Inspection on 14/06/05 for Villa Scalabrini

This inspection was carried out on 14th June 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 Scalabrini 22/04/10

Villa Scalabrini 23/02/10

Villa Scalabrini 20/03/07

Villa Scalabrini 27/01/06

Villa Scalabrini 15/11/04

Villa Scalabrini 08/07/04

Similar services:

Claremont House

Chesham House

Oak Ridge

Argyll House

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

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

CARE HOMES FOR OLDER PEOPLE Villa Scalabrini Green Street Shenley Hertfordshire WD7 9BB Lead Inspector Julia Bradshaw Unannounced 14.06.05 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 Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Villa Scalabrini Address Green Street Shenley Hertfordshire WD7 9BB 0208 207 5713 0208 381 5570 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) Scalabrini Fathers Ms Angela Onofri Care Home 53 Category(ies) of DE (E) DE(E) Dementia - over 65 53 registration, with number of places MD (E) MD(E) Mental Disorder - over 65 Female 1 OP OP Old Age - 53 Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home may admit one named female service user who has a mental health need. This variation applies to this named service user and would cease to be in force if the named service user permanently leaves the home for any reason. The manager must inform the CSCI when this occurs. Date of last inspection 15 November 2004 Brief Description of the Service: Villa Scalabrini is a large detached building set in substantial grounds, most of which are accessible to residents through attractive walkways, patios and gardens. The home specialises in providing care to Italian speaking elders. The home is divided into units on two floors, each with a bathroom, dining room, lounge and kitchenettes. There is large hall on the ground floor with a chapel, where daily communion takes place. The home has been created to reflect traditional Italian styles, including the furnishings, fittings, decor and floor coverings The home is situated in a rural location in Shenley, approximately one and a half miles from Borehamwood. Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection of the inspection year and took place over one day. The majority of time was spent talking to service users and staff. Some time was spent in the office looking at risk assessments; staff files and a tour of the environment. Discussions were held with the manager Angela Onofri and several senior and care support staff. Service users were welcoming and an invitation was made to join Father Vico at their lunchtime meal. Generally this was a positive inspection, feedback received was excellent and the standard of most aspects observed are high. There were requirements made in relation to the environment and health and safety standards. What the service does well: What has improved since the last inspection? The manager and staff have worked hard to improve and develop some new and existing policies into the home since the last inspection took place and has updated and amended the adult protection policy, providing training for all it entire staff.The home is endeavouring to computerize all their service user plans in order to provide a more “user friendly” document. The home has appointed a new chef since the last inspection took place and the service users are enjoying a variety of new meals and menus. The standard of meals within the home is excellent and all comments from service users were extremely positive. Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4. Information available to prospective service users is comprehensive and informative enabling a decision about admission. The atmosphere in the home is relaxed offering a welcoming environment to prospective service users. EVIDENCE: The home maintains adequate information within both the Statement of Purpose and the service user guide. These were both checked on the day of the inspection and cover all the required areas. This document should be updated annually or sooner if the service changes. The home produces both these documents in Italian and in English. The home has an adequate pre- admission assessment procedure so that all prospective service users have an opportunity to visit the home. The manager and deputy manager carry out a needs assessment and have the final decision regarding admission. On the day of the inspection the home was fully occupied with one person on a respite stay and one person receiving day care. Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10. Personal care and assistance offered to service users is of a very high standard, thus meeting the individual needs of the residents, whilst maintaining dignity and respect. Care staff are unobtrusive and sensitive in there approach. Care plans are detailed and are reviewed on a monthly basis ensuring changes to health and social care needs are recognised and met. EVIDENCE: Care plans were detailed and had been reviewed since the last inspection was carried out. The manager and senior staff members have a system of auditing these care plans on a monthly basis. Five service users spoken to regarding their care plan confirmed that they had been involved at varying levels with its compilation and implementation. Manual handling risk assessments were available on file and the manager has worked hard to implement individual risk assessments for service users living within the home. The manager stated the home has good working relationships with outside health professionals and support services. Individual care practice observed Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 10 was commendable. Service users requiring assistance with meals are seated in the smaller lounge/dining area where dignity was promoted and protected. The manager and senior staff carries out regular audits on the medication system in order to identify any errors that may occur and to rectify these immediately. All staff receive a full induction before they are cleared to administer medication to the service users. The home also receives a positive and effective service from the local GP’S and health care professionals. Service users are able to maintain their own GP wherever possible. There are regular visits from other professionals, which include opticians, dentist and chiropodist. Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Where possible the home tries to accommodate everyone’s individual preferences and feedback and suggestions are sought in all aspects. This promotes autonomy and choice. Visitors are welcome and the home promotes integration with the local community in accordance with service users preferences. The home does not currently provide adequate opportunities for service user to take part in activities outside of the home. EVIDENCE: The home provides a range of in-house activities for its service users, which include art and craft sessions, gardening, music and sewing. Service users spoken to were positive about the range of activities provided. However there was a consensus of opinion from service users that they would like the home to offer some trips outside of the home to places of local interest and to have the opportunity to go out for lunch and visit the local garden centres. The home holds several events during the year which relatives; friends and the local community are invited to. The home has recently celebrated Father Vico’s 50 years within the Priesthood. The home has a very welcoming atmosphere Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 12 and several visitors were seen during the day of the inspection. There are few restrictions on visiting times, which mainly include mealtimes. Evidence was available to indicate that service users are able to bring personal possessions with them, in order to personalise their bedrooms The manager ensures that service users and relatives are aware of their rights to access personal records, in accordance with the Data Protection Act. The current menus provide are both well balanced and an excellent variety of food is offered. The meal provided on this unannounced inspection was of outstanding quality and enjoyed by all service users. The home has appointed a new chef since the last inspection took place and service users were highly complimentary regarding the standard of food provided. The chef is both knowledgeable and experienced in the provision of wholesome and creative meals. There is fresh fruit made available on a daily basis and the dry food store cupboard presents more like a delicatessen than a care home! The chef holds a current food hygiene certificate. Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 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 standard(s) 16,17,18 The home has a detailed complaints procedure of which all service users spoken to were fully aware, ensuring that all issues can be dealt with effectively. The manager and proprietor have a presence within the home thus safeguarding service users. EVIDENCE: A copy of the complaints procedure is available to prospective and current service users. This is in both Italian and English. Reference is made to the Commission for Social Care Inspection. Those spoken to said that they have never had to make a complaint and felt that they would be able to speak to a member of staff or the manager if they had any concerns. No complaints have been received since the last inspection. However the home had a serious Adult Protection issue in May, which was managed by Hertfordshire Adult Protection Team. The home responded promptly to the actions made as a result of the strategy meeting held .The manager has also updated and amended their Adult Protection procedure as a result of this incident. The home also displays a comments and feedback questionnaire form which is located in the main entrance of the home. Staff confirmed they had received training on adult abuse and there is a copy of the Hertfordshire Adult Protection procedure kept within the home. The manager stated that staff have received training on POVA. (Last training was in March 2005) Staff spoken to were aware of the homes Whistle Blowing procedure and a copy of should be displayed in the main office of the home. Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26. The home and its surroundings offer a pleasant and comfortable environment to its service users. The home is extremely clean and well maintained and bedrooms are personalised offering a homely, lived in feel. The standards compromised. of health and safety within the home are currently EVIDENCE: Service users are encouraged to bring personal items such as furniture and pictures into their room when they move in. Service users spoken to were happy with their rooms and commented on the high standard of the laundry facilities and how great care is taken with all their personal items of clothing. One visitor commented ‘the home is always very clean and there are never any unpleasant smells’. The home is exceptionally clean and attention to detail is given. In-house domestic staff carries out the cleaning of the home. Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 15 Staff spoken to stated that that hygiene and infection controls are good and that gloves and aprons are always readily available. The homes provides sufficient lighting, heating and ventilation. A maintenance and renewal and redecoration plan is in place and a full time handy person is employed by the home. Service uses spoken to confirmed that they are offered a key to their room. Where a key is offered but the service user declines, a record of this should be made on their individual service user plan. The home provides a variety of communal spaces including a large airy living room with a chapel, which is divided off from the main communal area but still within the ground floor. There are several large dining areas on both the ground and first floor of the home. The issue of the “sighting” of the dining room table on the first floor was discussed with the manager as this currently means that service users are facing a blank wall whilst eating their meals. This is considered inappropriate and unsuitable and alternative arrangement needs to be made in order for service users to have the opportunity to engage in conversation with fellow service users. The standard of decoration throughout the home is exceptionally high and the manager and staff should be congratulated on their hard work and enthusiasm in creating a warm and stimulating environment for its service users. The manager must ensure that ALL DOOR WEDGES are removed from the home immediately as this practice compromises service users safety. Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 16 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) 27,29,30. The The The The staff team are enthusiastic and appear to take great pride in the service. skills and experience of the staff is varied. manager follows a robust recruitment procedure. manager is providing adequate training . EVIDENCE: The manager stated that the home was fully staffed and that the staffing levels are adequate to meet the required needs of the current service user group. These ratios provide a minimum of seven care staff on both the morning and evening shifts and three night-care per night. The manager has worked hard to improve and develop the supervision programme for all staff and this includes annual appraisals, which are carried out by the proprietor. Service users were complimentary about the staff and management of the home. Stating ‘ the carers are good, they look after us and are very kind’. Staff spoken to confirmed that they are receiving a variety of training, which includes, elder abuse, infection control, foot care, manual handling, food hygiene, dementia and elder abuse (October 2004). One member of staff currently has NVQ level 2 and one member of staff has NVQ level 3. Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 17 There was inadequate evidence to confirm that all staff have received appropriate fire training and therefore this presents a current risk to both service users and staff. All recruitment procedures are being carried out effectively in order to ensure the protection of service users. Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 18 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) 32,33,35,36,38. The management within the home is secure and effective ensuring that changing needs of service users are met and that the home is meeting its aims and objectives. Health and safety procedures compromise the safety of the service users and staff. EVIDENCE: The manager communicates a clear sense of leadership within the home, and promotes a sense of belong to it’s service users. Pride and dedication is taken in every aspect. Service users commented on how the manager is efficient and effective in addressing issues raised and responds appropriately. Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 19 Staff files contained minutes of supervision meetings. Service users appear to be extremely happy with the home and seen to be relaxed in their environment. The relationship between the service users and the staff is well balanced with interactions observed being appropriate and supportive. The ethos and management approach of the home creates an open, positive and inclusive atmosphere, staff and the service user spoken to commented that they feel supported and valued and that they feel the home is well managed. A clear commitment is made to equal opportunities within the home, with staff and service users expressing positive views with regards to this. All service user documentation is produced in both Italian and English. The service users appeared to benefit from this well structured and well run home. The staff and manager within the home are adequately and suitably trained in order to meet the changing needs of the service users. Quality assurance systems are in place and the home conducts an annual audit. The manager has daily contact with each service user and therefore the service users have the opportunity to raise issues or concerns informally. The service users spoken to felt that their views were listened to and considered. All records are secure within the home and were up to date and held in accordance with the Data Protection act 1998 ensuring that service users rights and best interests are safe guarded by the homes polices and procedures. Records regarding staff recruitment were inspected and there was adequate evidence to confirm that the recruitment and selection procedures were being adhered to. Individual and generic risk assessments were in place within home, with all external required safety checks occurring. All fire records were up to date and all health and safety records were in place and being maintained appropriately. However the manager must carry out a fire risk assessment on all aspects of the home and the practice of DOOR WEDGES being used to prop doors open must cease immediately. Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 20 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 3 3 3 3 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 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 2 3 3 3 3 x 2 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x 3 3 x 3 3 x 2 Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 21 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. 2. 3. Standard 38.2 38.2. 38.3 Regulation 23 (4) (a) 23 (4) (a) 13 (4) (a) Timescale for action The manager must conduct a fire 15/6/05 risk assessment on all aspects of the home The manger must ensure that 15/6/05 all door wedges are removed from the building The manager must conduct and 15/6/05 complete a risk assessment on the doorways/stairwells on the first floor of the home. The manager must review the 30/6/05 current arrangment of service users facing a blank wall whilst eating their meals in the dining room. Requirement 4. 20.2 23 (2) (f) & (g) 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 Good Practice Recommendations Villa Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City Herts AL7 3BQ 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 Scalabrini I52_s19605 Villa Scalabrini v229960 140605 stage 4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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