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Inspection on 15/08/06 for The Villa Nursing And Residential Home

Also see our care home review for The Villa Nursing And Residential Home for more information

This inspection was carried out on 15th August 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Observations made at the inspection, as well as comments received from visiting professionals and relatives confirm that The Villa is committed to offering a good home to people who have both complex mental and physical care and support needs. One relative of an individual who requires a lot of psychological support and encouragement wrote: `I am fully satisfied with the care provided to our father.`Observations of knowledgeable staff dealing with day to day issues in the home confirmed that Mr and Mrs Juru have make sure good systems are in place to keep the home team well organised.

What has improved since the last inspection?

What the care home could do better:

As a result of this inspection 8 additional statutory requirements were made, making a total of 13 that the home has to take action to meet. Residents` records need more information to confirm they are issued with appropriate paperwork when they move in - including a detailed contract of residency with The Villa.Care plans need to be expanded to ensure all necessary information is kept up to date to realistically reflect the care the residents need and get, to keep them safe. The care records must show how the team encourages resident and relatives involvement with this process. Mrs Juru did comment that some processes for the safe receipt of medication need to be improved, and that a system had not yet been established to ensure all prescribed items received in the home could be accounted for. Although cleanliness has improved in the home, some of the communal carpeting and armchairs are in need of attention. A sash window in the smoking lounge room also needed to be made safe. The home manager also needs to devise an action plan in response to the Infection control audit carried out by the Health protection agency in march this year. Changes in the staff team now mean that currently 42% of staff are NVQ qualified - this needs to be 50% minimum. Staff recruitment, induction training and supervision records all need further details added. Staff Supervision sessions need to be carried out more frequently with more details recorded to show how staff are working to improve resident care even more. Accident recordkeeping needs more evidence to show the right action has been taken to reduce the chance of any accidents happening again. This will then make sure, that care staff are aware of, the needs of people who have been injured as a result of an accident.

CARE HOMES FOR OLDER PEOPLE The Villa Nursing And Residential Home Park Avenue, Maddocks Madeley Telford Shropshire TF7 5AE Lead Inspector Janet Adams Key Unannounced Inspection 11:45 15th August 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 The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 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. The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Villa Nursing And Residential Home Address Park Avenue, Maddocks Madeley Telford Shropshire TF7 5AE 01952 581022 01952 582431 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) Mrs Susan Juru Mr Douglas Juru Care Home 33 Category(ies) of Dementia (26), Mental disorder, excluding registration, with number learning disability or dementia (7) of places The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate a maximum of 33 service users. Within this 33, a) the maximum requiring nursing care shall not exceed 26 of whom 22 may be older people with dementia requiring nursing care. b) 7 may be younger adults with a mental disorder requiring nursing care. c) The remainder may be older people with dementia not requiring nursing care. The minimum staffing requirements are as follows: 08.00 - 14.00 14.00 - 20.00 20.00 - 08.00 1 Qualified Nurse 1 Qualified Nurse 1 Qualified Nurse (RGN, EN or RMN) (RGN, EN or RMN) (RGN, EN or RMN) 5 Care Assistants 4 Care Assistants 3 Care Assistants 4th January 2006 3. Date of last inspection Brief Description of the Service: The Villa is a care home which provides both personal and nursing care in single and double accommodation for older people as well as younger people with mental health needs. Owned and managed by Mr and Mrs Juru, The Villa is situated in Madeley, a long established Shropshire town, situated above Ironbridge Gorge, and now part of the Telford conurbation. Opportunities for shopping and recreational activities are to be found within walking distance and in Telford Town Centre, which is reached via a frequent bus service. The Villa is set in its own grounds and comprises of an original 19th century house which has been added to by more recent extensions. It has several communal areas, including a large lounge/diner, a separate dining room, a lounge area in the nursing wing, and a smoking lounge. These are all on the ground floor. A ‘quiet’ sitting area is also available on the first floor. In addition to this, two outside patio areas with good access are furnished with quality garden furniture for residents to use if they choose to. The owners of The Villa make their services known to prospective service users The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 5 in: Their statement of purpose, and its brochure/service user guide. The current fees charged vary between £337 and £535 per week depending on the care, support and accommodation required. The only additional charges to service users are for hairdressing, toiletries and newspapers. Consideration is also given to accommodate residents’ pets, and at the time of the inspection, five cats were seen to be living there. The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out the inspection visit to the home. This lasted six hours. A few weeks before the inspection was carried out, CSCI (The Commission for Social Care Inspection.) wrote to the home manager to request some necessary information to assist with the inspection. This meant that although The Villa knew the inspection was imminent, they were not aware of any date or time. It included observing activity within the home, inspecting the premises, an ‘in depth look’ at records for residents and staff, observing, talking and listening to over half of the 32 people living there, and the staff on duty at the time of the inspection. No written comments were completed by residents on this occasion although all were happy to share valid comments when they were spoken to in private with people on their own, or together in groups in the lounges. These are included in the main body of the report. Although no visitors were available to talk to on this occasion, two relatives sent back comment cards to CSCI (The Commission for Social Care Inspection.) Both made positive comments about the home. Everyone, including residents and staff were very welcoming and helpful throughout. A total of 28 out of a possible 38 National Minimum Standards for Older People were assessed on this occasion. What the service does well: Observations made at the inspection, as well as comments received from visiting professionals and relatives confirm that The Villa is committed to offering a good home to people who have both complex mental and physical care and support needs. One relative of an individual who requires a lot of psychological support and encouragement wrote: ‘I am fully satisfied with the care provided to our father.’ The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 7 Observations of knowledgeable staff dealing with day to day issues in the home confirmed that Mr and Mrs Juru have make sure good systems are in place to keep the home team well organised. What has improved since the last inspection? What they could do better: As a result of this inspection 8 additional statutory requirements were made, making a total of 13 that the home has to take action to meet. Residents’ records need more information to confirm they are issued with appropriate paperwork when they move in - including a detailed contract of residency with The Villa. The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 8 Care plans need to be expanded to ensure all necessary information is kept up to date to realistically reflect the care the residents need and get, to keep them safe. The care records must show how the team encourages resident and relatives involvement with this process. Mrs Juru did comment that some processes for the safe receipt of medication need to be improved, and that a system had not yet been established to ensure all prescribed items received in the home could be accounted for. Although cleanliness has improved in the home, some of the communal carpeting and armchairs are in need of attention. A sash window in the smoking lounge room also needed to be made safe. The home manager also needs to devise an action plan in response to the Infection control audit carried out by the Health protection agency in march this year. Changes in the staff team now mean that currently 42 of staff are NVQ qualified - this needs to be 50 minimum. Staff recruitment, induction training and supervision records all need further details added. Staff Supervision sessions need to be carried out more frequently with more details recorded to show how staff are working to improve resident care even more. Accident recordkeeping needs more evidence to show the right action has been taken to reduce the chance of any accidents happening again. This will then make sure, that care staff are aware of, the needs of people who have been injured as a result of an accident. 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. The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 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 The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 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): 2 &3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The way individual’s needs are assessed means that people’s diverse needs are identified and planned for before they move to the home. However, people who use this service do not receive all the necessary details about the home in order to make an informed decision about whether the service is right for them. EVIDENCE: The records of four people who have been admitted to the home since the last inspection were looked at in depth. All records were seen to have enough information and assessments from a variety of professionals upon which the manager uses to assess if people’s needs can be fully met at The Villa. The manager also goes to assess the person ‘face to face’ in order to discuss the person’s needs and to share information about the home. The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 11 It is positive that information seen in records shows that the way a person is admitted is very much influenced by the person’s individual choices as well as the circumstances resulting in them having to move into a care home. This makes sure all decisions are made to suit the needs and preferences of the person before they think about moving in to The Villa. However, on this occasion it was seen that not all of the formal necessary information is written down in all resident’s records looked at. For example; When the records of a person who is paying for his own care were looked at it was seen that the contract of terms and conditions provided by the home for this person did not contain enough specific information. This lack of information means the person does not have a written agreement signed on behalf of the home and the individual himself to confirm who is responsible for paying his weekly care fees. This was discussed with the manager at the time of the inspection. She confirmed the matter would be put right. The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The Villa’s care planning and medication systems do not fully provide staff with the information they need to look after residents satisfactorily. EVIDENCE: Points of view and opinions received from all residents met in the home as well as the five written comments from a GP, relatives and staff confirmed inspection observations that that people feel they are well cared for, are treated well and their dignity is respected. The Villa provides care and support for the people living there, as they need and desire, although on the inspection day, residents records did not reflect this. The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 13 In depth examination of four sets of residents’ records show that care plans lack necessary details. Current care plans show reviews as up to date, but they do not reflect total care to be provided. Though most peoples’ health, personal and social care needs are written down, some are not personalised with enough detailed information about the people or their medical conditions to fully describe how those people need to be properly looked after. For example, in one set of care records of a person admitted four days before the inspection, lack of information about ‘activities of daily living’ and guidance on how to safely move and handle the person had not been written down by the person who had assessed her needs. This meant there were no care details to guide staff how to look after the individual with known conditions of epilepsy, Parkinson’s disease and dementia, from the point of admission. In addition, poor recording of other necessary assessments does not enable staff to plan and deliver effective care. In one set of care records, a person was identified to be at risk of falls and a fire risk as a result of being a smoker. No proactive measures are written down to guide staff and offer assurance that the home team is doing everything it can to keep the person as safe as possible. These findings are similar to those in the care records at the last inspection. Furthermore, the care plans do not have the information to show if residents are encouraged to be involved in this process to show they know what is written about how they are to be cared for. At the inspection in January this year, a requirement was made for this issue stating ‘care plans must show evidence of resident /relative involvement’. This has not been met. The above findings were shared with Mrs Juru, the Registered Manager/Provider during the inspection. A new ‘complex needs form’ is in the process of being launched in order for the team to use to make sure residents need are better met in the future. It is noteworthy to see that the manager has set up a medication audit system since June to ensure the home is meeting necessary legislation for this matter. This has resulted in many aspects of medication management in the home being explored and reviewed. The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 14 Mrs Juru did comment that some processes for the safe receipt of medication needed to be improved, and that a system had not yet been established to ensure all prescribed items received in the home could be accounted for. This means that a requirement made at the last inspection which stated that records must be kept to show when any prescribed dressings are used has not yet been met. It is noteworthy an air conditioning unit has been provided to make sure the drug storage cupboard is at the right temperature. Other aspects of medication management in the home were satisfactory. The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 15 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a variety of opportunities to participate in stimulating and motivating activities. Meals and mealtimes are an enjoyable, social occasion for all of the service users EVIDENCE: Individuals are encouraged and empowered as far as it is practical to maximise their independence and be involved in choices about all daily activities in and out of the home. Residents are encouraged to keep in contact with family and friends and visitors were seen to come and go during the inspection. The home has the advantage of a variety of communal areas where residents can congregate to join in group activities or entertain visitors if they so wish. Some communal and group activities were reported to happen regularly. All residents reported they enjoyed their recent annual trip to Rhyl. The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 16 Several residents take advantage of the local facilities in Madeley, which are within walking distance of the home. The Villa also uses ‘Dial a Ride’ to get people out and about in the locality. One resident said he is a regular user of this service to carry out the voluntary work he enjoys. The younger residents also get input from professionals such as the community occupational therapist and mental health team in order to have a formal structure to their lifestyle activities. When the recordkeeping for these activities was looked at they lacked necessary details to either guide staff how to enable residents to lead as full a life as possible, or give a full picture of how the home actually meets peoples needs. This lack of recording of preferred social activity/hobbies etc in resident care information means that information provided by other visiting professionals or relatives is not accounted for or incorporated within the home care planning records. For example: A ‘timetable of proposed activities’ a community occupational therapist had compiled with one person is not linked to other relevant information in care records, although observations during the inspection showed staff were trying to carry them out. This results in records which are not as ‘user friendly’ as they could be, especially for people with mental health challenges. It was seen the home does not ‘sell itself’ fully by accounting for all the regular activities people participate in. Observations and discussions with staff on duty confirmed they were very knowledgeable about many of the residents’ personal interests. The lunch and high tea seen prepared and served was in line with the menu planned for the week. Six residents currently have special dietary requirements to manage medical conditions such as diabetes and swallowing problems. At lunchtime, all 16 residents seen dining in the large lounge /diner area commented that they enjoyed their meals. Staff were seen assisting those who required help in a discreet unhurried manner. Discussion with the cook who has worked at the home for many years confirmed that a variety of options are available for people if they do not fancy the ‘meal of the day’. The home has improved the meal provision for high tea in line with residents preferences. When it was seen being prepared it comprised of a variety of six different sandwiches and the there was also a choice of three hot meal alternatives. The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 17 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 &18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with evidence that service users feel that their views are listened to and acted upon. Staff are provided with training to safeguard service users from many types of abuse. EVIDENCE: The CSCI has not received any complaints about the home, nor have there been any adult protection issues raised about this service. One complaint made by a resident’s representative direct to the home was seen to have been logged and investigated appropriately by the registered Manager. Service users spoke of their ability to talk to any staff member. They didn’t have any complaints but would feel very comfortable to speak with the manager or staff at any time. Staff records looked at showed evidence of adult protection training held for the team in May of this year – this shows staff have been kept up to date and The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 18 have an awareness how to deal with this sensitive issue should such a situation arise. Relevant paperwork to offer staff formal guidance about this matter is freely available for staff to access in the downstairs office. The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 19 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): 19,20,21,22,24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The majority of accommodation at The Villa provides a clean, safe, comfortable environment for residents to live in. However, there are still areas requiring improvement. EVIDENCE: External improvements to the garden have made The Villa welcoming. Hanging baskets and flower tubs have survived the recent heat wave and the provision of new garden furniture on both patio areas means that there are pleasing outside spaces for residents to use. The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 20 At the start of the inspection the inspector was shown round the home and introduced to residents by the registered manager so people were aware it was being carried out, and were welcomed to share information about life at the home. All communal areas were seen to be clean and cosily furnished with the exception of carpeting in hallways and seating in the lounge area of the ‘Nursing Annexe.’ These were badly stained and were in need of a deep clean, and in the case of the armchairs consideration for replacement. Since the last inspection visit in January, several improvements were observed to have been carried out, and comments written by staff confirmed inspection findings. They all stated that the cleanliness of the home has got better over the past six months. As a result of this no permanent unpleasant odours were detected whilst walking around the premises. Newly installed thermostats were seen to be doing their job when hot water temperatures were tested at random in various parts of the home – all were satisfactory. The hot water system is no longer a risk to residents. In March, the home management welcomed the advice and support from the infection control nurse specialists who came to carry out an audit at The Villa. As a result of this several changes have been carried out in order to improve infection control within the home. These changes include: • Replacement of the main kitchen floor. • The provision of appropriate hand washing equipment throughout the home. • Improved laundry management systems to reduce cross infection. Several other issues were identified to be improved, such as sluicing of equipment, clinical procedures and waste management – these will be reviewed as part of the next inspection. Many residents’ bedrooms were seen during the home tour including those of the people whose records were looked at. It was seen that the accommodation provided was meeting their needs. Discussion with the manager confirmed that the sash window in the smoking lounge room would be repaired to maximise resident safety. The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 21 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home employs supportive staff in sufficient numbers to meet the needs of residents, although some recruitment and training measures require improvement to fully offer protection to people living and working at The Villa. EVIDENCE: By looking at the staffing rotas on display in the downstairs office, it was noted that on some occasions the staffing numbers and skill mix on the rota more than meet those the CSCI home registration certificate stipulates. On the inspection day itself, an extra carer was on duty on the early shift. This reflects the efforts of the home management to ensure there is enough staff on duty to care for the 32 people currently living there. Just over half of the people employed as carers at The Villa are either NVQ qualified, or are trained nurses recruited from overseas undertaking training in the home in order to be registered as nurses in this country. This shows that the residents are being cared for by a workforce where the majority of people have relevant care experience. The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 22 An in depth look at four sets of staff files including those of two new starters shows that recruitment systems continue to improve. All application forms were seen to have appropriate health declaration information. Documentation provided by the recruitment agency that introduces overseas staff to the home is of the necessary calibre to enable successful employment of these personnel. However, the records of a locally recruited individual did not have two written references in place or have evidence to show that the applicant’s employment history had been checked out. The manager confirmed that although the home uses the professional resources of a management consultancy to ensure full induction training is carried out staff records lacked details about this. As a result it could not be established how people were safely introduced to working at The Villa. The staff files did show that a lot of necessary mandatory training has been held since the last inspection. The home management team have been accessing the resources of Shropshire Partners in Care – a professional organisation of care home providers. This makes sure the staff get the appropriate training they need to carry out their job. Discussion with Mrs Juru also confirmed that further training for staff to manage challenging behaviour was in the process of being organised. Changes in the staff team now mean that currently 42 of staff are NVQ qualified this needs to be a minimum of 50 - staff commented that . The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 23 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): 31,33,35,36, &38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Experienced, suitably qualified individuals ensure management arrangements are meeting the majority of the needs of the service, However, some systems for the health, safety and welfare for residents, staff and visitors need to be improved and adjusted to make sure that they are kept up to date, to meet people’s changing needs as well as necessary legislation. EVIDENCE: Mr and Mrs Juru have open approachable systems in place for the day to day management at The Villa. Mrs Juru continues to show her ongoing commitment to be a competent care provider. She has recently undertaken mentorship training for overseas The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 24 nurses, which enhances the nursing and management qualifications she already holds. Several improvements recorded earlier in this report have been as a result of the management team acting in response to the staff and service user satisfaction survey carried out in December 2005. This demonstrates the home is run for the benefit of the people living there. The home is now well on the way to making sure all staff are getting formal supervision. When staff records were looked at it was seen that this responsibility has been shared between the senior team members. These sessions need to be carried out more frequently with more details recorded to maximise the team performance. Robust systems to manage service users monies have been introduced since the last inspection, safeguarding residents’ financial well-being. All necessary service and maintenance records requested were seen to be up to date and complied with necessary health and safety legislation. The current safe working systems in the home has resulted in good accident recordkeeping, although there is not enough detail to make sure the right action has been taken to reduce the chance of any accidents happening again, and that care staff are aware of, and are monitoring people who have been injured as a result of an accident. When the care records of a person who had four falls in less than three weeks were looked at, there was no falls risk assessment and management plan formulated in the individual’s care plan to show the issue had been fully looked at to reduce the chance of further falls. The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 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 X 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 3 3 X 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 OP2 Regulation 5(1)(d) Schedule 4. Requirement The registered manager must ensure each person is issued with a contract of terms and conditions as they move into the home which clearly identifies who is responsible for fee payment as well as the other details listed in NMS 2.2 Care plans must contain risk assessments for all aspects of resident care including those for moving & handling, smoking, and the potential effects of medical conditions such as epilepsy. (Previous timescale of 11/02/06 not met.) Care plans must show evidence of resident /relative involvement. (Previous timescale of 11/02/06 not met.) All care plans must include details of all aspects of a persons care needs. (Previous timescale of 11/02/06 not met.) Records must be show receipt and administration of all prescribed items received in the DS0000022281.V293811.R02.S.doc Timescale for action 10/09/06 2 OP7 13(6) 10/10/06 3 OP7 15(1) 10/10/06 4 OP8 12(1)(b) 15(1) 10/10/06 5 OP9 13(2) 10/10/06 The Villa Nursing And Residential Home Version 5.2 Page 27 6 OP12 16(1)(2), (m, n) 7 OP20 16(1) 23(2)(c, d) 8 OP26 13 (3) home. (Previous timescale of 11/02/06 not met.) The home must have written 10/10/06 evidence in residents’ records to show the flexible way individual’s routines of daily living and activities meet their preferences and capacities. All parts of the home including 10/10/06 carpets, armchairs and communal lounge windows must be kept clean safe and in good repair. (Previous timescale of 11/02/06 not met.) The home must devise and carry 10/10/06 out an action plan to meet the recommendations of the Infection control audit by the Health Protection agency in March 2006 The registered person shall not employ a person to work at the care home unless the person is fit to work at the care home. Recruitment procedures must ensure all pre employment screening has been carried out. Staff records must show they receive training appropriate to the work they are to perform including structured induction training. Care staff records must have details to demonstrate they get supervision at least 6 times a year, which must include signatures of the staff involved. (Previous timescale of 31/01/06 not met.) Accident management systems in the home must show effective remedial actions are carried out and documented in care records to maximise resident safety. DS0000022281.V293811.R02.S.doc 9 OP29 19(4, 5) 10/10/06 10 OP30 18 (1) (c) (i) 10/12/06 11 OP36 18(2) 10/12/06 12 OP38 13 (4) (c) 10/10/06 The Villa Nursing And Residential Home Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Villa Nursing And Residential Home DS0000022281.V293811.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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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