Care Home: Thornbury Villa

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What the care home does well The people living at Thornbury Villa are all very positive about the care and attention they receive from the staff working there. The registered providers know and are able to communicate their responsibilities to achieve the aims and objectives of providing a homely place where people are treated as individuals, and know their dignity and self respect will be preserved. The staff are all well trained. Policies and procedures are kept up to date and revised accordingly. The safety and well being of the people living at Thornbury Villa is paramount. What has improved since the last inspection? A new bedroom and laundry have been created in a disused garage of the home. Planning permission has been sought and gained to replace all the remaining sash windows and doors with double glazed PVC. What the care home could do better: The registered providers know what changes they have to make and how to continue to provide an excellent service for the people living at Thornbury Villa. Key inspection report Care homes for older people Name: Address: Thornbury Villa 128 Peverell Park Road Peverell Plymouth Devon PL3 4NE     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Megan Walker     Date: 1 8 1 2 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 27 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: Thornbury Villa 128 Peverell Park Road Peverell Plymouth Devon PL3 4NE 01752262204 01752672272 thornburyvilla@btconnect.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mrs Jacqueline Anne Van Deijl,Mr James Marinus Van Deijl care home 14 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The Maximum number of service users who can be accommodated is 14. The registered person may provide the following category of service: Care home only Code PC to service users of either gender whose primary care needs on admission to the home are within the folowing category: Old age, not falling within any other category (Code OP) Date of last inspection Brief description of the care home Thornbury Villa is a care home registered to provide accommodation and personal care for up to fourteen older people. It provides care services for people whose assessed needs are of a lower level and who maintain a certain level of independence. It aims to ensure a non-institutionalised and homely environment. Thornbury Villa does not provide care for people with a dementia or severe physical disability. It is not registered to provide nursing care. It is not registered to provide intermediate care. Care Homes for Older People Page 4 of 27 Over 65 14 0 Brief description of the care home All the accommodation is in single/ en-suite bedrooms located on two floors. Stair lifts ease access to the 1st floor. The house is spacious and provides sufficient shared space for the numbers and needs of the people who live there. The home is situated opposite Plymouth Central Park, close to shops and is on a bus route. The current weekly fees for Thornbury Villa range from local authority rates starting at £348.00 pwk up to privately funded rates of £425.00 pwk and are according to assessment of the persons individual care needs. Additional charges include hairdressing, chiropody, toiletries, newspapers, magazines, personal telephone line, etc, all charged at commercial rates. All charges information was provided to the CQC in December 2009.Information regarding the services provided at Thornbury Villa can be obtained directly from the home. Care Homes for Older People Page 5 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is three star. This means the people who use this service experience excellent quality outcomes. This was a Key Inspection undertaken by one regulation inspector. The fieldwork part of this inspection was unannounced. It took place on Friday 18th December 2009 between 08:40 and 17:20. Thornbury Villa was last inspected on 17th January 2007 and there was an Annual Service Review on 17th January 2008. This inspection included talking to the majority of the people who live at the home collectively and three on their own. We spoke to one relative who was visiting the home during our visit. We also spoke to care staff working at the time of this visit as well as observing interactions between the staff and the people using this service. We conducted a tour of the premises, inspected four care plans, four staff files, medication and other records and documentation. The registered providers and the manager were available throughout the inspection visit to provide relevant information such as the Care Homes for Older People Page 6 of 27 day-to-day routines as well as the management of the home. Eleven surveys were returned from people living in the home. Three staff members were spoken with individually and nine surveys were received from staff. One survey was received from a health and social care professionals. An Annual Quality Assurance Assessment (AQAA) was completed by the registered provider prior to the inspection. The AQAA is a selfassessment that focuses on how well outcomes are met for the people who live in the home. In addition we used the last Key Inspection report and all other information relating to Thornbury Villa received by the CQC since the last inspection to inform this inspection. Throughout this report, the term we will be used as the report is written on behalf of the Care Quality Commission (CQC). There are no requirements or good practice recommendations made as a consequence of this inspection. Care Homes for Older People Page 7 of 27 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 8 of 27 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents can be confident that their needs will be assessed to ensure that these can be met when they move into the home. Evidence: Twelve people living at Thornbury Villa who completed and returned a survey about the care home, told us that they had received enough information before they moved in that helped them to decide if it was the right place for them. The people we asked at the home also told us that they had received enough information about Thornbury Villa that had helped them to decide to move in. People are encouraged to visit and spend time at the home with the other people who live there over a transitional period. Often people come in for short respite stays so are familiar with the home and the staff. People are offered a months trial when they move in. There is wide consultation with families and carers who know the person to glean better insight and understanding about an individual. This helps the staff to gather Care Homes for Older People Page 10 of 27 Evidence: basic information so ease transition from home to care. This is because they have a comprehensive and holistic assessment on which they base a decision to offer someone a place at the home. We looked at three care plans. They all had pre-assessments of care needs. One person told us they did not have a contract and one person told us they did not know if they had a contract.Each of the care files we looked at had a signed contract.The provider told us that a Statement of Purpose is given to every prospective resident. This contains a copy of the contract, information about charges at the home, the Complaints policy and the Fire Safety procedure. A copy of the Service Users Guide is given to the person when they move into the home. Prospective residents are also sent a letter confirming that their care needs can be met at Thornbury Villa. One person who returned a survey told us I have been here at Thornbury Villa for 3 years and soon settled in and have made the right decision. Care Homes for Older People Page 11 of 27 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using this service are involved in their individual plan of care and are supported and encouraged to make decisions as part of an independent lifestyle. The practice regarding the planning and delivery of care means that people can be sure that their health and personal care needs will be always be met. Evidence: One person who returned a survey told Good all round care for each resident. Four people told that the home does everything well. A health care professional told us that the staff provide a high level of care to all residents. All care is carried out to a high standard. As we toured the premises we observed daily life at Thornbury Villa. Staff were seen to be courteous and sensitive with people. Two people we spoke to told us that they received the care and support they needed, the medical support they needed, that the staff listened and acted on what they say, and that the staff were available when they needed them. Feedback from relatives and staff, as well as information contained in personal files, confirmed that people living in the home have access to health care services such as doctors, dentists, chiropodists and opticians. The manager told us that when possible people can see a General Practitioner (GP) of Care Homes for Older People Page 12 of 27 Evidence: their choice. This is dependent however on where the person lived prior to moving into Thornbury Villa. In some circumstances it is necessary for a new resident to be registered at a local health centre near Thornbury Villa because their own GP will not travel across the city. In the event of a hospital admission, each person has a Hospital Transfer form that has up to date information such as allergies, current medication as well as current health status. We chose four people, both men and women, to look at their care files and care generally. Each care file seen stated the name by which the person preferred to be called. Each had a Resident Profile that gives a summary of the person and their care needs. Each file had a Resident Assessment Index that cross references risk assessments with care assessments. This provides the staff with a full assessment of all the care needs. The manager told us that although a thorough pre-assessment is undertaken before someone moves into Thornbury Villa, a Resident Care Assessment is completed once the person has moved in to the home. This is done over a period of time as the staff get to know the person, and as the person adapts and settles into their new home. Each care plan is reviewed monthly with the individual. A family member/representatives is also invited if this is the persons wish. The GP is kept informed of the outcomes of the reviews and if the person has any changes in their capabilities. Daily Records showed that changes in physical and/or health condition is monitored and recorded. The staff have various tools such as a mini nutritional assessment for anyone about whom they have concerns regarding their weight. Similarly, another tool they use to monitor and where feasible limit risk is for anyone who is at risk of falling or has a high risk of fractures. The staff meeting is also used as a conduit by the staff if they have concerns about an individual. One example was regarding a persons mobility that was putting other residents and the staff at risk. This prompted a review of the whole care plan. We saw evidence of good liaison with health care professionals such as district nurses and GPs. It showed timely action by the care staff, and appropriate interventions by the primary care teams to provide treatment plans for the staff to follow. There was also provision of any additional equipment if it was needed. Allergies, medications, and personal preferences for assistance with personal care were all documented. People are able to choose to have dental checks, eye-sight checks and chiropody services and these can be provided at the care home by visiting contractors. This enables a pro-active approach by staff to provide suitable care for individual health care needs. We looked at Accident records. These were kept securely according to relevant guidelines. All the care staff are qualified first aiders. Care Homes for Older People Page 13 of 27 Evidence: The manager explained the medication system at Thornbury Villa to us. Five members of the care staff team are trained and take responsibility for medication handling and administration. Medication is ordered monthly and each resident has a monthly review of their medications. All the medication is kept in a lockable cupboard. Two people at the time of our visit had prescribed controlled drugs. We saw these securely stored in a separate controlled drugs lockable cupboard. There was also a lockable medication refrigerator. The temperature checks are recorded in the Safer Food Better Business daily log book (This is a log book provided used to record all information required by the Environmental Health Agency.) We found that medication boxes were labeled for each individual. The medications were numbered and these were cross referenced with the medication sheets. Inspection of the medication records found that all had been given correctly and signed for accordingly. We observed medication being given to people during a meal. We were told by the manager that most people had medication at mealtimes however for anyone requiring specific times, these were adhered to. People are given their medication however the staff member does not wait to see that it is taken. Some people prefer to take it later during or after their meal. Anyone who had a medication prescribed Take as required is asked if they would like to take it. It not given unless requested by the person. There were clear procedures for staff to follow regarding refused medication, spoilt medication and medication for return to the dispensing pharmacist. There was a clear audit for all drug disposals. The medication sheets did not have photographs of the individuals to identify them. We suggested this to the manager at the time of our visit as a safety precaution and good practice. Care Homes for Older People Page 14 of 27 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Thornbury Villa are encouraged to exercise choice and control over their lives. People are supported to continue to enjoy familiar supportive relationships with family and friends, and within the local community. Evidence: One person who returned a survey told us that Thornbury Villa Creates a warm friendly atmosphere and also welcomes family and friends who visit. On the day of our visit the people living at Thornbury Villa enjoyed a leisurely breakfast from about 08:30 either in their room or in the dining room. Someone later told us Its a first class service. At my age I like a lie in and I can have breakfast in my own room. Another person living at Thornbury Villa told us I couldnt wish for a better place. Its a good laugh and everyone is very friendly. Throughout our visit there were several visitors and we were told there is no restriction on times people may visit. During the morning a group played a lively session of cards whilst others stayed in their rooms or sat in the lounge. We spoke to a number of residents collectively about the activities provided for them. They told us they do quizzes, play Hangman, bingo and cards regularly. A couple of people told us they enjoyed these because it kept Care Homes for Older People Page 15 of 27 Evidence: them mentally active. Someone else told us that someone comes in to do armchair exercises with them so everyone can keep physically fit too. There are also arts and crafts sessions for those people who are interested. People have opportunities to go on outings such as recently when they took tour of the city to see all the different Christmas lighting displays. The week after our visit a big Christmas party was planned to which families and friends were also invited. Lunch is served in the dining room at 12:30 although people can have it taken to them in their room if they are unwell. Tea is at 16:30, supper at 19:00, and evening drinks at 21:00. Drinks and snacks are also provided throughout the day, and staff have access to the kitchen at night. On the day of our visit lunch was fish and chips with mushy peas followed by trifle and cream. We were told by the staff and some of the people living at Thornbury Villa mushy peas were recently re-introduced on the menu by popular demand along with proper chips, not frozen oven cooked chips! There was an option about the way the fish was served so people could choose with or without batter. The chef told us that it was not a problem to make other food and he told people If its there you can have it. He confirmed that everyone living at Thornbury Villa has a good appetite and he enjoys cooking for them all. He has no food budget so that people can have what they like. The registered provider also confirmed this and told us the residents choose the food. He also emphasised how important this was as it allows people to continue to feel they are valued in their opinion about food, what they like and dislike, and have a choice about what they would prefer to eat. Care Homes for Older People Page 16 of 27 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living at Thornbury Villa and their families and friends can feel confident that any issues of concern or complaints raised by them will be dealt with appropriately. People are protected from abuse, neglect and self harm by the homes policies and procedures, and by a robust recruitment process. Evidence: Twelve people living at Thornbury Villa or their relative returned a survey about Thornbury Villa. They all told us that there was someone they could talk to informally if they were not happy. They all knew how to make a formal complaint. One person told us the home does Everything [well] I have no complaints. We saw the Complaints procedure prominently displayed in the entrance hall. It was clear and included up to date contact details for CQC. The AQAA told us: We have a very positive and open attitude to comments and promote discussions about all aspects of our service. We reinforce our beliefs regarding protection from abuse and carry out risk assessments on all seven areas of potential abuse.We have been educated in the requirements of the Mental Capacity Act and Deprivation of Liberty Safeguards and have drafted policies that cover our legal requirements staff have shared this information and are aware of the new requirements. Since the last inspection there have been no safeguarding referrals and the provider Care Homes for Older People Page 17 of 27 Evidence: has not received any complaints. All the staff working at Thornbury Villa have had training about how to recognise abuse of vulnerable people and how to report it approximately 18 months ago. This included training about whistle blowing. We discussed other training relating to safeguarding vulnerable adults, including the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DOLS), and what it means for staff working with people in registered care services. This is legislation that came into force on 1st April 2009 and applies to people living in services registered under the Care Standards Act 2000, regardless of who funds their place. The provider confirmed as stated in the AQAA that two staff have had training on these subjects and this has been disseminated to the other staff. Each care file also has a risk assessment for the protection from abusive practices. Care Homes for Older People Page 18 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living at Thornbury Villa have a comfortable and safe environment that is adapted to promote their independence and meets their needs. Evidence: Thornbury Villa is a large adapted house with residential domestic external look to it. The house has two floors with bedrooms on both ground and first floor level. They all have en-suite facilities. Access to the first floor is via stairs or using a stair-lift. As we toured the premises we met people in their rooms. Some people had brought personal items of furniture from their own homes with them. Most people had photographs and other personal items. Each room was decorated in a domestic style. We were told that that people could bring in their own curtains and bed covers. All the rooms seen were personalised to suit individual preferences. The bathroom on the first floor is domestic in style with hand rails fitted next to the toilet and the bath. There is a raised toilet seat for those people who need it. There is a shower over the bath. We also noted there are handrails along the hall and landing on both sides. The hallway leads into the dining room/lounge. There is a conservatory leading off this room. Both rooms are comfortably furnished and homely in style. Two further bedrooms lead off the lounge, one of which is a recent conversion of an unused garage. Part of this conversion also houses the laundry. The chef told us he is happy with the kitchen and it suits its purpose. There is sufficient storage. An Environmental Health Officer was Care Homes for Older People Page 19 of 27 Evidence: due to inspect the week following our visit. Thornbury Villa has a large patio with seating was provided. There is also a balcony at the front of the house with chairs and tables for people to use. The home was clean and tidy with no offensive odours. All the staff are trained in Infection Control and Food Health and Hygiene. A Health care professional who returned a survey told us Thornbury Villa maintains a very homely feel. Care Homes for Older People Page 20 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Thornbury Villa are supported by well-motivated and caring staff in sufficient numbers to meet the needs of those currently living at the home. Staff training and supervision is carried out regularly for all staff to ensure that the assessed needs of the people living at the home are met. Evidence: A health care professional told us Staff are aware of their limitations and always seek advice when required. We received nine surveys from staff. They were all very positive about the home and the support and training they receive from their employers, the registered providers. Comments included: It is a pleasure to work at Thornbury Villa; Policy and procedures are relevant and up to date, constantly being reviewed, consequently residents have best possible care. Regular entertainment, personal care is excellent, and any health worries are dealt with quickly and efficiently. Training is available and possibilities of furthering your career is available.; I think this home is a very friendly place to work and live; Adopt new procedures when necessary to improve standards and working conditions, staff are all very friendly work well together as part of a team; Residents at Thornbury Villa are very well cared for, they only have to ask for anything and management and owners are always there to provide needs and Care Homes for Older People Page 21 of 27 Evidence: also staff very efficient and caring; The interest that is shown to each individual resident, the choices they make are catered for also changes, breakfast in bed, etc. We have a lovely working team which makes for a friendly home for all. There is a low turnover of staff and this helps care to be consistent. Two staff we spoke to have worked at the home for ten and fourteen years. At the time of our visit ten care staff, two catering staff and a cleaner were employed to work at Thornbury Villa. Additionally there are is a manager and an assistant manager. The registered providers are also at the home daily. The AQAA states that there are sufficient staff on duty throughout the day and night to meet the needs of the people living at Thornbury Villa. During our visit there were two carers and the cleaner who worked from 08:00 until 12:00. The chef worked 08:00 until 14:00 and he is responsible for preparing breakfast and lunch. During the morning there was also an external contractor who came in to organise the card games with the people living at the home. In the afternoon from midday until 17:00 there was one carer working with the manager and the registered providers. Another carer came on duty at 17:00 so there would be two carers until 21:00 when two night staff took over until 08:00 the following day. We looked at four staff files. They all had two written references, a police check and a staff contract with terms and conditions of employment. Two staff are relatively new and the manager confirmed that photographs would be taken in the near future for their files. All the staff files showed they had followed an induction and had comprehensive training and development records. The manager told us that all the staff had up to date mandatory training in First Aid, Food Health and Hygiene, Moving and Handling, Fire Safety, Protection of Vulnerable Adults and Deprivation of Liberty Safeguards, and Infection Control. Staff also had access to training DVDs about nutrition, and Three steps to a safe, clean home. Some staff had completed stages 1 and 2 on signing. Another external contractor was providing training about sight which would give care staff some insight into different sorts of visual impairments. The staff group at the time of this visit was both female and male, assorted ages, and they are all white and the majority are British. The people using this service are all white, British and Christians. The current staff group therefore is able to meet the needs of the people living at Thornbury Villa. They provide care that is unprejudiced and recognises peoples differences and values. Throughout this visit our observation of the staff found they were friendly and caring towards everyone. They were gentle and respectful as they assisted people with daily living tasks, and mindful of preserving peoples dignity and self respect Care Homes for Older People Page 22 of 27 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Registered Provider and manager shows a responsible attitude and continues to implement changes and improvements in order to keep improving and achieving positive outcomes for people using this service and staff working with them. Evidence: We were told in a survey returned to us A friendly home, the manager and owners are easily approachable, and are quick to deal with issues that arise. Someone else told us They the registered providers] are lovely and very caring bosses. On the day of our visit both registered providers and the manager were present throughout the day. They were found to be approachable, willing and able to provide information to assist with the inspection. We saw evidence of quality assurance checks (surveys are given out every three months to the people living at the home) showing consultation about the home, for example, communal areas and individual bedrooms, meals, staff and staff attitudes, the manager, activities and events. General comments cards are available for families and visitors. There is a Residents Discussion group held Care Homes for Older People Page 23 of 27 Evidence: approximately three times a year that has minutes taken and an action plan. Additionally staff pick up matters of concern or niggles during daily chats with the people living in the home. The manager confirmed that all the necessary maintenance checks as reported in the AQAA were correct and up to date. We inspected the Fire Log and confirmed that the smoke detectors, emergency lighting and fire alarms were checked regularly, dated and signed. The Accident Book was seen and accidents were recorded correctly. The CQC is notified of any serious incidents affecting the health, safety or well being of any of the people living at Thornbury Villa. Care plans inspected had risk assessments included in them that were relevant to the individual person. On the day of our visit the home was clean and tidy, free from offensive odours throughout. The registered providers know and are able to communicate their responsibilities to achieve the aims and objectives of providing a homely place where people are treated as individuals, and know their dignity and self respect will be preserved. Care Homes for Older People Page 24 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 27 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 26 of 27 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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