Inspection on 13/11/06 for Villa Adastra

This inspection was carried out on 13th November 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Villa Adastra 16/11/05

Villa Adastra 30/06/05

Villa Adastra 14/12/04

Villa Adastra 10/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Villa Adastra 79 Keymer Road Hassocks West Sussex BN6 8QH Lead Inspector Mrs J Hough Key Unannounced Inspection 10:20 13th November 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 Villa Adastra DS0000035172.V316300.R01.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. Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Villa Adastra Address 79 Keymer Road Hassocks West Sussex BN6 8QH 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) 01273 842184 01273 841420 The Salavation Army Territorial Headqauarters Mr Chris Shields Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th November 2005 Brief Description of the Service: Villa Adastra is care home registered to provide personal care and accommodation for up to forty older people. The accommodation is provided in single bedrooms each offering en-suite facilities. The accommodation is divided into five separate units each containing eight bedrooms, a lounge and dining room, which are located on three floors. A vertical passenger lift provides access to all floors. The property is situated in well-maintained grounds, which are accessible to residents. The property is located in Hassocks, close to shops and other local amenities. The Registered Provider is The Salvation Army and Captain Elaine Furminger is the Responsible Individual, who acts on behalf of the Registered Provider. The Registered Manager is Mr Chris Shields who is responsible for the day to day running of the care home. Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection was undertaken by one inspector June Hough on 13th November 2006 starting from 10:20am and ending 16:20 hrs. Information for this report was taken from the provider’s monthly monitoring reports, plus evidence from previous inspections, and the evidence gained during the inspection visit. A pre-inspection questionnaire was not received by the provider prior to the inspection. During the inspection process records were examined in relation to resident’s care plans and assessments, complaints and accidents, staff files, staff rosters, and maintenance. A tour of the premises took place and both residents and staff were spoken with to gain their views on what it was like living and working in the home. The scale of fees is £583.17 per week. What the service does well: What has improved since the last inspection? Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 6 The medication practice considered unsafe at the last inspection had now ceased. 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 summary of this inspection report can be made available in other formats on request. Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 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 Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All prospective residents have a full needs assessment carried out prior to admission to the home. The home does not provide intermediate care. EVIDENCE: Senior management carry out a full needs assessment on all prospective residents. Residents are visited either in their own homes, hospital or care settings. The use of a new pre-admission assessment that is more detailed is being piloted at present. Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 9 Admission to the home also has to take into consideration the suitability of prospective residents to live with existing residents, being that residents are accommodated in small units of eight. The home also takes residents for respite care. It was noted that some residents were in the first stages of having mild dementia and the home was able to provide evidence that they were meeting these resident’s needs at present. The home was not registered for dementia care and this issue was discussed with the manager for consideration. The home does not provide intermediate care. Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have a care plan that is individual to their needs. The medication procedures carried out in the home ensure safe practice. Residents have their privacy and dignity respected by staff. EVIDENCE: Two resident’s care plans and assessments were looked at, as part of the case tracking process. Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 11 It was noted that one handling risk assessment and care plan did not give clear direction to staff in the use of equipment for transferring the resident. The care plan stated the need to use a standing aid or hoist leaving the carers to assess the situation on a daily basis. Also, when it was identified that residents can present with extreme behaviour, the care plans/risk assessments did not give the actions required by staff at these times. The second care plan and assessment was clear and detailed in identifying the level of care and support required, and the actions needed by staff to meet the resident’s needs. The care plans and assessments were in the process of being reviewed with the prospect of changing to a new format for easier reference. Care plans seen were reviewed and updated monthly. Medication administration records were accurate in completing administration of all medicines. Some handwritten entries on records were not signed and dated and gave no indication to the number of medicines in stock. One handwritten entry for painkillers, to be given when required had no instructions to the dosage or frequency of the medication. The practice of administering medicines from medicine pots to those residents in their rooms had now ceased and all medicines were administered directly from the original containers contained in the medicine trolley. All senior staff that administers medicines had all undergone training in the safe handling and administration of medicines. A list of specimen signatures of staff that administer medicines was available for reference in the folder containing the medication records. The medication policies and procedures were in place and dated 2003 giving no evidence of regular reviews. The residents praised the staff saying that they were always courteous and kind, and respected their privacy and dignity by knocking on bedroom doors and providing personal care in the privacy of their rooms or bathrooms ensuring door were shut. . Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 12 Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 13 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. 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 were happy with the social aspect of life in the home. Residents can see friends and family whenever they liked. Residents received a nutritious and varied diet and snacks were available at all times. EVIDENCE: The home employs two activity co-ordinators who plan and facilitate the activities for residents. Activities take place in the central lounge downstairs or in the separate units depending on the needs of residents. One to ones are also arranged for those residents staying in their rooms. Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 14 There is a programme of regular activities and outside entertainment is arranged periodically. Some of the residents chose to join clubs outside the home and some residents had been on a holiday to Margate in September 2006. The home has its own mini bus that can take up to 13 residents out for trips. Residents spoken with were happy with the activities on offer and said there was plenty to do for those who wished to join in. The catering, laundry and domestic services in the home were provided by a contract catering company who were also responsible for the recruitment and training of its own staff. Menus were prepared and planned by the company in liaison with staff, and taking into account the resident’s likes and dislikes in food. The menus run for four weeks and had recently been reviewed taking off the least popular dishes. Menus offer an alternative meal each day including a jacket potato with various fillings, and a choice of salad. The evening meal offers a variety of salads, sandwiches and soup. Each unit has a kitchenette where drinks and snacks are available for residents at all times. Visiting arrangements in the home are open and residents confirmed that their visitors were welcome to visit at any reasonable time. The home handles small amounts of spending money for some residents and money is secured in the office safe. Resident’s money is kept in individual wallets and all transactions were recorded and signed by two persons with receipts kept where appropriate. Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 15 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. 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 residents can be reassured that the home takes all complaints seriously and assured that issues would be resolved to their satisfaction. Residents are protected from abuse. EVIDENCE: The home had a clear complaints procedure in place. The complaints log was seen and there were 37-recorded complaints in the past 12 months that had all been dealt with satisfactorily in line with the correct procedures. The home records all complaints/concerns even those that have been resolved immediately. Following several complaints about the laundry the home is in the process of purchasing a new washing machine that washes at low temperatures but still meets the disinfection standards. Staff training records showed that in 2006 staff had training updates in adult abuse. Staff spoken with showed they were fully aware of their individual Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 16 responsibilities in having to report any incidents, or allegations of abuse in the home. Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live a safe, clean and homely environment. EVIDENCE: A tour of the premises was made and all areas of the home were clean and fresh. The home consists of five separate units that accommodate eight residents. All resident’s accommodation is provided in single rooms all with en-suite facilities. Each unit has its own kitchenette, dining and lounge areas. Being that the units are small, all had a homely and relaxed atmosphere. Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 18 The home has an on-going maintenance programme where areas of the home are decorated as required and when rooms become vacant. Some of the resident’s rooms were furnished with their own small items of furniture and personal possessions. The last fire assessment carried out by the local fire service was on 6th October 2006 and the outstanding requirements of having cold smoke seals around doors had been given an extension for completion by the fire officer until 2nd January 2007. Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers of staff was sufficient to meet the needs of the residents. The recruitment procedures in the home ensure residents are protected from harm as far as practicable EVIDENCE: Staffing rosters showed that there is one care assistant working on each unit during the day and night. A senior care assistant is included in these numbers on each shift. An extra care assistant floats between units during the day and is available for assistance when needed. Staff can summon assistance during the day via the call-system, and at night carry walkie- talkies. The home had some vacancies for day and night staff. It was confirmed that due to the re-structuring of the management within the Salvation Army, that staff recruitment was on hold at present. Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 20 Staff spoken with felt the staffing numbers were sufficient to give the residents the care and attention they needed. Residents said that staff generally responded to their calls for assistance promptly. However when walking around the home it was seen that all the staff working on the afternoon shift where taking a tea break at the same time, therefore leaving some units without a member of staff being present. The staff confirmed that this was the usual practice. This issue was discussed with the manager for his attention. Three staff files were examined to check recruitment procedures. All files seen had evidence that all the necessary checks had been carried on staff prior to staff working in the home. All new members of staff commence on the induction programme and work under supervision until they have been assessed as competent to work on their own. The home supports and encourages staff to work towards a National Vocational Qualification in care, and over 50 of the staff had achieved this qualification. Residents felt the staff attended to their needs very well. However it was said that when agency staff were on duty the level of care was not so good, being that the agency staff were not always aware of resident’s individual needs. Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run well by an experienced and competent manager. The health and safety of residents is protected. EVIDENCE: Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 22 The registered manager was registered with the Commission in October 2006 and met the requirements for registration. A satisfaction survey is being processed at present, and will be sent out to families and residents in due course to find out their views of the home and the services it provides. An in-depth annual inspection had taken place on 3rd October 2006 by the Salvation Army that had highlighted some matters that needed attention that were in hand. Accident, incidents and injuries were recorded and reported to the appropriate authorities. A monitoring system for accidents is in place to ensure risk assessments are put in place where required. Maintenance records showed that all systems, and equipment used in the home were maintained and serviced. The assessment carried out by the Salvation Army showed that all fire extinguisher checks should be recorded monthly. Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 23 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Villa Adastra DS0000035172.V316300.R01.S.doc Version 5.2 Page 26 - 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. 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