CARE HOMES FOR OLDER PEOPLE
THE VILLA NURSING AND RESIDENTIAL HOME PARK AVENUE MADDOCKS MADELEY TELFORD TF7 5AE Lead Inspector
JANET ADAMS 15
TH Announced JUNE 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service THE VILLA NURSING & RESIDENTIAL HOME Address PARK AVENUE MADDOCKS MADELEY TELFORD SHROPSHIRE TF7 5AE 01952 581022 01952 582431 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) MRS SUSAN JURU CARE HOME 33 Category(ies) of 26 DEMENTIA registration, with number 7 MENTAL DISORDER EXCLUDING LEARNING of places DISABILITY OR DEMENTIA THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home may accommodate a maximum of 33 service users. 2. 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. 3. 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 Date of last inspection 12th October 2004 Brief Description of the Service: The Villa is a Care Home for older people, providing both personal and nursing care in single and double accommodation. The Home, owned by Mr and Mrs Juru, 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 Home, set in its own grounds with flower borders and mature trees, comprises an original 19th century house which has been added to by more recent extensions. THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was announced and commenced at 9.30am lasting seven hours. It included observing activity within the home, inspecting the premises, looking at records, ‘case tracking’, talking and listening to residents, their visitors and staff working at the home in a variety of roles. The Proprietor / Managers Mr and Mrs Juru, and staff on duty were welcoming and helpful throughout the inspection. As part of this announced inspection, comment cards were circulated to residents, relatives and visiting professionals so that their experiences of life at The Villa could be included in this report. Although no residents returned comment cards, many were happy to talk to the inspector about the home on the day of inspection. It was obvious a lot of preparation had been undertaken to make sure all information needed was available on the inspection day, and the details the home provided to CSCI (Commission for Social Care Inspection) before the inspection was most worthwhile. 31 people were reported to be living at the home at the time of the inspection. On this occasion a total of 26 out of 38 National Minimum Standards were assessed. It was found that the National Minimum Standards assessed had been met with some minor exceptions. The Commission does not currently have any concerns regarding this home. What the service does well:
This home provides a very specialist service for older individuals with dementia related illness as well as a service for some younger people with mental disorders. The home makes every effort to provide individuals with a high standard of care to meet individual needs following a plan of care. It was unanimous in all comments received about the home that there was a consistent, satisfactory service provided. One comment received stated that the residents were treated as if they were part of the family. Comments from social workers, district nurses, relatives and the local GP confirmed that they were satisfied with the overall care delivery in the home. All of them confirmed that they have never had to make or to deal with any complaints about this home. The comment below sums up the numerous replies received. “The home manages to provide dignified and professional care to many residents who were previously unhappy in other homes. The young persons have been particularly successful in settling into the home.”
THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The policies and procedures that are in place have been professionally followed, to ensure that the home undertakes all necessary assessments for successful and satisfactory admissions to take place. EVIDENCE: Documentation examined for three residents indicated that individuals have a comprehensive assessment of their needs prior to admission, which is reviewed and amended as requirements change. When this issue was discussed with residents it was obvious that some people living in the home did not wish to have an active interest in this procedure. However, it was noteworthy to see written evidence of efforts made to liaise with social workers and other professionals in order to get as much up to date information about the people being assessed. THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8, 10 and 11,12 There is a consistent care planning system in place, which confirms residents get the care they need and expect. The staff are sensitive to the individual needs of each service user and meet these in a professional manner. EVIDENCE: The care plans of three residents at the home were looked at. The persons’ health, personal and social care needs were seen to be set out in their records. It was positive to see relevant details how to manage a lot of individual needs. For example to manage continence, the community link nurse had been involved in order to get the right advice to deal with a persons individual needs organised. Special forms to assess the persons continence needs were seen to have been filled in by the staff in order to collect as much information as possible in order to decide what the best way of managing this issue. Other important needs including mental health and personal hygiene were seen to be dealt with professionally. Staff spoken to on the day of the inspection showed they had a good understanding of what was in the care plans for the people they were looking after. The sensitive issue of caring for a person’s needs in the event of their passing away was also seen to be suitably dealt with. All residents spoken to confirmed
THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 10 they were fully involved with what was written about their needs if they wanted to be. One person specifically stated he was not interested in what was written about him, and in that case it was seen that the person’s brother had been involved in the process with his consent. District nurse, Doctor’s, and occupational therapist visits were recorded well. All contact with relatives confirmed that they could see their relative in private if they wish. Individual’s receiving care during the inspection were taken to their rooms or bathrooms. Good segregation systems were seen in place in shared rooms and when talking to staff these systems were described to be a part of their usual working routine in order to make sure peoples possessions were kept separate. Staff observed during the inspection spoke respectfully to service users. All contact with residents confirmed that the residents felt safe in the home; staff treated them well, and respected their privacy. THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Staff work in close liaison with residents and their relatives to understand their individual lifestyles and preferences in order that these can be continued when they move to The Villa. In consultation with individuals living at the home or their relatives if appropriate, choice and control over their lives is promoted where possible. Improvements in the meals provided at the home evidence that residents are offered quality and choice. EVIDENCE: The residents are encouraged and enabled to personalise their bedrooms, enjoy good meals in the pleasant dining room or in their own rooms and have a number of activities arranged for them within the home and out in the community. Plans reported for outings to Rhyl and a garden centre were in progress and most of the younger residents were planning on taking a holiday, although one had expressed she had no wish to go away. Individual needs, likes and dislikes are clearly shown in the care plans. Visitors are always made welcome, are included in events and are given all the necessary information on aspects of the home and the welfare of the residents. Visitors comments have been complimentary regarding the quality of life for the residents at the home. All commented that they were satisfied with the overall care provided.
THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 12 When residents and staff were asked about the food, it was said that improvements had already meant that the lunchtime meals were a lot better, and were more suited to different peoples tastes. However some replies received from people on the inspection day all confirmed that they felt the supper menu could be improved as residents usually got sandwiches. One younger service user commented a hot alternative such as pizza would be a nice change. Menus for breakfast and lunch were provided prior to the inspection. These were seen to be rotated on a four weekly basis in order to maximise variety. The supper menus will be reviewed at the next inspection visit. THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a complaints system that ensures that concerns are listened to and acted upon. The arrangements for the protection of residents from abuse are satisfactory. EVIDENCE: From the information provided to CSCI before the inspection it was confirmed that two complaints had been received. Both complaints were about issues CSCI were aware of and were dealt with appropriately. A minor issue observed to be addressed was that complaints notice in the hallway needed to be updated to ensure that it informed complainants they could contact CSCI at any stage of the complaint if they wished to do so. All comment cards received back from relatives and visitors contained details to confirm that they knew how to make a complaint if they needed to, although they all acknowledged they had not made a complaint. All feedback from visiting professionals such as social workers and district nurse confirmed that they had not dealt with any complaints about the home. The home has a policy in place with regard to the protection of adults from abuse. The home works with the framework of the local area adult protection procedure and a copy of this guidance was readily available within the home. Three members of staff spoken to confirmed that they would report any allegation or suspicion of abuse immediately. THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21, 22,24 & 26 The satisfactory standard of the environment within this home provides most service users with an attractive and homely place to live. EVIDENCE: An extensive tour around the home including the opportunity to look into the majority of bedrooms confirmed that most areas were clean and individual and communal rooms were decorated and furnished to a satisfactory standard. It was seen however, in one of the shared bedrooms that both people did not have their own personal locking storage. A smell of stale urine was noted to be prevalent in one of the double bedrooms and a single bedroom. This was discussed at the time of the inspection with Mr and Mrs Juru. The hot water temperature in one bathroom was 48 degrees Centigrade. This was identified to be prioritised to be dealt with on the day of the inspection by the home maintenance man. The provision of exercise equipment was reported to be a welcome facility to the home. Some residents who are reluctant to attend the ‘exercise as
THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 15 prescription’ classes were reported to be encouraged to use it in the privacy of a quiet area in the home. Liquid soap and paper towels was not available in all areas where staff would need to wash their hands. The Environmental Health Officer had visited on 11th February 2005 and the written requirements made were seen to have been met. The Fire Authority carried out a visit on 12th April 2005 and fire safety arrangements appeared satisfactory. The home has CCTV, and has an effective management system for the recordings it provides. THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28.29,30 The home employs staff in sufficient numbers to meet the needs of residents, although some recruitment and training needs have to be met. EVIDENCE: Observation of the staffing rotas confirms that levels on the rota meet those on the registration certificate. Information seen in three files looked at confirmed that most information was in place. It was notable to be informed that any staff recruited from overseas have face to face interviews by the registered providers/managers. When the Criminal Record Clearance certificates were checked, it was seen that all three people had commenced employment before the certificates had been received. In addition to this, not all staff members had signed declarations of health. Perusal of the staff training matrix dated 2nd May 2005 confirmed not all staff had completed their mandatory training such as food hygiene. Discussion with some staff members confirmed that there had not been any training for mental health issues. The manager commented that she was in the process of compiling a ‘Learning style Indicator’ to determine best practice for further training. It was seen that the neighbouring private physiotherapist does the entire home’s moving and handling training. The induction programme was notably good as it was seen to have been designed to ensure staff were aware of all the specific equipment that is used at The Villa. The information provided before the inspection confirmed that the home has 24 of its carers NVQ qualified, although it was hope to increase to 57 once all candidates currently undertaking the training had completed their course.
THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35, 36, 38. The home is managed by competent registered manager/providers who lead the staff team with knowledgeable expertise. This is reflected in the manner in which the health, safety and welfare of all who live, work and visit The Villa is promoted. Records for staff supervision and residents monies need to be further developed to reflect the way these procedures are carried out. EVIDENCE: The home has some very effective systems in place for its day to day management resulting in all team members being aware of their roles and responsibilities. The information provided by the home about its maintenance before the inspection was checked, and the records and service certificates were seen to be satisfactory. A newly devised Legionella risk assessment further ensures the safety and well being of all people involved in daily life at The Villa. Spot checks of the home’s policies and procedures showed that there was clear guidance accessible to staff.
THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 18 When the system of how the monies held on behalf of the residents was looked at, it was seen that a method of double signatures was needed to be introduced to further improve it to meet the required standard. Staff clearly work well together as a team and evidence of yearly appraisals were seen on some files. However, to ensure that staff have the opportunity for individual discussion about their performance and personal development with the manager or delegated supervisor the home still needs to put in place formal supervision carried out at least 6 times a year and keep a record on file. Although standard 37 was not assessed in full regards the keeping of records it is recommended to include maintenance of bed rails in the records for routine checks of equipment and health and safety audits. Guidance for this was agreed to be forwarded to the home during feedback at the end of the inspection. THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score N/A N/A 3 N/A N/A N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 N/A 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 2 N/A 2 3 3 2 3 2 STAFFING Standard No Score 27 3 28 N/A 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 N/A 3 3 3 N/A N/A 2 2 N/A 3 THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 20 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP19 OP21 Regulation 13 (3) Requirement Timescale for action 30/11/05 30/11/05 3. OP26 4. 5. OP24 OP29 6. OP30 7. OP35 The home must be free from unpleasant smells in all locations. 23 All hot water outlets accessed by (2)(p),13 servic users must be maintained (4)(a) at around 43 Degrees Centigrade at all times. 13 (3) Liquid soap and paper towels must be provided in areas where staff wash their hands after attending to service users. 16 (1), 13 All residents especially those in (6) shared bedrooms must have locking storage space. 19 All staff records must contain all elements listed as required in Schedule 2 including CRB and medical clearance before they commence employment in the home. 18 (1) (c ) All staff records must reflect that they have undertaken all mandatory as well as specific training training to meet the needs of the people living at The villa. 13 (6) Systems to manage service users finances must be further develoed to ensure double signatures confirm all transactions.
E56 S22281 The Villa AI V213469 150605 Stage 4.doc 31/12/05 31/12/05 30/11/05 31/01/06 30/11/05 THE VILLA NURSING AND RESIDENTIAL HOME Version 1.30 Page 21 8. OP36 18 (2) Care staff records must have details to demonstrate they get supervision at least 6 times a year. 31/01/06 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 OP37 Good Practice Recommendations To ensure recordkeeping is in place to demontstrate training appropriate for staff who who are responsible for selecting, fitting/using and checking bed rails. as well as maintenance of bed rails in the records for routine checks of equipment and health and safety audits. THE VILLA NURSING AND RESIDENTIAL HOME E56 S22281 The Villa AI V213469 150605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn SHREWSBURY SY2 5DE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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