Inspection on 07/06/05 for Thornbury Villa

This inspection was carried out on 7th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 07/12/05

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 PL3 4NE Lead Inspector Sheila Giblin Announced 7 June 2005 th 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. Thornbury Villa D52-D04 S3541 Thornbury V222688 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Thornbury Villa Address 128 Peverell Park Road, Peverell, Plymouth, Devon, PL3 4NE 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) 01752 262204 01752 672272 parkviewpl3@btopenworld.com 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 D52-D04 S3541 Thornbury V222688 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 9 November 2004 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 65yrs . 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 D52-D04 S3541 Thornbury V222688 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection which took place over eight hours. A preinspection questionnaire had been completed and submitted prior to the inspection. There were 12 residents living in the home and all were introduced to the inspector. Four residents gave an account of life in the home and two visitors spoke of the care services their relatives received. A sample of residents’ care plans, pre-admission assessments, fire safety and accident records were inspected. The medication administration system was inspected. The registered providers, Mr and Mrs Van Deijl were present throughout the inspection and offered information and topics for discussion regarding the changing approach to inspection and regulation of care homes included in the document ‘Inspecting for Better Lives’. During the tour of the home all bedrooms, bathrooms and toilets, living rooms and kitchen were inspected. Nine Commission for Social Care Inspection questionnaires were completed. Every one answered positively to the questions asked which cover all aspects of life in the home. What the service does well: Thornbury Villa is a smaller home that provides a friendly personal service in comfortable homely accommodation. Mr and Mrs Van Deijl lead the staff team in promoting a warm caring atmosphere where the residents feel relaxed and at home and are encouraged to make decisions and choices about their daily routines. The care manager regularly reviews and reassesses the care needs and care plans of residents whose health may be beginning to deteriorate and communicates clearly to staff any changes. Meals are well planned, cooked and served and consist of a variety of traditional dishes that residents like and enjoy. Recording systems and record keeping has been well developed and provides clear information that enables good communication between staff. Living rooms are comfortably furnished and set out in a style that encourages conversation and socialising. Outside in the secure gardens patios provide seating areas in sun and shade where residents and visitors can sit. On the first floor, balconies provide further opportunities to sit out when the weather allows. Mr and Mrs Van Deijl have introduced sanitising hand gel for visitors to use on entry to the home to minimise the risk of cross infection. Thornbury Villa D52-D04 S3541 Thornbury V222688 070605 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. Thornbury Villa D52-D04 S3541 Thornbury V222688 070605 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 Thornbury Villa D52-D04 S3541 Thornbury V222688 070605 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) 1, 3, 4, 5, 6 Prospective residents can be confident that the information they are given prior to admission will help them make a decision as to whether this home is suitable for them. EVIDENCE: Residents and their relatives described the home’s admission procedures as they had experienced them recently. Residents said they were warmly welcomed and made to feel at home. A contract was provided and details of fees payable and the terms and conditions of the occupancy were clearly written. A preadmission assessment to see if the home is able to meet the care needs is carried out by the manager and recorded in the file. A letter to confirm that the home is able to meet those assessed care needs isn’t sent to the prospective resident. 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 D52-D04 S3541 Thornbury V222688 070605 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, 9, 10, Residents can be confident that their written care plans will include input from relatives ensuring all care needs are met. EVIDENCE: There is a clear care planning system in place and changing needs are reviewed to ensure attention is offered to residents whose condition had deteriorated. The manager had responded positively to comments from a relative to ensure appropriate support and attention would be provided. Care plans were clearly written and included health and personal care needs. Residents’ health care concerns are referred to their GP who either visits the home or an appointment made at the surgery. Community nursing services are provided and the district nurse visits regularly. The changing needs of a resident had prompted a nursing needs assessment resulting in a recommended move to a care home that provides nursing care. The registered manager had provided information to assist in the choice of a suitable home. The medication administration system was inspected and staff were knowledgeable and competent. Three named staff members administer medication. Records were accurate and complete. All the residents said that they were treated with the utmost dignity and that their privacy was always respected when they were receiving personal care. Thornbury Villa D52-D04 S3541 Thornbury V222688 070605 Stage 4.doc Version 1.30 Page 10 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, 15 Residents can be confident that the lifestyle in the home will be relaxed, interesting and promote their independence and choices. EVIDENCE: During the inspection there was an exercise session and a resident played the piano for an impromptu sing-a-long. The atmosphere was relaxed and comfortable whereby people wandered in and out of the living rooms and did as they pleased. Some residents stayed in their own rooms and received visitors and ate their lunch. Two relatives spoke to the inspector and both praised the staff for their kindness. Everyone said how much they enjoy the food served and praised the cook for the quality of the meals and the standard of cooking. The inspector ate lunch with the residents in the dining area and noted the high level of satisfaction with the food served. Tables were immaculately laid with white table linen and china. Service was prompt and unhurried. People were offered alternatives if they didn’t want what was on offer. Residents said that there were no rules as such: they could get up when they wanted and went to bed when they liked. Residents said they didn’t go out on trips as such. The manager said that previous arrangements had been made but residents had not wished to take up the seats in the hired coach provided. Some residents said they went out with their families or walked to the local shops. Thornbury Villa D52-D04 S3541 Thornbury V222688 070605 Stage 4.doc Version 1.30 Page 11 Activities in the home include weekly bingo sessions, fortnightly exercises and sing-a-longs to the piano. There was to be a Country and Western evening on the weekend following the inspection with a barbecue for staff, residents and visitors. Thornbury Villa D52-D04 S3541 Thornbury V222688 070605 Stage 4.doc Version 1.30 Page 12 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) 16,17, 18 Residents and their relatives can be confident that their views will be listened to and any complaints will be taken seriously. EVIDENCE: None of the residents spoken to said that they had ever had to make a complaint. If they wanted anything or had a worry they would speak to the manager or any of the staff and know it would be taken care of. The complaints procedure was posted on the notice board and included in the Statement of Purpose and Service User Guide. All residents had postal votes in the recent elections and everyone resident in the home at the time would be entered on the electoral register. Mr Van Deijl is a member of the POVA review committee and is conversant and very knowledgeable about the procedures in place for the protection of the residents in the home. All residents in the home are risk assessed as to their vulnerability with regards to all types of abuse. He gave examples whereby the risk assessments had revealed the need to refer residents for legal advice regarding protection of their property and finances. The latest Alerter’s Guide and prevention of abuse procedures were available to staff. Managers undertake the formal training and cascade it to staff. NVQ training also includes elements of protection of vulnerable adults. Thornbury Villa D52-D04 S3541 Thornbury V222688 070605 Stage 4.doc Version 1.30 Page 13 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, 23, 24, 25, 26 Residents are assured of a safe, clean, well-furnished home where they can maintain their privacy and live in comfort. EVIDENCE: Thornbury Villa is a stylish corner property with accommodation on two floors. A stair lift provides access to the upper floor. One separate bedroom off the lounge involves stairway access. The home provides 13 single bedrooms all with en suite toilets. All the rooms are lockable and central heating radiators have been risk assessed. The rooms are well furnished and reflected the style and interests of the person living in the room. Some rooms are smaller than others but all meet the amended standards. Rooms were bright, clean and tidy. The living room is a large lounge with a dining area at one end. There was sufficient space for residents to sit and watch TV or participate in an exercise session. Large patio doors open out onto the enclosed garden where seats and tables with parasols provide either sunny or shaded places to sit and relax. Residents can take refreshments in the garden if they wish. On the first floor Thornbury Villa D52-D04 S3541 Thornbury V222688 070605 Stage 4.doc Version 1.30 Page 14 there is a balcony that provides further seating areas overlooking the road and gardens. There are two bathrooms one of which is assisted with a hoist, there are raised toilet seats where required and hand rails to provide support and to aid mobility around the home. Those residents who require walking frames had been assessed. Cot sides were provided as a safety measure for a bed bound resident and were included in the care plan. The kitchen was clean and well ventilated and housed all the usual equipment and utensils for cooking and storing food which was reflected in the high standard of meals provided. Thornbury Villa D52-D04 S3541 Thornbury V222688 070605 Stage 4.doc Version 1.30 Page 15 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, 30 Residents can be confident that enough staff will be on duty who are experienced and competent to meet their care needs. EVIDENCE: The duty rota showed that two care staff are on duty at all times together with a cook and sometimes a cleaner. All care staff hold a first aid certificate and Mr Van Deijl is the First aid at work representative. Mr and Mrs Van Deijl oversee the running of the home and a part time manager supervises staff in the care of residents. Training plans were in place and information included in the pre-inspection questionnaire showed that staff have undertaken training in medication administration, infection control and NVQs. Two staff are to commence NVQ3 courses in September 2005 and all staff are to update their training regarding moving and handling. Two staff in the home have undertaken the Osteoporosis Audit training whereby residents health and risk of osteoporosis have been assessed. Staff have been given delegated responsibilities for staff rotas and duty cover. The home does not use agency staff. Thornbury Villa D52-D04 S3541 Thornbury V222688 070605 Stage 4.doc Version 1.30 Page 16 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) 31, 32, 33, 35, 37, 38 Residents benefit from living in a well run home which is overseen by the owners Mr and Mrs Van Deijl. EVIDENCE: Mr Van Deijl is the Registered Manager of Thornbury Villa. He has long experience in owning and managing care homes. He has enrolled on the Registered Manager’s Award course this year. Mr Van Deijl 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 is reflected in his knowledge of the standards and the regulations concerning the conduct and management of the home. The atmosphere in the home is very positive, warm and inclusive. Quality Assurance questionnaires are distributed every six weeks to residents to gather their views about the services being provided in the home. Ways of gathering the views of health and social care professionals who visit the home Thornbury Villa D52-D04 S3541 Thornbury V222688 070605 Stage 4.doc Version 1.30 Page 17 were discussed. It was recognised that people are very busy and may not always have the time to complete a questionnaire. Residents manage their own finances as far as possible. Mr Van Deijl will assist residents to access financial advice but will not handle anyone’s financial affairs as stated in the pre-inspection questionnaire. Residents’ records and personal files are maintained in a locked cupboard to maintain confidentiality. Residents and their relatives would have access to them on request. Policies and procedures have been written and reviewed regularly and cover all the activities in the home including health and safety risk assessments. Accidents have been recorded in an accident book. 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 held on file. Thornbury Villa D52-D04 S3541 Thornbury V222688 070605 Stage 4.doc Version 1.30 Page 18 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 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 4 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 4 4 4 3 x 3 x 3 3 Thornbury Villa D52-D04 S3541 Thornbury V222688 070605 Stage 4.doc Version 1.30 Page 19 yes 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. Standard 3 Regulation 14 Requirement Following the preadmission needs assessment the registered person must confirm in writing that the home can meet the residents care needs. Central heating radiators must be guarded Timescale for action 1st September 2005 1st September 2005 2. 3. 25 23(2)(p) 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 Good Practice Recommendations Thornbury Villa D52-D04 S3541 Thornbury V222688 070605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Thornbury Villa D52-D04 S3541 Thornbury V222688 070605 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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