Inspection on 25/08/05 for Villa Maria

This inspection was carried out on 25th 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 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 09/01/07

Villa Maria 19/01/06

Villa Maria 24/02/05

Villa Maria 11/10/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Villa Maria Villa Maria Nursing Home 62-68 Croham Road South Croydon CR2 7BB Lead Inspector Margaret Lynes Unannounced 25 August 2005, 09:30 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 G53 G53 S19045 villamaria V203538 150805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Villa Maria Address Villa Maria Nursing Home, 62-68 Croham Road, South Croydon, Surrey, CR2 7BB 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) 020 8680 1777 020 8680 7001 info@villamaria.co.uk Miss Jean Margaret Hedgeland Mrs Maureen Donnelly Care Home 26 Category(ies) of Old age registration, with number Terminally ill of places Terminally ill - over 65 Villa Maria G53 G53 S19045 villamaria V203538 150805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24/2/05 Brief Description of the Service: Villa Maria is a traditional nursing home, founded in 1974, and registered for 26 service users in the older person and/or terminally ill categories. It is situated close to the centre of Croydon and is easily accessible by public transport. Accommodation is arranged over two floors and there is a passenger lift. There are both single and double rooms, some with en-suite facilities. All the communal rooms overlook large, well-maintained and very attractive gardens, which are well used in the summer months. The home benefits from having its own ambulance. Service users can enjoy the benefit of this being a pet-friendly home. Villa Maria G53 G53 S19045 villamaria V203538 150805 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 was conducted over one day. During that time a number of records were examined, a tour was made of the premises and time was spent talking with service users and staff. The report of the last visit to the home contained just one requirement, which had been carried over from the previous inspection and related to incomplete medication administration records. On this visit the records were found to be in order. This report contains just two recommendations, which is reflective of the good practice found. What the service does well: 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. Villa Maria G53 G53 S19045 villamaria V203538 150805 stage 4.doc Version 1.40 Page 6 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 G53 G53 S19045 villamaria V203538 150805 stage 4.doc Version 1.40 Page 7 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 (6 is NA) Each of the service user files selected for examination contained a satisfactory pre-admission assessment. This means that the service user and their relatives can be reassured that the home has taken into account their individual needs, and feels that it can meet them; and the staff in the home can be as familiar as possible with new service users, and have an understanding of what specific service they will need to provide. EVIDENCE: The files of six new residents were examined. Each one contained a preadmission assessment from the placing authority, and/or a (sometimes) brief in-house assessment. While it is acceptable for the pre-admission assessment to be provided by the placing authority, it is usually beneficial for the home to also carry out its own assessment. There is a proforma in place for this at Villa Maria, however the amount of information on the ones seen varied, and it is recommended that more detail be recorded. Villa Maria G53 G53 S19045 villamaria V203538 150805 stage 4.doc Version 1.40 Page 8 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 and 10 The service user plans seen adequately covered the health, personal and social care needs of the service users. This means that the staff team are aware of the differing needs of their residents, and know what specific care needs to be given. Staff ensure that each resident is able to access community based health facilities as and when required. The medication administration records were examined. These were all in order, which means that the service users are protected by the home’s good practice. From observation and discussion, service users were treated with respect, and their right to privacy was upheld. EVIDENCE: There was good documentation in each of the service user files inspected. Supplementing the care plans were a number of assessments, including those for risk, nutrition, pressure areas, moving and handling and an assessment of daily living skills. Villa Maria G53 G53 S19045 villamaria V203538 150805 stage 4.doc Version 1.40 Page 9 While service users are able to access community based health services, the manager did raise her grave concerns with regard to treatment some service users received when admitted to one of the local hospitals. The manager has discussed the problems with the relevant authorities. The previous inspection report contained just one requirement, which related to incomplete medication administration records. On this visit, the records were found to be appropriately completed. From observing the interaction between the staff and the service users, and having also talked to a number of service users, it was evident that they felt that they were being treated with respect and that their privacy was upheld as much as was possible. It was particularly noted that one carer took the trouble to ask a service user how they could assist them when helping them to the toilet, rather than just assuming what help was needed. The carer promised to return within a few minutes and did so. This thoughtful care was evidently appreciated by the service user. Villa Maria G53 G53 S19045 villamaria V203538 150805 stage 4.doc Version 1.40 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 - 15 The relatively small size of this establishment means that staff are able to provide a sufficient amount of stimulation to satisfy the service users social and recreational interests. Visitors are encouraged to call, and are made welcome. This means that service users are enabled to maintain contact with family and friends and the local community as they wish. A number of service users met with the Inspector and they all felt that they were enabled to exercise choice and control over their lives to the extent that it was possible. The lunchtime meal was observed and appeared to be well prepared and appetising. Service users confirmed that the food was more than satisfactory. EVIDENCE: The home benefits from having its own, wheelchair accessible transport. Service users are enabled to participate in many in-house activities including talking books, films, gardening, knitting, darts and painting. They are also encouraged to go out, and provided with the means to do so. On the day of Villa Maria G53 G53 S19045 villamaria V203538 150805 stage 4.doc Version 1.40 Page 11 this inspection the manager, and one of the proprietors were about to leave for a day trip to Brighton with some of the service users. Service users are encouraged to exercise personal autonomy and choice. They are enabled to bring in personal possessions to make their rooms more homely. It was pleasing to see home cooked food in ample supply being served hot, and with attention to presentation and personal choice. Staff were available to assist residents where needed. Villa Maria G53 G53 S19045 villamaria V203538 150805 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) 16 and 18 The home has a satisfactory complaints procedure in place, which is accessible to service users. There was also a satisfactory adult protection procedure in place which, if followed by staff, will offer sufficient protection to service users. EVIDENCE: No complaints had been made since the last inspection visit. One service user had raised a concern which was in the process of being investigated. The manager has compiled a comprehensive amount of adult protection information, and some of the staff team have attended a POVA training course. Just one recommendation will be made with regard to the aforementioned information and that is for the manager to ensure that it is consistent. For example, policy 103 states (incorrectly) that the Commission will refer to the Department of Health any member of staff who has been prosecuted/convicted of an offence relating to adult protection. Any such referral must come from the home itself, and indeed policy 433 clearly states this. Villa Maria G53 G53 S19045 villamaria V203538 150805 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) Not assessed on this visit. EVIDENCE: Villa Maria G53 G53 S19045 villamaria V203538 150805 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 and 30 The Inspector felt that the staffing numbers were sufficient to ensure that service users needs could be met in a timely manner. Staff are able to access a variety of in-house and external training courses, and these are put on at regular intervals. This can only have a beneficial effect on the care being provided to service users. EVIDENCE: Staffing levels in this home have been the subject of discussion with the CSCI and was agreed that there will be a minimum of two qualified nurses on duty at all times during the day. However, as both proprietors are usually present in the home on a daily basis and carry out the majority of the administrative work, the registered manager can, on the occasions when there is only one RGN on the rota, act as the second qualified nurse. On this visit, these agreed levels were being maintained. The home has a detailed staff training programme in place, which includes courses in, for example, food safety and hygiene; infection control; manual handling; care procedures; safety compliance; POVA and NVQ courses. The home has achieved an Investors in People award, and it was pleasing to note staff certificates were on display in the home, so that they could be seen to be valued and appreciated. Villa Maria G53 G53 S19045 villamaria V203538 150805 stage 4.doc Version 1.40 Page 15 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) 33 and 38 The Inspector was satisfied that the home was being run with the best interests of the service users in mind, as a number of quality assurance checks were in place, and the records examined were being appropriately maintained. From a fire safety perspective, the Inspector felt that the welfare of service users and staff was being adequately protected. EVIDENCE: A number of quality assurance records were available for inspection including those of the medication charts, the environment, client reviews, daily care notes and discussions with service users to ascertain their views of the care being provided. On this visit, only the fire safety records were examined. The alarms were being tested on a weekly basis while fire drills were being carried out at regular intervals. Villa Maria G53 G53 S19045 villamaria V203538 150805 stage 4.doc Version 1.40 Page 16 Villa Maria G53 G53 S19045 villamaria V203538 150805 stage 4.doc Version 1.40 Page 17 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 x x 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 x x x x x x x x STAFFING Standard No Score 27 3 28 x 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 x 3 x x 3 x x x x 3 Villa Maria G53 G53 S19045 villamaria V203538 150805 stage 4.doc Version 1.40 Page 18 no 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 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. 2. Refer to Standard 3 18 Good Practice Recommendations It would be good practice to ensure that pre-admission assessments are recorded in as much detail as possible. It would be helpful to staff if the POVA procedures/ information was consistent. 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