Inspection on 17/08/05 for Villa Maria

This inspection was carried out on 17th August 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

Villa Maria 24/01/07

Villa Maria 07/12/05

Villa Maria 14/01/05

Villa Maria 17/08/04

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 Maria 53 Seabrook Road Hythe Kent CT21 5QE Lead Inspector Julian Graham Unannounced 17 August 2005 9:30 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. Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Villa Maria Address 53 Seabrook Road, Hythe, Kent, CT21 5QE 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) 01303 266723 Marist Sisters Beverley Allen Care home only 23 Category(ies) of Older People x 23 registration, with number of places Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 14/01/05 Brief Description of the Service: Villa Maria occupies purpose-built, detached premises which are linked to the adjoining convent. The home is registered to provide accommodation and personal care for up to 23 persons. The home is owned by a religious order, the Sisters of the Marist Congregation, and offers the care and service to Marist Sisters only. Mrs Beverley Allen is the registered Manager. Major building works were completed in 2003, and the Home provides a spacious and comfortable living environment decorated and furbished to a high standard. There is a choice of sitting areas. All bedrooms are for single occupancy and have ensuite facilities. Assisted baths, one with a jacuzzi, are available on all floors. The home is located on the outskirts of a small sized town with good access to shops, public transport and other public amenities, some of which are within walking distance Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 10.30 and lasted five hours. Twelve of the Sisters were spoken with, with all saying how kind and caring the staff are. Time was also spent with the manager and her line manager, and a team leader and carer were interviewed in private. Staff were observed directly and indirectly as they were going about their work. The lunch time meal was shared with the Sisters. A tour of the premises was undertaken and a number of records were inspected. The Sisters, manager and staff are thanked for their assistance during this inspection. What the service does well: What has improved since the last inspection? Care planning has improved considerably. The manager has worked very hard in completely revamping Sisters’ case files, which are now very orderly and accessible. Care plans are very comprehensive and detailed and provide staff with the information they need to meet the Sisters’ needs. Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 Page 6 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. Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 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 Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 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 Satisfactory arrangements are in place for admitting new Sisters to the home. EVIDENCE: It was noted in previous inspections that Sisters move into the home from other Communities some distance away. All have knowledge of the home before moving in, and have assurance that the home is able to meet their needs. A Sister new to Villa Maria said that whilst she did not visit the home before moving in, she knew all about the home as she “knew all the Sisters already living here.” A comprehensive needs assessment is nonetheless completed at or around the time of admission, and provides a detailed account of the person’s needs. An example of this was seen. As recommended at the last inspection, a history of falls now forms part of the initial assessment. Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 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 The care planning system is comprehensive, clear and consistent and provides staff with the information they need to meet the Sisters’ needs. The health needs of the Sisters are well met with evidence of good multi disciplinary working taking place. Personal care is provided in a way that promotes residents’ dignity and privacy. Medication is being generally well managed but still needs improvement in some areas. EVIDENCE: As noted in the summary of this report, care planning has improved considerably and care plans are now being prepared to an excellent standard. A very wide range of needs is detailed in the plans with the action needing to be taken clearly recorded. There are sections on each area of need in the file making it easy for staff to find and follow. Needs include mobility, continence, dietary, mental health, foot care and so on. Excellent monthly reviews are being undertaken and recorded showing that the home is able to promptly pick up on any health or other condition or area of need requiring attention. Staff demonstrated good understanding regarding monitoring skin condition so as to prevent the development of pressure areas. Waterlow assessments are in place and reviewed monthly. Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 Page 10 There was evidence of accessing specialist health care intervention when required. A community psychiatric nurse is working closely with the home to support one of the Sisters, for example, and the suggested daily recordings to monitor this person’s behaviour are being made and were seen at the inspection. Records showed that a physiotherapist assessed the mobility of one of the Sisters and specialist equipment has subsequently been provided. All the Sisters spoken with said that staff are vigilant is respecting their dignity and privacy. Staff were observed interacting with the Sisters with warmth, good humour and respect. Some of the matters identified as needing attention regarding medication from the last inspection have been addressed, including the arrangements for storing Controlled Drugs. Others remain outstanding, however, and include expanding the policy and procedure to cover covert medication, the taking of verbal orders, and self-administration. There is still no evidence that the competence of staff in administering medication has been assessed. Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 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) 12,13,14,15 The Sisters are being enabled to lead the lives they want without restriction. The meals are good and offer both choice and variety. EVIDENCE: The Sisters said that they are free to follow the religious life in the way they wish, which includes attending services in the chapel. Afternoon tea is available in the lounge at 3 p.m followed each day with the opportunity to join in with activities such as arts and crafts, hand massage, flower arranging. Staff who were interviewed were clear that it is an important part of their work to engage with the Sisters either in general chatting or other social or recreational activities and that there is time for this. Sisters spoken with said that they are satisfied with the range of activities provided, with some saying they are not interested in participating and that their wishes are respected. Sisters said that they are able to maintain contact with family and friends who are made very welcome when they visit. Comments from the Sisters regarding the food provided were very positive. There have been some changes in kitchen personnel since the last inspection, and whilst the former chef is greatly missed, Sisters said the overall standard of food is being maintained. Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 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) Not inspected EVIDENCE: Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 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) 19,20,21,23,24,25,26 The standard of the environment within the home is excellent. EVIDENCE: A tour of the communal areas of the home revealed very good decorative standards, and the overall quality of the furnishings and fittings is excellent. The accommodation is spacious and is being very well maintained. The Sisters are therefore able to live in comfortable and attractive surroundings. Bedrooms, too, are of a good size and in good order. All parts of the home seen were clean, hygienic and free from offensive odours. Bathrooms and toilets were clean and welcoming. There needs to be disposable towels and a pedal bin in the downstairs disabled toilet, however, to reduce the risk of the spread of infection. Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 Page 14 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 There is an insufficient number of care staff on duty. Staff are well qualified and trained, although the arrangements for inducting new staff are poor. Recruitment procedures are generally sound. EVIDENCE: Staffing levels have been reduced since the last inspection and morning shifts are now covered by two carers and a team leader with the manager in addition to these numbers. This means that the team leader has to do more “hands on” work with the Sisters and has less time available to assist the manager with administrative and training duties. The manager is also needing to spend some time on caring duties like transporting Sisters to hospital appointments, and therefore not able to spend sufficient time on some of her managerial duties. This is proving stressful for the manager. The need for an additional carer for the morning shifts and for some of the afternoon shifts has been recognised by the home and the process of recruiting additional staff is underway. Staff presented very well and it was evident through talking with the Sisters and staff and observing how they interact that relationships between the Sisters and staff are very good. The two staff who were interviewed privately were clear as to their role and responsibility. Approximately 75 of the care staff have an NVQ which is a good achievement, and which means that staff have the skills and understanding to meet the Sisters’ needs. The induction programme, however, is not adequate and does not cover all the areas necessary to equip new staff with the knowledge and skills needed to do their job. This is an outstanding requirement and must receive prompt attention. Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 Page 15 The file of a newly appointed staff member was viewed and generally revealed good recruitment practice. A health declaration statement is available but is not being completed. Whilst there was evidence that a POVA and CRB check have been requested for this staff member, they have not yet been received. As this is several weeks ago now, the home must make sure to chase these checks up. Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 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) 31,32,37,38 The manager is supported well by her line manager and senior staff in providing clear leadership throughout the home with all staff demonstrating awareness of their roles and responsibilities. Care staff feel supported in their work. Records are being well maintained. EVIDENCE: The manager has been in post less than a year and has a management approach that is open and positive. Both the Sisters and the staff said she is approachable and helpful, and the staff said they feel supported in their work. This management style and approach helps to ensure that the residents receive consistent quality care. The manager has the RMA qualification and updates her knowledge regularly. Since the last inspection, she has undertaken training on supervision and appraisals, risk assessments and care planning. As noted in the previous section of this report, insufficient staffing levels are resulting in the manager feeling under some pressure at the moment. She said she is receiving good support from her line manager. Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 Page 17 Records viewed include care plans, daily contact notes and accident records, and these were up to date and in good order. This helps to safeguard the Sisters’ rights and best interests. Staff are being trained in safe working practices, including moving and handling and First Aid. A visiting health care professional queried whether there is the need for a gate at the top of a flight of stairs. This was in relation to one of the Sisters who may be at risk of falling. A risk assessment is required in this instance. No other obvious health and safety hazards were noted. Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 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 x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 3 x x x x 3 3 Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 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 9 Regulation 13 Requirement With regards to medication: a) policy and procedure to be expanded and to include selfadministration, covert medication, verbal orders and homely medicines. (Timescale of 14/04/05 not met); b)record of the assessment of staff competence to be maintained. (Timescale of 14/02/05 not met.); c) ) handwritten entries in MAR charts to be checked and signed by two staff. (Timescale of 14/01/05 not met). Disposable towels and pedal bin to be provided in disabled toilet. At all times, suitably qualified, competent and experienced persons to be working in the home in such numbers as are appropriate for the health and welfare of the Sisters. CRB and POVA checks to be obtained for all staff. New staff to receive proper induction training. Individual risk assessments in relation to the Sisters to be reviewed and made available. Timescale for action 17/09/05 2. 3. 26 27 13 18 17/09/05 18/09/05 4. 5. 6. 29 30 38 19 18 13 18/08/05 18/09/05 18/09/05 Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 Page 20 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. 2. Refer to Standard 8 33 Good Practice Recommendations Accurate set of scales to be available; Sisters to be regularly weighed. The comments in a recent Sisters Meeting regarding the lack of comaradie to be looked into and addressed. Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 11th Floor, International House Dover Place Ashford, Kent TN23 1HU 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 Villa Maria H56-H05 S23618 Villa Maria V238304 170805 Stage 4.doc Version 1.40 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!