Care Home: Villa Maria

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What the care home does well The people who live at Villa Maria benefit from their home environment, which is comfortable, spacious and well maintained. The residents/Sisters enjoy their meals and are offered a choice of appealing food. Attention is paid to the physical and spiritual needs of the people who live in the home. Staff are caring, always treating the residents/sisters with respect and have a good relationship with them. The staff are very proud of the high level of care the residents/Sisters receive at Villa Maria. What has improved since the last inspection? Further improvements have been made to care plans so that staff can use them on a daily basis to attend to the needs of the people in their care. When a resident/Sister falls this is being recorded in their care plan so that they can be more closely monitored and advice sought if necessary. Staff files are being reorganised with a checklist at the front of each file. Once completed, it will be easy to see if all the necessary information about that member of staff has been obtained and if they have been trained in all essential areas. What the care home could do better: There were two areas that were identified at the last inspection as needing improvement. These are firstly, the re-establishment of a quality assurance system to seek the views of the people who live in the home so that it can be run in their best interests. Secondly, the formal supervision of staff, so that the manager can be certain that staff are doing their jobs safely. Since the last inspection neither of these areas have been addressed. This is partly because there has been an acting manager in post and now a new management team has been appointed. It is hoped that once the new management team have been established in the home that these two areas will be addressed to the benefit of the staff and people who live in the home. The records held for checking fire equipment are not easy to understand and the visual checks of fire extinguishers and hoses have not been carried out. This needs to be attended to, to make sure that the home is doing all it can to minimise the event of a fire in the home. Good records are held of when staff give medication to residents/Sisters. However, there were two gaps in the medication chart, which means that it cannot be certain whether one resident received their medication as prescribed by their GP. The manager needs to put a system in place to minimise the possibility of this happening again. CARE HOMES FOR OLDER PEOPLE Villa Maria 53 Seabrook Road Hythe Kent CT21 5QE Lead Inspector Nicki Dawson Key Unannounced Inspection 15th February 2008 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Villa Maria Address 53 Seabrook Road Hythe Kent CT21 5QE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01303 266723 villamaria@btinternet.com Marist Sisters Tamara Brown Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with Personal Care (PC) to service users of the following gender: Either M/F Whose primary care needs on admission to the home are within the following categories: 2. Old Age, not falling within any other category (OP) The maximum number of service users to be accommodated is twenty-three (23) 24th January 2007 Date of last inspection Brief Description of the Service: Villa Maria provides accommodation and support for up to 23 older people. It is a purpose built home that is owned by a religious order, the Sisters of the Marist Congregation and linked to the adjoining convent. The majority of people for whom care is provided are Sisters of the Marist Congregation. Accommodation is to a high standard and all rooms are single with ensuite facilities. For the less mobile a shaft lift provides access to both floors and all bathrooms have a hoist fitted. The home is located on the outskirts of Hythe town centre. There is good access to the sea, shops, public transport and other public amenities, some of which are within walking distance. The statement of purpose gives information about the home and the service provided there. A copy of this and the most recent inspection report can be obtained from the home. Currently the fees £400 per week. There are no charges for additional services. Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means the people who use this service experience good quality outcomes. The inspection was unannounced, which means that the Sisters, residents, staff and deputy home manager did not know that the inspector was calling at the home. The inspection started at 9.15am and took 6 hours. Discussion took place with Sisters, residents, staff and the deputy home manager, to gain their views and knowledge of the level of care, provided by the service. The shared areas of the home and a number of resident’s bedrooms were entered. A number of records to do with resident’s care and safety were looked at. The home sent us their annual quality assurance assessment (AQAA) when it was asked for. It gave a clear and detailed picture of how well outcomes are being met for people using the service. Survey questionnaires (“Have Your Say About...”) were sent by the CSCI to the home before the inspection visit. Those returned from residents/Sister were generally positive about the level of care provided by the home. One resident/sister commented, “I am very blessed to be living in such a happy, warm and welcoming ‘home’”. The people who live at Villa Maria are referred to as ‘Sisters’ and ‘residents’ throughout this report since this is what the care staff team calls them. What the service does well: What has improved since the last inspection? Further improvements have been made to care plans so that staff can use them on a daily basis to attend to the needs of the people in their care. When a resident/Sister falls this is being recorded in their care plan so that they can be more closely monitored and advice sought if necessary. Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 6 Staff files are being reorganised with a checklist at the front of each file. Once completed, it will be easy to see if all the necessary information about that member of staff has been obtained and if they have been trained in all essential areas. 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 Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Villa Maria DS0000023618.V358354.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): 1 – 3 and 5 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents/Sisters have most of the information that they need to help them to decide whether to move to the home. Prospective residents/Sisters needs are fully assessed before they move into the home so that they can be sure that they will receive the right type of care. EVIDENCE: The aims and objectives of the home are set out in the home’s ‘Statement of Purpose’. The document is easy to understand. However, it is not clear what the criteria are for admitting residents who are not Marist Sisters. There have been changes to the management structure of the home and these have not been included in the document. The services and facilities that are available to residents living in the home are detailed in the home’s ‘Service User Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 9 Guide/Welcome Pack’. The home manager states that she plans to review both documents and the deputy manager said that she would address both these omissions when doing so. When a resident or Sister enters the home, their rights and responsibilities are explained to them, before signing a contract of their terms and conditions. Signed, written contracts were seen in resident’s/Sister’s files. Before new residents/Sisters are admitted to the home a full needs assessment is carried out to decide whether or not the home is a suitable place for the person to live. This information is used to start the development of an individual plan of care. The home manager and/or deputy manager aim to meet the prospective resident/Sister in their own home. If the person is funded by the local social services, then a copy of the social services assessment is obtained from social services. Very detailed pre-assessment information was viewed for a resident/Sister that had recently been admitted to the home. Residents/sisters said that they had the opportunity to visit Villa Maria before they moved into the home. This is helpful since it enables residents/Sisters to meet the staff and other residents/Sisters to see if they fit into the pattern of life in the home. Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 -11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents/Sisters health, personal and social care needs are clearly identified in their care plans, so that staff have the information they need to look after them safely. Residents/Sisters are treated with dignity and respect and their privacy is maintained. EVIDENCE: Each resident/Sister has an individual plan of care that clearly sets out their health, personal and social care needs, together with the staff support that is required to meet these assessed needs. In all the plans examined, each person had signed the plan to say that they had been involved in writing it. Every part of the care plan is thoroughly reviewed at least every month and more frequently when needed. Staff said that residents/Sisters care plans are easy to use on a daily basis to make sure that residents/Sisters are looked Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 11 after correctly and safely. Most residents/Sisters care plans contain a photograph of the person to help staff identify them easily. The deputy manager said that she would make sure that there is a photograph available for everyone who lives in the home. Written plans are in place to minimise the effect of potential risks to residents/Sisters. A record is kept if a resident/Sister has an accident or fall. One record examined showed that a person had had a large number of falls, before action had been taken to minimise the risk of this person falling. A falls monitoring form has now been introduced so that if a person has frequent falls, this triggers calling in health care professionals. Residents/Sisters are supported to maintain their health by accessing health care services such as their GP, district nurse, optician and dentist. These visits are clearly recorded and show that appropriate action is usually taken. The home uses a pre-dispensed system for administration of medicines. This means that the majority of medicines arrive at the home in blister packs with the medication already measured by the pharmacist. This system is used to reduce risk of the residents/Sisters of receiving incorrect doses or incorrect medication. The person that is giving out the medicine then records on a pre printed form that the medicine has been given or, if it hasn’t been given, the reason why. On examination of this record it was found that there were two gaps in recording medicine for one resident/Sister so that it was not clear if the resident had received their medication. The deputy manager said that she would look into this oversight immediately and that in addition she would put in more effective systems to help prevent this happening again. The deputy manager said that all staff, which administer medication have received training in how to do this safely. Staff spoken with said they feel confident that they have the knowledge and skills they need to deal with residents/Sisters’ medication safely. Residents/Sisters are supported to take their own medication if they have been assessed as able to do this safely. During the visit staff talked with residents/Sisters in a respectful and individual way. They were observed knocking on bedroom doors before entering. Staff are very aware of the individual routines and choices of each resident/Sister. For example, they respect the wishes of some people to spend periods of time in their rooms, alone. Through discussion with relatives, residents/Sisters and staff, it is apparent that careful consideration is given to the care of people who are ill or dying who live at Villa Maria. If a person is dying there is always someone with them day and night as care staff and the Sisters join together to provide the emotional and spiritual support that is needed. Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 People who use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents/Sisters are able to choose their life style and to keep in touch with family and friends. Residents/Sisters enjoy mealtimes and receive a healthy and varied diet. EVIDENCE: Residents/Sisters were occupied with various activities on the day of the visit. Some were reading newspapers in the lounge, one was playing the piano, and others were in their rooms. The focal point of the day for the Sisters is morning mass, which is held at the chapel. In the afternoon, staff take turns to arrange activities for the people who live in the home, who wish to. One relative said, “there are lots of activities for mum to get involved in, but she chooses not to”. There is a dedicated activities room, which contains a piano, library books, games, and a computer. A few Sisters are able to go out independently and enjoy going out for walks around the area and to the sea Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 13 nearby. For those who are less able, the deputy manager said that occasional trips out are arranged. Surveys returned from residents/Sisters indicated that there are ‘sometimes’ or ‘always’ activities arranged by the home that they can take part in. Residents/Sisters and relatives confirmed that family members are able to visit them at any reasonable time. There is a separate room where visitors can meet their relative in private. The pace of daily life in the home is relaxed and unhurried. Residents/Sisters are able to choose when to get up, when to go to bed, what to wear and how to spend their day. Everyone who was spoken with commented on the high quality of the food. Comments include, “I cannot fault the food”, “my relative comes just for the food”, “the food is excellent and they have tea and cake in the afternoon”. A temporary cook has been employed for the last two weeks and it is a credit to him that such a high standard has been maintained. The menu showed that a wide range of nutritious and appealing dishes are provided each day. There are always two choices each day. The dining room is very attractively laid out and there are a number of kitchenette areas around the home where residents/Sisters, who are able, can make themselves drinks and snacks. Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents/Sisters are confident that any complaint they make will be listened to and resolved to their satisfaction. Staff feel confident to speak out if they have a concerns about the care of a resident/Sisters, which protects residents/Sisters’ well being. EVIDENCE: The home has received one complaint since the last inspection, which it has fully investigated. The commission has not received any complaints. The home has a complaints procedure, which explains how residents/Sisters or others can make a complaint about any aspect of the service provided. Residents/Sisters and relatives said that if they had any concerns, that the home or deputy manager are easy to approach. When one resident/Sister was asked if she knew how to make a complaint she responded, “I have only praise not complaints about the home “. All residents/Sisters who returned a survey, said that they knew how to make a complaint and that staff always listened and acted on what they said. Staff have a good understanding of what is good care practice. They said that there is an open ethos in the home whereby they or residents/Sisters are Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 15 confident in bringing any concerns or complaints to the attention of a senior member of staff. The home manager states that some care staff have received formal training in safeguarding vulnerable adults. She plans to make sure that all staff have undertaken this training in the next year. Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 29, 21, 23, 24, 25 and 26 People who use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents/Sisters benefit from living in a home that is comfortable, clean and well maintained. EVIDENCE: The home is purpose built and was completed in 2002. All areas are extremely well decorated and maintained to a very high standard. A relative commented, “the home is always clean and comfortable”. All, but one resident/Sister who was surveyed said that the home was ‘always’ clean. The other respondent stated that the home was ‘usually’ clean. Residents’/Sisters’ rooms are situated over three floors. Each floor is accessible by a shaft lift. All bedrooms are single with en suite facilities, most Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 17 of them including a shower. Bedrooms are large and contain a small living area with a television, music centre and a desk and chair. Each has been decorated to the resident/Sisters’ individual tastes and reflects the person who lives there. Many residents/Sisters commented on how beautiful their rooms are. There are communal bathrooms, which contain a hoist for the less mobile. The lounge is very attractively decorated, with comfortable seating and large windows overlooking the extensive gardens to the front of the home. An activity room leads off the lounge. There is a veranda, where the people who live in the home may sit in fine weather and relax looking at the sea. In addition there is a small quiet room where residents/Sisters may entertain their visitors. There is a separate dining room that is large enough for the residents/Sisters and their visitors to eat there comfortably. Kitchenettes are available so that more able residents/Sisters can make drinks and snacks at any time of the day. There are a number of sluice rooms around the home so that hygiene levels can be maintained and the residents/Sisters are protected against the spread of infection. The home manager states that some staff are trained in how to minimise the spread of infection in the home and she is planning further training for those staff who have not, or those that require an update. There is a separate laundry room and a laundry assistant is employed five days a week. The home was spotlessly clean and smelled fresh on the day of the visit. Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27-30 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is enough staff on duty to meet the needs of the residents/Sisters and a staff training programme is being developed to make sure that these needs are met in a satisfactory way. The recruitment procedure for new staff is robust so that residents /Sisters can be confident that they are protected from potential harm. EVIDENCE: The staff rota indicates that there are three or four care staff on duty during the day and two at night. The deputy manager said that the home aims to deploy four care staff each day but this is proving difficult due to staff sickness and holidays. Staff said that there are enough of them to meet the needs of the residents/Sisters, but that a fourth member of staff enabled them to give residents/Sisters more individual attention. All, but one resident/Sister who was surveyed said that there was ‘always staff available when they were needed. The other responded stated that there was ‘sometimes’ enough staff available. One resident/Sister added that staff are available, “even though they are always busy”. A cook is available to cook meals each day and a laundry assistant is employed during the week. Feedback received about the service is that the care provided by the staff team is good and that staff are Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 19 kind and caring. Comments about the staff team include that they are “quiet and efficient”, “welcoming”, and “All the staff are caring, not just some”. 57 of staff are trained to National Vocational Qualification (NVQ) level 2 or above and two more staff are currently working towards level 2. This award is useful because it helps staff develop good care practices and their skills in working with people who live in a residential care home. Before new members of staff are employed at the home a number of checks need to be carried out to make sure that all members of staff working at the home are suitable to care for vulnerable residents. Files were seen for four new members of staff. All the relevant checks and documentation including Criminal Record Bureau enhanced disclosures, two references, contract of employment and application form were included showing that the recruitment process followed protects the residents/Sisters. There is a checklist on the front of each file showing the information that should be included. When this is used consistently for each staff file, it will be a valuable way of making sure that all staff files contain the information that is needed. Most staff files contain a photograph so that they can be identified easily. The deputy manager said that she would make sure that there is a photograph available for everyone who works in the home. The home manager is responsible for making sure that care staff have the skills they need to support the residents who live in the home. The deputy manager said that all new care staff receive introductory training, arranged by St John of God, which gives them the basic competencies they need to be able to work without direct supervision. The home manager needs to check that it covers all of the areas in the ‘skills for care’ induction programme, to ensure that it meets the National Minimum Standards. In addition to the introductory training, care workers undertake a number of training courses that develop their skills in caring for the people that live in the home. Each staff file that was viewed contained individual staff training certificates. In addition, the home manager has stated that she intends to develop a staff training matrix for recording all staff training and alerting her when mandatory training is due that needs to be implemented. She has already identified some areas where staff require training, including fire, health and safety, infection control and safeguarding adults. Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents/Sisters benefit from living in a home that is well managed. EVIDENCE: The home manager has been in post for eleven months. The deputy manager has worked at the home previously and has been in her current role for 4 months. The home manager is registered with the commission and is responsible for the day-to-day running of the home. She was not available on the site visit, but the deputy manager said that she has had experience of working with older people in a residential setting at management level. She has one of the formal qualifications specified by the National Minimum Standards and is currently working towards the other. These awards are Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 21 recognised by the commission to be useful because they help to make sure that people who manage residential care services have the competencies that are necessary to do so. The atmosphere in the home was calm and unhurried. The inspector was made to feel very welcome and a good relationship was observed between the deputy manager, staff and residents/Sisters. One person commented that the home manager, “will do any job that needs doing. She is very approachable”. Another that, “I always find the manager most approachable, ready to listen, and sort out problems”. For the home to run in the best interests of the residents/Sisters it is important to have a system in place which regularly obtains the views of residents/Sisters and visitors about the standard of care that they receive from the home. At the last inspection it was observed that it had been some time since a quality assurance survey had taken place to gain the views of people who live in and visit the home. The deputy manager said that this piece of work is still outstanding and that questionnaires will be sent out to residents and relatives in the near future. Currently, residents/Sisters can air their views and concerns formally at meetings, which are held every two months. A copy of the minutes of the meeting are made available to everyone. The deputy manager said that the home does not deal directly with any monies belonging to the residents/Sisters. The Superior Sister acts as appointee for the Sisters and residents all have family members who act on their behalf. The home manager confirmed that pocket monies are held for individuals and that a book is in place to confirm monies in and out, with receipts. At the last inspection it was observed that the regular supervision of staff had slipped. The home believe that staff supervision is important for staff to have the opportunity to discuss care practice, the philosophy of the home and their own development needs. Therefore, the deputy manager and team leader are to attend a training course on how to supervise staff effectively, before they start to supervise staff on a regular basis. The home manager has already received training in how to supervise staff effectively and says that she has done so. Staff said that they receive verbal supervision daily at shift handovers and are clear about their roles and responsibilities. They said they are able to speak with the deputy or home manager if they have any issues or difficulties. The deputy manager said that all items of equipment in use in the home remain in good working order and the home manager has provided the dates on which they have been serviced. Fire records indicate that fire equipment is serviced and tested regularly. However, visual checks are not being made to make sure that fire extinguishers and hoses remain in good working order to be effective if there is a fire. The deputy manager said that she would make sure that the recording of fire equipment checks are better organised and Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 22 includes visual checks of all fire equipment. A fire risk assessment has been drawn up and recently reviewed to make sure that the home is doing all it can to reduce the risk of a fire occurring in the home. As mentioned previously, the home manager plans to develop of staff training matrix to identify the staff training needs of the whole team. She has already identified that all staff need to be training in fire, health and safety, infection control and safeguarding adults. Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 23 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 2 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 X 4 4 3 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 3 2 X 3 2 X 2 Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 24 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 OP33 Regulation 24 Requirement The views of residents, relatives and other interested parties must be regularly sought and evaluated so that the home is run in the best interests of the people who live in the home Timescale for action 15/06/08 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. 2. Refer to Standard OP9 OP36 Good Practice Recommendations The medication administration records should be regularly reviewed to make sure that people receive the correct levels of medication Formal supervision for care staff should be reintroduced and carried out at least six times a year so that staff are able to do their jobs properly and safely. Villa Maria DS0000023618.V358354.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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