Inspection on 20/03/07 for Villa Scalabrini

This inspection was carried out on 20th March 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 Scalabrini 22/04/10

Villa Scalabrini 23/02/10

Villa Scalabrini 27/01/06

Villa Scalabrini 14/06/05

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 Jeffrey Orange Key Unannounced Inspection 20th March 2007 08:55 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 Scalabrini DS0000019605.V331120.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 Scalabrini DS0000019605.V331120.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Villa Scalabrini Address Green Street Shenley Hertfordshire WD7 9BB 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) 0208 207 5713 0208 381 5570 www.carehomesuk.net/villascalabrini Villa Scalabrini Trustees Ms Angela Onofri Care Home 53 Category(ies) of Dementia - over 65 years of age (53), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (53) Villa Scalabrini DS0000019605.V331120.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 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. 27th January 2006 Date of last inspection 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 mass is celebrated daily. 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. The home has a guide for service users and a statement of purpose, which include contact details for the Commission for Social Care Inspection (CSCI). Copies of the latest inspection report are available in the home. Fees range from £415 - £560 per week for long stay residents and from £465 £595 for short stay or respite residents. These prices are current for 2007/8 The guide for service users includes very clear details of what is included in the weekly fees and what is subject to additional charge. Villa Scalabrini DS0000019605.V331120.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit took place over six and a quarter hours and provided an opportunity to meet service users, observe the care and activities provided for them in the home, speak to staff and members of the management team, tour the premises and to inspect some key records including those for the administration of medication, staff recruitment and service user care plans. This report also draws on information gathered during previous visits to the home and on any other information received about Villa Scalabrini since the previous inspection in January 2006. This was another in a series of very positive inspections of the home. What the service does well: What has improved since the last inspection? Any requirements or recommendations made following the previous inspection have been met. An improvement to the office accommodation for the home has also enabled the medication storage area to be enhanced. Villa Scalabrini DS0000019605.V331120.R01.S.doc Version 5.2 Page 6 The maintenance of the previously established high standard of care is, in itself, an achievement. 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. The summary of this inspection report can be made available in other formats on request. Villa Scalabrini DS0000019605.V331120.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 Scalabrini DS0000019605.V331120.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): Standards 1 3 (Standard 6 does not apply to Villa Scalabrini) Quality in this outcome area is good. This judgement has been made using all available evidence including a visit to this service. The information available to prospective service users is comprehensive and includes full details of fees and what is and is not included in them, this helps prospective service users to make a well-informed decision about moving into the home. The care needs of prospective service users are assessed and established before they move into the home; this means that only those whose needs can be appropriately met are admitted. EVIDENCE: Villa Scalabrini DS0000019605.V331120.R01.S.doc Version 5.2 Page 9 The guide to service users and the statement of purpose are available in Italian and English and have been revised to give the required information about fees following recent changes in the Care Home’s Regulations. The details about how levels of need are assessed and the way this affects fees is very clearly set out and there is also very clear information provided about what is included in fees for care and accommodation and what will attract additional charges. Pre-admission assessments for three recently admitted residents were seen to provide the necessary information staff require to identify and understand their care needs and how they should be met. Villa Scalabrini DS0000019605.V331120.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): Standards 7 8 9 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care plans are comprehensive and detailed and are regularly reviewed, this ensures that any changes to health and social care needs are identified and appropriate action taken to ensure that they are still being met. Service users are treated with respect and dignity and care is provided in a sensitive way. The standard of records for the administration of medication for service users is good and service users are protected by the home’s policies and procedures including the training of staff involved. The controlled drug register needs to be changed in order to meet current requirements and the temperature of the medication storage area should be monitored to ensure it is within the required range. EVIDENCE: Villa Scalabrini DS0000019605.V331120.R01.S.doc Version 5.2 Page 11 “The carers are lovely, you couldn’t ask for more” was one typical comment made by a service user. Care plans are detailed, well completed and are regularly reviewed to ensure that they are up to date. Those medication records checked were accurate and up to date. Staff involved in medication administration spoken to confirmed that they receive appropriate and adequate training and support to enable them to do so safely. The controlled drug register currently being used was not bound with numbered pages. This does not meet the current guidelines produced by the Pharmaceutical Society followed by registered homes. Although the temperature of the new medication storage area was cool on the day of this inspection, it should be monitored and recorded to ensure that it remains within the range recommended for the medication stored there. Medication can loose effectiveness if not stored appropriately. A G.P was seen to be visiting the home and was being supported by staff to meet the healthcare needs of his patient. Villa Scalabrini DS0000019605.V331120.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): Standards 12 13 14 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are central to the home and its operation and care is taken to involve service users in decisions about the daily routines of the home in order to ensure, as far as it is possible, that individual expectations and preferences are met. EVIDENCE: The home has a programme of regular activities and special events arranged for service users. A party was recently held to celebrate Father’s day in Italy and Mother’s day in England which involved male members of the staff team dressing as women, photographs on display in the home indicated that this was obviously enjoyed by both the service users and staff! Villa Scalabrini DS0000019605.V331120.R01.S.doc Version 5.2 Page 13 On the day of the inspection a lively music session was in progress. Regular activities include craft, sewing and gardening and trips out of the home are also arranged. The home’s food was the subject of very positive comments by most of those service users spoken to during this inspection. Visitors are welcomed with very few restrictions as to time and the atmosphere in the home is warm and welcoming. Those service users’ rooms seen have been personalised to reflect the individual tastes and interests of the service user. Villa Scalabrini DS0000019605.V331120.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 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 a robust and through complaints procedure in place which should enable any service user with concerns to raise them with confidence that they will be addressed promptly and effectively. Staff receive training in how to recognise potential or actual abuse and what to do if it is seen or suspected. EVIDENCE: Previous experience has demonstrated that the home take complaints seriously and that they are dealt with appropriately. No concerns have been raised with the CSCI since the previous inspection. Villa Scalabrini DS0000019605.V331120.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): Standards 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe, comfortable and pleasant environment for those who live and work there and is clean and well maintained. EVIDENCE: The standard of cleanliness and hygiene seen on the day of this site visit was exceptionally good, with no trace of unpleasant odours at all. “They keep the home very clean” was one comment received during this visit. As has previously been noted, the standard of décor throughout the home is exceptionally high and reflects the Italian cultural background of many of the residents. Villa Scalabrini DS0000019605.V331120.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 28 29 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are recruited, trained and supported in a way that enables them to safely and appropriately meet the needs of the homes’ service users. EVIDENCE: Files for recently employed staff were examined and found to contain the necessary checks, including full employment histories. Those staff spoken to had all received NVQ training and were supported by a system of regular, routine supervision. Supervision records are currently being revised and updated. The home has training and development schedules in place for staff, these include induction and routine training in key skill areas such as moving and handling, infection control and food hygiene, that are regularly updated. No adverse comments were received about staffing numbers, which appear adequate. Care was seen to be provided to service users in a timely and unhurried way. There is quite a settled staff team and this provides a good level of continuity for service users. Villa Scalabrini DS0000019605.V331120.R01.S.doc Version 5.2 Page 17 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): Standards 31 33 35 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is effectively and efficiently managed, with the needs of service users at the heart of its operation. The health, safety and welfare of service users are well protected. EVIDENCE: The manager communicates a clear sense of leadership within the home, assisted and supported by her staff team and the spiritual/pastoral leadership of the home. Villa Scalabrini DS0000019605.V331120.R01.S.doc Version 5.2 Page 18 The home has a history of prompt and full compliance with any requirements or recommendations made, and this visit was no exception. “This is a marvellous home you know” was a very typical comment made by a service user. The standard of record keeping is high; one recommendation is made in respect of the audit of financial records; (This is to promote best practice and is not a reflection on any staff currently involved in the recording of service users financial transactions.) One requirement is made in respect of the kind of book used for the recording of any controlled drugs in use. Care plans contain a series of appropriate and thorough risk assessments. Villa Scalabrini DS0000019605.V331120.R01.S.doc Version 5.2 Page 19 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 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 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Villa Scalabrini DS0000019605.V331120.R01.S.doc Version 5.2 Page 20 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. 1 Standard OP9 Regulation 13(2) Requirement The controlled drug register must be bound, not loose leaf and must have numbered pages. All controlled drug administrations recorded must be signed and witnessed. The temperature of the home’s medication storage must be monitored and any necessary action taken to ensure it remains appropriate for the medication contained in it. Timescale for action 30/04/07 2 OP9 13(2) 30/04/07 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 OP35 Good Practice Recommendations The manager should put in place a system for the routine, regular audit of any monies held on behalf of service users. Villa Scalabrini DS0000019605.V331120.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Scalabrini DS0000019605.V331120.R01.S.doc Version 5.2 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!