufficient staff on duty to care for the residents at all times and it was noted that staff had sufficient time to spend with the residents. Staff spoken to voiced the fact that it may be beneficial to look at re-adjusting the hours to better provide cover in the kitchen and the manager is to address this. However it was noted how easily and comfortably staff felt able to discuss this issue during a staff meeting held during the inspection. All residents, that were verbally able to, confirmed that the staff care for them well. Training is provided regularly. Recent training provided has included statutory fire training with additional first aid training booked for the end of May and infection control training being planned for in the near future. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 21 Induction training takes place for any new staff member and other recent training events have included a recent training day, for several staff members, spent with an external trainer looking at aspects of dementia care. Further NVQ training is being provided with several staff members having already obtained NVQ 2/3 and seven more staff identified to undertake NVQ level 2 in the near future. This level of training ensures that staff are both appropriately trained and consequently able to provide suitable care for the residents at the home. Staff on duty were spoken with and it was evident that they took pride in their role and felt that ensuring residents had a good quality of life, irrespective of need or diversity, was the most important part of their role. Questionnaires received back from staff contained such comments as: “I think the staff work as a good team and that this care home has a nice family atmosphere”, “All staff and residents have a great family relationship and the home should be commended for being the best place to live and work”, “ I have really enjoyed working here and over the two years it has helped build my confidence and it has been lovely to work in a friendly environment. It is more like a home and people are more like a family than just a care home” The home maintains a fairly stable staff group. Minor changes that have occurred have been mostly on the night shift. This overall staff stability allows residents to feel secure and confident of the carers’ ability to care for them. Since the last inspection the manager has appointed four new staff members. On one occasion the manager had liaised closely with the CSCI to ensure all was in accordance with the Commission’s recommendations. All of the staff records were inspected and it was noted that a thorough and robust recruitment programme had been carried out which had included the receipt of a detailed application form, two references, and in two instances the receipt of an enhanced CRB disclosure. For two other recent appointments the CRB had yet to be received back (although they had been sent off for). Whilst waiting for these to be returned it was noted that both staff members are working under senior staff’s supervision, however the manager should formally name and record the supervisor in respect of each staff member. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The quality in this outcome area is good. The home is managed efficiently and well, with the manager being easily available and approachable. The registered manager undertakes her role professionally and has an awareness of residents’ needs and the staffs’ abilities to meet them. The manager’s leadership ensures that the home is run in the best interests of the residents. The home provides a safe, secure environment where residents’ safety and well being is maintained. EVIDENCE: The manager has completed her registered manager’s award and is waiting for verification of the award. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 23 The registered manager continues to improve the overall management of the home by ensuring all practices, policies and procedures, as well as the home’s records, are up to date and as required. The manger, her deputy and the home’s senior carer are all in the process of undertaking “achievement training”. This is to help them supervise and mentor other staff and so enhance the lines of communication and supervision within the home, which will help ensure that staff are fully supported in the care of mentally frail and vulnerable residents. This input has resulted in an effectively run home, which ultimately benefits residents and staff. She is well respected by both staff and residents. Residents, who were able to, and staff spoke highly of her ability to help and support them and of her willingness to listen and act upon any concern etc they may have. They all felt confident because they felt she ran the home efficiently and in the best interests of the residents. One staff member stated “everything is done well. Above board, the way it should be done. Residents are well cared for”. The registered provider and manager recently undertook a significant amount of work required to allow the home to be assessed for the “Investors in People” award, which took place in November last year and in which the home was successful. The manager undertakes quality auditing on an informal basis using such feed back as residents’ and families’ questionnaires etc. Discussion at the inspection led the manager to consider improving her record keeping regarding the quality assurance undertaken, within the home, so that an accurate and workable record can be maintained which will better inform the staff generally and help the home build on its strengths and address any weaknesses that may present. The manager is aware of the need to respect diversity issues arising from caring for such a vulnerable group or residents. Due to the residents’ mental frailties, the manager and staff respect and work with differing behaviour issues ensuring all are treated with respect and equally valued. The manager ensures that appropriate training is available to offer support in this area. The residents’ families/advocates mostly deal with any financial matter appertaining to the residents. The owner is an appointee for one resident and details were given at this inspection, with financial records being seen. The home holds small amounts of monies for residents and there were adequate records in respect of this, which protects the residents’ financial affairs. Residents’ health and safety continues to be maintained within the home and the manager continues to update risk assessments and comply with required health and safety legislation as necessary. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 24 Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 25 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 2 2 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 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 4 x 3 x 3 x x 3 Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 26 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 OP1 Good Practice Recommendations All residents and/or their families/advocates, including residents that have been at the home for lengthy periods of time should be given a copy of the home’s service user guide. All residents and/or their families/advocates, including those residents that have been at the home for lengthy periods of time should be given a copy of the home’s own contract. In the event that a CRB disclosure has not yet been received back and subsequently approved, before a staff member needs to commence work, a named supervisor should be appointed to work with the staff member until such times as the disclosure is received back. This should be recorded. The contract for the general assistant’s post should fully detail the fact that personal care is not part of this post holder’s duties. DS0000018373.V290341.R01.S.doc Version 5.1 Page 27 2 OP3 3 OP29 4 OP29 Holwell Villa 6 OP33 A formal written record should be kept in respect of the home’s quality auditing procedures. Holwell Villa DS0000018373.V290341.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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