Inspection on 07/12/05 for Thornbury Villa

This inspection was carried out on 7th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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.

Other inspections for this house

Thornbury Villa 17/01/07

Thornbury Villa 07/06/05

Thornbury Villa 10/11/04

Thornbury Villa 06/07/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

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 Thornbury Villa 128 Peverell Park Road Peverell Plymouth Devon PL3 4NE Lead Inspector Wendy Baines Unannounced Inspection 7th December 2005 09.30 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 Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 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. Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Thornbury Villa Address 128 Peverell Park Road Peverell Plymouth Devon PL3 4NE 01752 262204 NONE 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 James Marinus Van Deijl Mrs Jacqueline Anne Van Deijl Mr James Marinus Van Deijl Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th June 2005 Brief Description of the Service: Thornbury villa is a care home situated on the edge of Central Park, Peverell, Plymouth, and within walking distance of Mutley- Plain shopping precinct. The home has a family atmosphere due to there being a maximum of 13 service users at any one time, and due to the efforts of the owners and staff to ensure a non-institutionalised and homely environment. All the accommodation is in single/ en-suite bedrooms located on two floors. The house is spacious and provides sufficient shared space for the numbers and needs of the 13 people who live there. The home is Registered to provide care for up to 13 older people aged 65 years . Thornbury villa does not provide care for people with Dementia or severe physical disability. The home is not Registered to provide Nursing care. Thornbury Villa sets out to provide care services for people whose assessed needs are of a lower level and who maintain a certain level of independence. Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on the 7th December over four hours. The senior member of staff on duty and the Registered Providers, Mr and Mrs Van Deijl were available throughout the inspection. All service users were spoken to and several gave an account of life in the home. One service user who had recently moved to the home said that ‘ all the staff are caring’, and that ‘Thornbury Villa was the next best thing to her own home’. One service user was staying at the home for a trial period and a relative said that staff and management had provided good support and information to their mother and the family during this time. A sample of service users records, care plans, pre-admission assessments, fire safety and accident records were inspected. During the visit two of the service users bedrooms, the living/dining room and office were inspected. The home was beautifully decorated for Christmas and had a warm and welcoming atmosphere. During the afternoon service users enjoyed Christmas Carols in the main sitting room organised by a local youth group. The homes service user questionnaires were available that had been completed since the last inspection, and included very positive comments about the home and the care provided, these included; ‘ Would recommend this home to anyone’ ‘ Kindness and love and all we ask for is given’. What the service does well: Thornbury Villa provides a friendly personal service in a comfortable, homely environment. Mr and Mrs Van Deijl lead the staff team in promoting a warm, caring atmosphere where the service users feel relaxed and at home and are encouraged to make decisions about their daily routines. Good information is passed to anyone who may consider moving to the home and a thorough assessment is completed prior to admission to ensure that needs can be met. The care manager regularly reviews the care needs and care plans of service users and clear information is documented regarding general and complex healthcare needs. Living rooms are comfortably furnished and set out in a style that encourages conversation and socialising. Arrangements are made for entertainment and Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 Page 6 social opportunities in the home and service users are given the choice if they wish to partake. Family and friends are welcomed by staff and can visit at any time. The homes complaints procedures and service users questionnaires ensure that all concerns are listened to and addressed. 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. Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 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 the following standard(s): 1,3,4,5,6. Prospective service users can be confident that the information they are given prior to admission will help them make a decision about where they live. Prospective service users can also be confident that their care needs will be assessed to ensure that the home will be able to meet their needs. EVIDENCE: Prospective service users are provided with a Statement of Purpose and Service User Guide to assist them to make a choice about where they live. The home has had five new admissions since the last inspection. Records were seen and several of these service users were spoken to and said that they had settled well, and had been warmly welcomed and made to feel at home. Preadmission assessments had been completed and letters sent to all parties to confirm whether or not the home could meet the service users needs. One service user spoken to was visiting the home as part of a trial. A relative of the prospective service user said that the staff and management had offered support and information to the family during this time to assist them to make a decision about the suitability of the placement. Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 Page 9 Thornbury Villa does not provide intermediate rehabilitative care although they will accommodate a resident who plans to return home following an extended period of recuperation after being in hospital. Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 Page 10 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): 7,8,10,11. The health needs of service users are well met with evidence of good multidisciplinary working taking place on a regular basis. EVIDENCE: A sample of service user care plans and health records were inspected. There is a clear care planning system in place and changing needs are regularly reviewed to ensure attention is offered to service users whose condition has deteriorated. Care plans were clearly written and more detailed information was recorded separately when needs are more complex. All service users are supported to attend regular health checks and appointments and community/district nurses visit the home regularly. A record is kept of service users who fall and senior staff have been trained to assess service users vulnerability of suffering from fractures/ Osteoporosis. All service users spoken to said that the staff were kind and caring and treated them respectfully at all times. Staff were observed knocking on service users bedrooms doors and respecting privacy when providing support with personal care. Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 Page 11 Changes are made to care plans to reflect any deterioration in health and since the last inspection three service users have been supported to move to a service where nursing care is provided. Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 Page 12 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. The atmosphere of the home is warm and welcoming. Service users are encouraged and supported to maintain contact with family and friends. EVIDENCE: The atmosphere of the home was warm and welcoming. Several service users were sat chatting whilst finishing breakfast, others were having breakfast in their room, and staff were supporting some service users to make arrangements for the day. The house had been beautifully decorated for Christmas and during the afternoon service users were invited to join in with Christmas Carols organised by a local youth group. Service users said that a Christmas Raffle and party had been arranged. Service users welcomed the inspector and were keen to praise the staff for their care and kindness. The inspector was able to speak with some relatives and friends who were visiting the home and all said that they were made to feel welcome by the staff and were able to visit at any time. Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 Page 13 The senior member of staff on duty said that a monthly questionnaire is given to service users, which covers social and leisure opportunities in the home. This information in addition to regular discussion is used to encourage service users to make decisions and have choices about this area of care. Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 Page 14 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. Service users and relatives can be confident that their views will be listened to and any complaints will be taken seriously. Procedures and training are in place to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: The Commission for Social Care Inspection has not received any complaints regarding this service. The home has its own complaints procedure and also records any minor concerns and how these have been addressed. Service users spoken to said that they feel the staff listen to them and feel confident that any of their concerns would be dealt with. The home has a copy of the latest Alerter’s guide, and prevention of abuse procedures are available to all staff. All residents in the home are risk assessed as to their vulnerability with regards to all types of abuse. This information was available for inspection and examples given of how the home had requested external advice and support when a significant risk was identified. Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 Page 15 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 standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: All parts of the home inspected on this occasion were found to be clean, tidy and well maintained. Since the last inspection there has been some minor adaptations including new handrails and a stair-lift to one service users bedroom. The manager said that one of the bedrooms had been redecorated and there had been some general maintenance work to flooring and plastering. Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 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 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): 29. The homes standards of vetting and recruitment procedures are good and protect service users. EVIDENCE: A sample of staff files were seen for members of staff recently appointed in the home. These files contained; application forms, two written references, proof of ID and Criminal Record Bureaux checks. The manager confirmed that staff are not able to work in the home before this information is received. Staff are issued with a Statement of Terms and Conditions, GSCC Codes of Conduct and a job description. The home does not recruit agency staff or volunteers. Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 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 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): 31,32,38. Residents benefit from a well managed home where their best interests are always considered. EVIDENCE: Mr Van Deijl is the Registered Manager for Thornbury Villa. He has long experience in owning and managing care homes. He has played a prominent role in promoting standards of care in care homes by being involved in consultation working groups locally and further afield. This continues to be reflected in his knowledge of the standards and the regulations concerning the conduct and management of the home. The atmosphere of the home is very positive, warm and inclusive and the staff spoken to said they felt well supported and part of a team. Some of the members of staff in the home on the day of the inspection said they were not Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 Page 18 on duty but had popped in to ‘ say hello’ and visit the service users. This would seem to be a reflection of the staff commitment and high staff morale in the home. Policies and Procedures have been written and reviewed regularly and cover all the activities in the home including health and safety risk assessments. Discussion has previously taken place with the Registered Manager regarding the Requirement to cover all hot surfaces, including radiators in the home. The manager has chosen to complete risk assessments and cover radiators dependent on the level of risk. Therefore, not all radiators are covered. During this inspection a radiator was found to be very hot in the room of one service user who was quite frail. Discussion took place with the Senior member of staff regarding this area of concern. Fire safety systems have been properly maintained and tested. All bedroom and access doors have recommended hold open devices – door wedges are never used to keep doors open. Portable electrical equipment has been tested to ensure its safety and test certificates are held on file. Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 4 4 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 x x x x x 2 Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 Page 20 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 OP38 Regulation 23(2) (P) Requirement Central heating radiators must be covered. The Registered Provider must ensure that the hot surface within the bedroom discussed during the inspection is dealt with as a matter of urgency. Timescale for action 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Thornbury Villa DS0000003541.V259723.R01.S.doc Version 5.0 Page 21 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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