Inspection on 07/12/05 for Villa Maria

This inspection was carried out on 7th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 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 Julian Graham Announced Inspection 7th December 2005 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.V257784.R01.S.doc Version 5.0 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.V257784.R01.S.doc Version 5.0 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.V257784.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 2005 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 DS0000023618.V257784.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and started at 09.30 and lasted approximately six hours. A pre-inspection questionnaire and provider’s assessment form completed by the manager were received prior to the inspection. Eight feedback comment cards were also received from the Sisters, with most indicating satisfaction with the care and service. Several Sisters were spoken with, some in the privacy of their own rooms. Lunch was taken with the Sisters. Staff were observed both directly and indirectly as they were working with the Sisters. Three care staff were interviewed privately, and a member of the domestic staff was spoken with. Time was spent with the manager, including looking at some paperwork and a brief tour of the premises was undertaken. Feedback from the Sisters on the day of inspection was mainly very positive, and included comments such as: “the staff are very kind and attentive”, “They’ll do anything for you”, “You only have to press the buzzer and someone will come straightaway to help”. Three feedback comment cards referred to “sometimes” being provided with suitable activities. One Sister said that she would not know who to speak to if she was unhappy with her care. This was contrary to the comments made by all the other Sisters spoken with, who said they would go to the manager who they felt would listen to them and do what she could to put things right. What the service does well: The Sisters live in a very comfortable and well-maintained home. Routines are very flexible, and the Sisters are given every encouragement and support to live their religious lives. Staff were seen engaging the Sisters with warmth and care, and all the Sisters spoken with said how kind and attentive the staff are. The Sisters are also encouraged to comment on the care and service they receive through regular group meetings and periodic quality assurance questionnaires. The manager gave two examples of issues raised by Sisters in a recent questionnaire which she has been able to address. Staff who were spoken with referred to the excellent support they receive from the manager who is “absolutely brilliant” and “always there for you”. Care plans have been written to a high standard. Villa Maria DS0000023618.V257784.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Villa Maria DS0000023618.V257784.R01.S.doc Version 5.0 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.V257784.R01.S.doc Version 5.0 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): EVIDENCE: Not inspected on this visit. Villa Maria DS0000023618.V257784.R01.S.doc Version 5.0 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): 7,8,10 The care planning system remains very clear, comprehensive and accessible and provides staff with the information they need to meet the Sisters’ needs. The health care needs of the Sisters are being met with access to relevant professionals when needed. The Sisters’ dignity and privacy is promoted. EVIDENCE: A sample of care plans was examined, and these are to a high standard. Files are extremely well ordered and accessible, making it easy for staff to know what each Sister’s needs are and how to meet them. There was clear evidence to show that each identified need is reviewed each month and any changes were seen to be clearly noted. Records are in place detailing contacts with health care professionals, like GP’s, District Nurses, opticians and so on. Medication was not inspected in full on this occasion. However, it was noted that as required from the last inspection, there are now policies on selfadministration, verbal orders, covert administration and homely medication. Night staff still need to be assessed as competent to administer medication. Staff gave very good examples of how they are promoting the Sisters’ dignity and privacy when undertaking personal care tasks, like assisting Sisters with Villa Maria DS0000023618.V257784.R01.S.doc Version 5.0 Page 10 their baths. Clarity of their role and responsibilities in this area was demonstrated. New staff confirmed that how they are expected to treat the Sisters was emphasised in their induction training. Sisters spoken with confirmed that staff are meticulous in respecting their privacy and dignity. Staff were observed during the visit, knocking and waiting for an answer before entering bedrooms, and speaking with and about the Sisters with respect. Villa Maria DS0000023618.V257784.R01.S.doc Version 5.0 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): 12,14,15 The Sisters are able to lead the lives they want without restriction. Meals are nutritious and balanced and offer a healthy and varied diet. EVIDENCE: A number of the Sisters were spoken to about the lives they are leading in the home, and all said that freedom of choice is encouraged. An activity, such as flower arranging, armchair exercise, watching a video, is offered each afternoon, and the Sisters can decline to take part if they wish. Two Sisters said they would like a more varied programme of activities. Afternoon tea and a chat is always available at 3 p.m. Lunch was shared with the Sisters, and a choice of three main meals was provided with a wide range of vegetables. The Sisters said they enjoy the meals provided and that the standard is consistently good. Villa Maria DS0000023618.V257784.R01.S.doc Version 5.0 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 the following standard(s): 18 The vulnerable adults procedure needs amendment, and needs to be followed more rigorously to more effectively protect the people living in the home. EVIDENCE: It became evident during the inspection that several staff had expressed concern regarding the way a Sister has been spoken to by a colleague. This was reported by staff to the manager at the time, who took prompt action herself to address the matter. No evidence was available, however, to show the outcome and whether any further action is necessary. In addition, this should initially have been reported to Social Services in line with the Kent and Medway adult protection protocol and to the commission under regulation. The manager took immediate action on the advice of the inspector at the time of the visit and reported the allegations to Social Services. The home’s written policy on adult protection needs revision to reflect the Kent and Medway policy on abuse. Staff who were interviewed individually were all clear of the action to take in the event of any allegation or suspicion of abuse. All staff would benefit from training on adult protection and this is a requirement of this report. Villa Maria DS0000023618.V257784.R01.S.doc Version 5.0 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 the following standard(s): 19,21,26 The standard of the environment within the home is excellent. EVIDENCE: A brief tour of the premises revealed excellent standards being maintained with regards to decoration and furbishment. The home was very clean and hygienic. Bathrooms were clean and welcoming and since the last inspection, disposable towels and a pedal bin have been provided as required. Several Sisters commented on how comfortable and pleasant their home is. Villa Maria DS0000023618.V257784.R01.S.doc Version 5.0 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 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): 27,29,30 There needs to be more staff on duty in the mornings. Induction training and recruitment practice have improved. EVIDENCE: Rotas show that there are normally three carers on duty throughout the day, with the manager supernumerary. Two of the care staff who were interviewed reported that mornings in particular are extremely busy. Whilst they have been given instructions by the manager not to rush the care they are providing to the Sisters, the high care needs of many of the Sisters means that just three staff is not sufficient. The Residential Forum guidelines regarding staffing levels indicate that the home is below the minimum numbers recommended. The home is aware of this, and is seeking to employ additional staff to ensure a fourth staff member on duty in the mornings. Difficulties in recruiting over the Christmas period are apparent, and the recruitment campaign is to continue in the New Year. It is testament to the good work of staff that the Sisters said that the care provided is consistently good, and that they do not have to wait for their needs to be met. A sample of staff files was seen, and good recruitment practice was noted with relevant checks and references being maintained. The induction process is thorough according to new staff, and records are in place in support of this. Over fifty percent of staff have a NVQ, and two of the new staff are down to commence this training in the New Year. Most staff are overdue for training in infection control. Villa Maria DS0000023618.V257784.R01.S.doc Version 5.0 Page 15 Staff spoke of a good team spirit, and feel very supported by the manager in their jobs. Regular one to one formal supervision is being provided, according to staff interviewed and the manager. Records of this were not viewed on this occasion. Villa Maria DS0000023618.V257784.R01.S.doc Version 5.0 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 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): 31,32,33,38 The manager has a clear vision for the home, which she effectively communicates to the Sisters and the staff. Sisters’ rights and best interests would be better safeguarded, however, by a more robust following of abuse procedures. Aspects of the home’s performance is effectively reviewed from time to time, through consulting with the Sisters. Fire safety records are being poorly maintained, which may be putting the Sisters at risk. EVIDENCE: The Sisters are benefiting from the general management approach of the home, with the manager being very approachable, supportive and caring to both the Sisters and the staff. (Note, however the section in this report on adult protection.) There is an open and friendly atmosphere in the home. Sisters’ views on the home and the care they are receiving are sought in regular meetings, and quality assurance feedback questionnaires. The results of the most recent survey have been collated and analysed and action is being Villa Maria DS0000023618.V257784.R01.S.doc Version 5.0 Page 17 taken to address the findings. No obvious health and safety hazards were noted on this visit, and accident records are being maintained satisfactorily. Staff require training in infection control, however, and fire safety records need prompt attention. The manager said that the handyman tests the fire alarm system each week, although the records were not available. There was also no evidence of any recent servicing of the system. A fire risk assessment was seen, although this was not dated nor signed, with no indication of any findings from the risk assessment. Staff have received training on fire safety during the past twelve months. Villa Maria DS0000023618.V257784.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 1 3 x 3 x x x x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 x x 3 x x Villa Maria DS0000023618.V257784.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? yes 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 YA9 Regulation 13 Requirement With regards to medication, a record of the assessment of staff competence must be maintained. (timescale of 14/02/05 not met.) All allegations of abuse must be reported to the appropriate authorities under adult protection procedures without delay in order to protect the Sisters. Recruitment programme to continue in the New Year to ensure that a fourth staff carer is on duty in the mornings. Staff to receive training on infection control Fire safety records to be maintained and made available for inspection. Timescale for action 07/01/06 2 OP18 13 07/12/05 3 OP27 18 07/02/06 4 5 OP30 OP38 19 13 07/02/06 07/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Villa Maria DS0000023618.V257784.R01.S.doc Version 5.0 Page 20 No. Refer to Standard Good Practice Recommendations Villa Maria DS0000023618.V257784.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Kent and Medway Area Office 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 DS0000023618.V257784.R01.S.doc Version 5.0 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. 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