Inspection on 09/01/07 for Villa Maria

This inspection was carried out on 9th January 2007.

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 19/01/06

Villa Maria 25/08/05

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 Surrey CR2 7BB Lead Inspector Margaret Lynes Key Unannounced Inspection 9th January 2007 09:40 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 DS0000019045.V325716.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 DS0000019045.V325716.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Villa Maria Address Villa Maria Nursing Home 62-68 Croham Road South Croydon Surrey CR2 7BB 020 8680 1777 020 8680 7001 villa@villamaria.co.uk 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) Miss Jean Margaret Hedgeland Mrs Linda Dianne Thompson Mrs Maureen Donnelly Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26), Terminally ill (0), Terminally ill over 65 of places years of age (0) Villa Maria DS0000019045.V325716.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A variation has been granted to allow day care to be provided for one specified service user. A maximum of five service users in the TI and TI(E) categories aged 40 or over. A variation has been granted to allow one specified service user in the category of Learning Disability - over 65 years of age (LD(E)) to be accommodated. 19th January 2006 Date of last inspection 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 DS0000019045.V325716.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over the course of a day, and involved examination of service user and staff files, policies and procedures and other relevant records; a tour of the premises; discussion with the manager and the proprietors and meeting with service users, a visitor and staff. There were no requirements made at the last inspection, as it was deemed that all of the Standards that were inspected were being met. This visit has not resulted in any new requirements. All of those who assisted the Inspector during the course of this visit are thanked for their input. What the service does well: What has improved since the last inspection? What they could do better: It was felt that the Standards that were assessed on this visit were being fully met. Villa Maria DS0000019045.V325716.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Villa Maria DS0000019045.V325716.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 DS0000019045.V325716.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 is not applicable) Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. From the files inspected, and from discussion with the manager it was determined that service users were adequately assessed prior to being admitted to the home. 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: Of the four files inspected, two were found to contain nursing needs assessment provided by the placing Authority. The other two contained a preadmission assessment carried out by the manager. Villa Maria DS0000019045.V325716.R01.S.doc Version 5.2 Page 9 It was noted that there were a number of service users who had medical diagnoses (dementia, physical disability) that appeared to fall outside the registration category of this home. This was discussed with the proprietors and manager, and advice given re the need to apply for a variation to registration if it is intended to admit a client whose primary need is not in a category for which the home is registered. Villa Maria DS0000019045.V325716.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. As was found at the last inspection, the service user plans 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, and good recording was in evidence. 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. Villa Maria DS0000019045.V325716.R01.S.doc Version 5.2 Page 11 EVIDENCE: The service user files contained a wealth of information. Alongside the regularly reviewed care plans were assessments relating to pressure area care, risk, moving and handling, continence and nutrition. Each service user also had an assessment of daily living. It was pleasing to note that the care plans were kept in each service user’s bedroom, so that they could more easily be accessed by the service user if they so wished. The medication administration records were examined and found to be in order. Unlike most homes, Villa Maria still uses the traditional method for dispensing medication, and has chosen not to move over the to monitored dose system. This is not problematic however, as staff are diligent and the records were all in order. A number of service users kindly took time to speak with the Inspector. They were unanimous in their praise for the staff team and for the care they received. None had any issues with regard to the maintenance of their privacy or their right to be treated with respect. What is particularly notable about this home, and what is not necessarily found amongst the documentation, is that the clear aim of the staff is to provide a service of the highest standard that they can attain. This positive attitude was found amongst all grades of staff, from qualified nurses to ancillary workers. Villa Maria DS0000019045.V325716.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 15 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Service users are provided with a variety of appropriate activities, and they are encouraged to take an active part in the local community. Dietary needs are satisfactorily catered for. Visitors are made welcome. Collectively this means that the lifestyle in the home, in general, matches the expectations and preferences of the service users. EVIDENCE: As was noted at the last inspection, the home benefits from having its own, wheelchair accessible transport. Service users are enabled to participate in many in-house activities including quizzes, pantomimes, reminiscence bingo, and parties to celebrate auspicious occasions such as Easter, Valentines Day, Halloween and St Patrick’s Day. External entertainers are brought in and service users are also encouraged to go out, and provided with the means to do so. Outings in the past year include visits to local parks, the seaside, Buckingham Palace and the Christmas lights. Villa Maria DS0000019045.V325716.R01.S.doc Version 5.2 Page 13 Visitors are encouraged and evidently made welcome. One took the time to speak briefly with the Inspector and was complimentary about the service provided. The mid-day meal was observed and appeared appetizing and well prepared. The chef clearly had good knowledge of each of the service users, their likes and dislikes and their specific dietary needs. The home is to be congratulated for having recently been awarded a Gold Award by the Local Authority’s Food Hygiene department. Villa Maria DS0000019045.V325716.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has satisfactory arrangements in place for service users to raise any concerns or complaints, and for ensuring that if such matters are raised they will be taken seriously and dealt with appropriately. There is a satisfactory protection of vulnerable adults procedure in place. EVIDENCE: There had not been any recorded complaints since the last inspection visit. One resident did raise concerns about another service user, who was not included on an outing, however this concern was quickly and appropriately allayed. There have not been any adult protection issues. Villa Maria DS0000019045.V325716.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. This is a relatively small nursing home and thus benefits from being able to create a homely, relaxed and comfortable atmosphere. A tour of the building evidenced that it was in a good state of repair, and it was felt that the home provided a safe and well-maintained environment. The communal areas were clean, pleasant and hygienic, as were the bedrooms. EVIDENCE: As mentioned above, a tour was made of the building, which was found to be clean, and in a good state of decoration and furnishing. Service users are able Villa Maria DS0000019045.V325716.R01.S.doc Version 5.2 Page 16 to bring in their own personal possessions, and it was nice to see rooms outfitted with furniture brought in by the residents. The premises continue to be generally fit for purpose. Mention has been made in the summary of the improvements made in the home since the last inspection. Some of the hallway carpet tiles were noted to be worn and in need of deep cleaning (or replacement). Assurances were given that this cleaning was carried out regularly, however the recent refurbishment work had had a detrimental effect on the cleanliness of the tiles. It also transpired that there was a stock of replacement tiles kept, so that the most worn can be easily replaced. Villa Maria DS0000019045.V325716.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. 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. From the rota provided it appeared that the staffing levels were maintained at the level previously agreed with the Commission. This means that the health and welfare needs of the service users should be adequately met. The manager confirmed that all care staff had achieved an NVQ award or an Asset level II award. Staff are also able to access a number of other training courses. This means that the residents are cared for by experienced and trained staff. The staff files inspected evidenced that the recruitment practice in the home was sufficiently robust enough to protect and support service users. EVIDENCE: From the rota it was evident that the home was being appropriately staffed. There were two qualified nurses on duty until 6pm, along with four carers in the morning and three in the evening. At night there was one qualified nurse with two carers. Villa Maria DS0000019045.V325716.R01.S.doc Version 5.2 Page 18 It is commendable that all of the care staff have achieved either an NVQ or an Asset award. It should also be noted that the ancillary staff have been enabled to partake in NVQ or certificated courses relevant to their area of expertise. New staff are expected to complete an induction based on the Skills for Care programme. Other training undertaken since the last inspection includes basic first aid, infection control, challenging behaviour, health and safety, fire safety, and aromatherapy. Training planned for this year includes palliative care, occupational health and nutrition and health. The manager ensures that the qualified staff undertaken sufficient training to keep their PREP up to date. All but the newest staff members have recently undergone an annual appraisal. It was pleasing to note that the staff had take the time to write down relevant issues and points for discussion, so as to ensure that the appraisal process was worthwhile. There was also evidence on the files of regular supervision. Villa Maria DS0000019045.V325716.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are enabled to live in a home which is managed well, and run in the best interests of the service users. Service users finances are safeguarded by the accounting and financial procedures in place in the home. It was felt, from examination of the relevant documentation, that the health, safety and welfare of services users and staff was being promoted and protected. Villa Maria DS0000019045.V325716.R01.S.doc Version 5.2 Page 20 EVIDENCE: The home manager has now been in post for a number of years, and can draw upon a wealth of experience in caring for older persons who require nursing care. The home benefits from a low staff turnover, and this has a positive impact on the care provided. A number of quality assurance systems are in use in the home. As well as periodically sending out surveys to service users and their families, quality checks are carried out on, for example, care plans, drug charts and reviews. The home’s management looks after the pocket money for only two service users. Where items are purchased on behalf of a resident this is clearly documented and receipts obtained. The records were available for inspection. The vast majority of service users have their finances looked after by family members or by their placing authority. Examination of health and safety documentation indicated that all of the periodic maintenance checks were up to date. These included maintenance of the lift, fire detection and fighting systems; hoists; gas and electrical installation and appliances and the water system. Villa Maria DS0000019045.V325716.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 CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Villa Maria DS0000019045.V325716.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Villa Maria DS0000019045.V325716.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Villa Maria DS0000019045.V325716.R01.S.doc Version 5.2 Page 24 - 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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