Inspection on 24/01/07 for Villa Maria

This inspection was carried out on 24th January 2007.

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 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 Maria 07/12/05

Villa Maria 17/08/05

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 Wendy Jones Key Unannounced Inspection 24 January 2007 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 Villa Maria DS0000023618.V301847.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 Maria DS0000023618.V301847.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Villa Maria Address 53 Seabrook Road Hythe Kent CT21 5QE 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) 01303 266723 Marist Sisters Mrs Beverley Allen Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: Villa Maria is a purpose built home that is owned by a religious order, the Sisters of the Marist Congregation. It is linked to the adjoining convent and offers care and service to Marist Sisters. It is registered to provide accommodation and personal care for up to 23 persons. The home is located on the outskirts of Hythe with good access to the sea, shops, public transport and other public amenities, some of which are within walking distance. The statement of purpose gives information about the home and the service provided there. A copy of this and the most recent inspection report can be obtained from the home. Currently the fees £400 per week. There are no charges for additional services. Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over a period of time and concluded with a site visit to the home between 10:15am and 3:30pm on 24 January 2007. A range of evidence has been used to inform this report and judgements have been made based on this evidence. Evidence used includes, concerns, complaints, allegations and other information received, reports of incidents and deaths that have occurred in the home since the last inspection, a tour of the home, inspection of some records, comments received from Sisters, and discussion with the acting manager, Sisters and staff. What the service does well: What has improved since the last inspection? At the last inspection the need to assess the competence of the staff who deal with the Sisters’ medication remained outstanding. This has now been met and the Sisters’ can be confident the staff who deal with their medication are well-trained and competent. The procedure for dealing with allegations of abuse has been reviewed. Any allegation that a Sister may be being abused will now be reported promptly to Social Services so that it can be investigated without delay. The recruitment programme, due to start at the last inspection, has been successful. Extra staff are now on duty in the mornings so that the Sisters’ needs can be met. Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 Page 6 Staff have received training in infection control since the last inspection. They can now be confident in their ability to protect the Sisters from the spread of infection. Records to confirm that the fire equipment is maintained regularly are now upto-date. 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 DS0000023618.V301847.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 Maria DS0000023618.V301847.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Prospective Sisters’ needs are assessed and they can make sure these will be met before they move into the home. EVIDENCE: Care plans contained an assessment of the Sisters’ needs that had been carried out before they moved into the home. Other assessments from doctors and other healthcare professionals had been used to put together a care plan that showed how to meet their needs and goals. Individual risks for each sister had been identified and assessed. Risk assessments showing the actions to be taken to minimise or remove these risks were in the Sisters’ care plans. Villa Maria does not provide intermediate care. Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 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 the following standard(s): 7 - 10 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. All the Sisters’ general health and personal care needs are extremely well met. EVIDENCE: Care plans are very clear, comprehensive and well laid out. They show the needs and goals of each Sister and how staff are to help them to achieve these. There are very clear and detailed records of when the Sisters have seen their doctor or district nurse and of optician, dentist etc., appointments. Details of the action that has been taken in response to a Sister’s need e.g. need to see a chiropodist, are clearly documented and show that prompt action is always taken. Detailed records show that every section of the care plan is thoroughly reviewed at least every month and more frequently when needed. Daily records give a good picture of each Sister’s day. Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 Page 10 Risk assessments are comprehensive and individual to each Sister. They show the risks that have been identified for them, what needs to happen to reduce or remove the risks and the outcome that is expected from putting this action in place. Clear, detailed records show that these assessments are also reviewed at least monthly. Every Sister has had a medication assessment carried out to see if they are able to deal with their own medication. Records show when these assessments have been reviewed and why, with reasons for any changes to them. Medication is stored appropriately and medication administration records were up-to-date and accurate. There are two medication storage areas in the home. Staff use a drugs trolley to take the Sisters’ medication to them. Training records show that staff have received appropriate training and are competent to deal with the Sisters’ medication. Staff spoken with said they feel confident that they have the knowledge and skills they need to deal with Sisters’ medication safely. Staff are helpful, patient and caring and have an extremely good rapport with the Sisters. All staff spoken with said they are very proud of the high standard of care provided at Villa Maria and thought it “would not be found anywhere else”. Sisters who completed surveys prior to the site visit said they always receive the care and medical support they need. They feel the staff are “most gracious and kind” and “very devoted”. They always listen to them and are always available when they need them. Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 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 the following standard(s): 12 - 15 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The daily routines and activities provided meet the Sisters’ needs and are flexible. EVIDENCE: There is a dedicated activities room where activities are provided for the Sisters to take part if when they want to. This room contains a piano, library books, games, a computer. Flower arranging, colouring, bingo and reminiscing are also organised. One Sister enjoys playing the piano and often plays the piano in the activities room. There is a chapel in the home. At the start of the site visit the Sisters were attending mass there. Daily newspapers are provided for the Sisters to read every day. They play bingo and have plenty of other activities, which they are “free to attend, no compulsion”. Some Sisters said they enjoyed going out for walks around the area and to the sea nearby. They were looking forward to an entertainment group coming to the home the next day. Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 Page 12 Copies of menus had been received prior to the site visit. These showed a wide range of nutritious and appealing dishes are provided each day. The acting manager said that there is always a chicken choice as all Sisters like chicken. The dining room was very attractively laid out and there was a wide range of cold drinks for the Sisters to choose from. They said they always enjoy the meals provided. They can choose what they want and there is always plenty. Visitors from the adjoining convent join the Sisters for lunch. Sisters who need help are served at their table and others can choose to serve themselves from the choices laid out at the serving hatch. There are a number of “kitchenette” areas around the home where Sisters, who are able, can make themselves drinks and snacks. Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The Sisters’ complaints are taken seriously and investigated. EVIDENCE: Information received before the site visit stated that there had been one complaint received by the home since the last inspection. This had been fully investigated within the 28-day timescale and feedback had been given to the person who had complained. The complaints procedure gives details of how to complain, timescales for investigating any complaint and how to contact the Commission. Training records showed that staff had attended training in the protection of vulnerable adults. Staff were clear about what to do if they suspected a Sister was being abused in any way. Allegations of abuse are now reported to Social Services in line with the Kent and Medway Multi Agency Adult Protection Procedures. An allegation, identified at the last inspection, had been reported. Although this allegation Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 Page 14 was not proved the home had taken measures to provide further training and support to staff and for the protection of all the Sisters. Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 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 – 21 and 23 - 26 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The Sisters live in a spotlessly clean and comfortable home with private and communal rooms that meet their needs. EVIDENCE: The home is purpose built and was completed in 2002. All areas are extremely well decorated and maintained to a very high standard. The home was spotlessly clean and there were no unpleasant odours. Sisters’ rooms were attractively decorated. They are all en suite, most with a shower. They are large and contain a small living area with a television, music centre and a desk and chair. Each has been decorated to the Sisters’ individual tastes and reflects the person who lives there. There are also communal bathrooms and toilets around the home. Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 Page 16 The lounge is very attractively decorated, with comfortable seating and large windows overlooking the extensive gardens to the front of the home. The kitchen leads from the dining room with a hatch for Sisters who are able, to choose their meals themselves. There is enough room for the Sisters and their visitors to eat there comfortably. The kitchen is modern and well equipped. There are a number of sluice rooms around the home so that hygiene levels can be maintained and the Sisters are protected against the spread of infection. Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 Page 17 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): 27 - 30 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The Sisters are protected by the home’s recruitment procedure. They are supported by staff who have the skills to meet their needs. EVIDENCE: There are 18 Sisters living in the home. The acting manager, four care staff (including a team leader), a cook, a laundry assistant, a domestic and administrative staff were on duty during the site visit. This was clearly enough staff to meet the needs of the Sisters living in the home at this time. The acting manager advised that the recruitment of new staff has been successful and continues. Staffing levels have been increased on weekday mornings to four as required at the last inspection. It is intended that the weekend mornings will also be increased to four when more new staff are employed. Two waking care staff are on duty every night. Files were seen for four members of staff. Two had been recruited in recent months. All the relevant checks and documentation including CRB and POVA first checks had been obtained showing that the recruitment process followed protects the Sisters. Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 Page 18 All staff attend an induction course when they first start. Completed records showing when they had completed this were seen. Information received y the Commission showed that staff have attended training in a number of subjects since the last inspection. These include adult protection, care planning, first aid, food hygiene, health and safety, mental health, stroke awareness, nutrition in older people, medication, moving and handling, infection control and NVQ level 2 in care. Staff said the training they have received has helped them to be confident they can care for Sisters well and meet their needs. Staff files contained details of the training staff had attended, the dates and certificates. Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 Page 19 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 – 33, 35, 36 and 38 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The Sisters live in a safe, well-managed home that is run in their best interests and safeguards their rights. EVIDENCE: Since the last inspection the manager has left and their previous line manager has been acting as manager. A new manager has been appointed. They are due to start in the near future. The atmosphere in the home was calm and unhurried. The inspector was made to feel very welcome and there was a good relationship between the manager, staff and Sisters. Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 Page 20 Sisters commented that the manager and staff were ““most gracious and kind” and “very devoted”. Records were seen of quality assurance surveys that had been carried out at regular intervals in previous years. The Sisters had been asked to complete satisfaction surveys and the results analysed and used to improve. The last survey recorded had been carried out in January 2006. Sisters and staff meetings had also been used to provide feedback on the quality of the service provided. Minutes of residents meetings showed that these are usually held every 3 or 4 months, but had not been held since February 2006. Minutes of staff meetings showed that these are usually held monthly, but had not been held since September 2006. The acting manager explained that she had, unfortunately, not been able to keep these meetings up since taking on the acting role. These meetings and the quality assurance surveys should be brought back in line. This will help to ensure that the current high standards are maintained. Information received indicated that the home acts as appointee for all of the Sisters. This is because the religious order, the Sisters of the Marist Congregation, own the home and all Sisters living there are members of this religious order. Small amounts of money are kept for some of the Sisters. Records are kept of how much is spent, on what and receipts. Supervision records were seen in staff files. These showed that regular, formal, staff supervision has slipped in recent months. Staff receive verbal supervision daily at shift handovers and are clear about their roles and responsibilities. They said they are able to speak with the acting manager if they have any issues or difficulties. Despite this, formal supervision should be reintroduced and carried out at least six times a year. This will ensure that the staff have the opportunity to discuss care practice, the philosophy of the home and their own development needs. Records of showing the fire alarm system is tested every week are now kept. Staff said that fire awareness training was one of the subjects they had had training in over the last year. Training records seen confirmed that staff had received this training. Information received prior to the site visit showed that all relevant maintenance and checks have been done and are up to date. Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 Page 21 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 Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 Page 22 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 4 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 x 4 3 3 4 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 4 2 x 3 2 x 3 Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 Page 23 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. 1 Refer to Standard OP33 Good Practice Recommendations The systems for assuring quality in the home, e.g. surveys, residents’ meetings and staff meetings, should be reintroduced. Formal supervision for care staff should be reintroduced and carried out at least six times a year. 2 OP36.2 Villa Maria DS0000023618.V301847.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Kent and Medway Area Office The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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 DS0000023618.V301847.R01.S.doc Version 5.2 Page 25 - 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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