Inspection on 26/04/07 for 19 Leicester Villas

This inspection was carried out on 26th April 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

19 Leicester Villas 20/04/06

19 Leicester Villas 24/11/05

19 Leicester Villas 26/05/05

19 Leicester Villas 26/01/05

19 Leicester Villas 31/08/04

19 Leicester Villas 03/03/03

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 19 Leicester Villas Hove East Sussex BN3 5SP Lead Inspector Merle Blakeley Unannounced Inspection 27th April 2007 10:00 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 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 19 Leicester Villas DS0000031913.V333230.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 Adults 18-65. 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. 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 19 Leicester Villas Address Hove East Sussex BN3 5SP 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) 01273 295840 01273 295853 www.fosteringinbrightonandhove.org.uk Brighton & Hove City Council Mr David T O’Neil Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 2006 Brief Description of the Service: 19 Leicester Villas is a detached property in a quiet, residential road in Hove. It is possible to walk to the shops, and public transport systems are within close proximity. The service is for up to five adults with learning disabilities. At the present time there are four service users who are supported 24-hours a day. Single bedroom accommodation is provided on the ground and first floor. There is one assisted bathroom on the ground floor and a non- assisted bathroom upstairs and toilets are located on both floors of the home. Meals are prepared by the staff with the people being supported to participate in the preparation. The home is domestic in scale and consists of lounge with a dining area and a kitchen. A large, rear garden provides a safe and pleasant area for residents to spend time in. More detailed information about the services provided at 19 Leicester Villas can be found in the home’s Statement of Purpose and Service User Guide - copies of these documents can be obtained directly from the Provider. Latest CSCI inspection reports are kept in the homes office. Residents currently pay a £60.45 contribution towards their care. 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out over a period of six hours on 27th April 2007. As well as this site visit information was also gained from a returned pre-inspection questionnaire, Regulation 26 visit reports, four residents feedback surveys and informal talks with the manager and five staff members. Document reading was also carried out and a health and safety check was conducted. The inspector was also able to spend time observing staff and residents throughout the day. What the service does well: What has improved since the last inspection? A random inspection was carried out on 26th September 2006 and six requirements were made. All the requirements have been fully met. The home has now provided people with terms and conditions in an easy read format and care plans and risk assessments are updated regularly. The home has also ensured that one particular bedroom door is compliant with fire regulations and a fire risk assessment has been produced. There were some previous concerns about the cleanliness of the home, however it was found to be clean and tidy on the day. The home has also made several other positive improvements since the last inspection. The kitchen has been totally refurbished and is now a bright, modern and clean. Other communal areas within the home have also been improved. The new registered manager has made some very positive changes within the home and staff stated that they felt the home was being managed in a much more positive and proactive manner. The staff team now appears more stable 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 6 and all who were spoken to on the day said that they felt that morale had improved and they felt more confident and supported in their work. 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. 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All residents have recently received an assessment of their care needs. All the residents have received a copy of the homes terms and conditions. EVIDENCE: During the last inspection on 26th September 2006 a requirement was made for the home to ensure that all residents received a copy of the homes terms and conditions. Brighton & Hove Council have produced a more user friendly document, which contains makaton signs and pictures to enable people to better understand the purpose of the document. The document also contains information about the house, the manager and the person’s key worker. During January and February of this year all four people living in the home had an assessment of their needs carried out by social workers. The outcome was that the home is continuing to meet the needs of these people. These people’s needs will again be assessed in six months time. 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new care plans are comprehensive. Where possible people are able to make decisions about their lives. People are encouraged to participate in the home and they are supported to take risks. EVIDENCE: At the previous inspection a requirement was made for the home to ensure that care plans were kept up to date and risk assessments were updated. New care plans have been produced and all four of these documents were viewed. The information they contained was informative, relevant and up to date. As well as these care plans, staff also maintain daily handover sheets that describe what has occurred to the person during that day. These are handed over to staff at each shift change. The manager was asked as to how people can make decisions about their lives. As some of the people are unable to effectively verbalise he stated that they are able to make gestures in many other ways. The home is starting to use 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 10 pictorial choice making with people so that they are able to communicate their needs and wishes more effectively to staff. Daily records indicate that people are choosing when they want to go out, where they want to go and who with. The manager stated that all four people living here need help with making appropriate choices. Staff were asked about how people are able to participate in aspects of home life. Staff said that people were offered support to assist with certain ‘chores’ within the home if they felt they wanted to participate such as shopping and cleaning their own rooms. They are also encouraged to put away their own clothes and help prepare lunch. Each person has a risk assessment carried out for various areas of their lives. Some people are able to manage more than others. The risk assessments were seen to cover the areas of being out of the home, activities inside the home, falls, finances, medication and personal care. Risk assessments are reviewed on a six-monthly basis. The manager stated that he was in the process of carrying out more work on the risk assessments documents. 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People attend appropriate activities and are part of the local community. People choose their leisure activities and maintain contact with their relatives. The home is providing a healthy and well balanced diet. EVIDENCE: All four people attend various day centres throughout the week and their care plans revealed that they also participate in other activities. Some people like to go out for walks and out for meals in local cafes and restaurants. Others are supported to go out shopping and visit places of interest. Some enjoy more personal activities within the home. During the day the inspector viewed two of the residents enjoying a music appreciation session. Annual holidays have been organised. Two people are going to be supported by three staff to visit relatives in Scotland and the others are going to a holiday camp. 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 12 All four residents are out and about in the community on a daily basis and visit local shops and other amenities. All four residents maintain fairly regular contact with their family and friends. The home has prepared a four weekly menu, which appeared well balanced and healthy. Staff prepare all the meals and they felt that residents were receiving a good diet and eating the types of food that they like. Staff said that occasionally take away meals are brought and at the weekends residents like to go out for meals in pubs and cafes as that is their choice. The dietician has currently put two residents on specific diets. People in the home are encouraged and supported to help with the weekly food shopping. 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff provide personal care in a manner that residents prefer. The home remains proactive in regards to people’s healthcare needs. Medication is correctly stored and administered. EVIDENCE: All four people who live in this home require support with their personal care. One person requires a hoist for bathing and all staff stated that they had received training to use this equipment correctly. Staff also said that people could choose who they wished to support them with their personal care on the day. Both male and female staff support the residents privately in bathrooms. Staff said they try to ensure that privacy and dignity is maintained at all times. People’s care plans showed that they have access to a number of healthcare professionals. The manager stated that the home tries to remain very proactive in this area to ensure residents are receiving the best possible care. They all have access to physiotherapists, occupational therapists, speech therapy, chiropody, dentists, dieticians and their own GP’s. Two people have 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 14 certain medical conditions, which require continuous monitoring and staff have received specific training regarding these conditions. Medication records were checked and no discrepancies were found. Two staff are required to sign when medications are administered. One resident recently had a medication review by her GP. Most of the staff have received medication training and the manager needs to ensure that ongoing refresher courses are made available. 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has produced a complaints procedure in an easy read format. The home has a suitable adult protection policy and procedure. People’s finances are safeguarded. EVIDENCE: The home has now produced a complaints procedure, which is in an easy read pictorial format. This leaflet helps people to understand how they can make a complaint if they are not happy about any aspect of their care and whom they need to go to. The newly revamped terms and conditions also describe how people can make a complaint. The home did receive a minor complaint from a neighbour, however this has been dealt with satisfactorily. The home has produced a policy and procedure regarding the protection of vulnerable adults. All staff have received adult protection training with two staff due to attend a refresher course later this year. The home has not received any adult protection alerts. All four residents need total support with their finances. These financial records were viewed on the day and were found to be in order. People’s monies and receipts are double checked by staff on a daily basis. 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There have been several positive environmental improvements made to the home. The home was found to be clean and tidy. EVIDENCE: During past inspections concerns have been raised by inspectors about the very poor state of the kitchen. In the last few months the kitchen has received a total refurbishment with new flooring, cupboards, work surfaces etc. The kitchen is now bright, modern and clean and the manager and staff stated that they were very pleased that this much-needed work had finally been completed. Another issue raised at the last inspection concerned the fire safety of one of the resident’s bedroom doors. This door has been checked by a fire safety officer and was found to be suitable. During the last random inspection some areas of the home were found to be not very clean. There were no concerns about the cleanliness of the home during this inspection, as it was found to be clean and tidy. The communal 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 17 lounge areas have also been brightened up. The only areas that require some attention are the bathrooms. They are old and in need of some refurbishment. Overall, the general environment was found to be comfortable and homely and was meeting the needs of the people that lived there. 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an experienced staff team who work well together. Staffing recruitment files contain all the required information and staff are receiving an adequate level of training. More staff need to be encouraged to obtain their NVQ qualifications. EVIDENCE: The current staff team who work at 19 Leicester Villas were found to be experienced and knowledgeable about their roles within the home. In the past the home has experienced quite a high turnover of staff, however for the past nine months the team has become more stable. All the staff who were spoken to on the day said they felt that the morale of the team had increased and the general atmosphere had improved and they all felt more confident in their work. They also felt that having a stable staff team had provided very positive outcomes for the people that lived there. From observing staff throughout the day it was apparent that they all got on well together and worked well as a team. Many of the staff have several years experience of working with people who have learning disabilities, however only one member of staff currently holds an 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 19 NVQ qualification. The manager stated that two staff members are now undertaking NVQ Level 2. The home currently employs six full time staff and one part-time staff member. Five staffing recruitment files were viewed and they were found to contain all the required information. None of the files contained application forms and this was discussed with the manager who stated that copies would to be obtained from Brighton & Hove Council and placed in each staff members file. Since coming into post nine months ago the manager has set up a training file for the staff and this was viewed. Records show that staff have attended various training courses such as positive behavioural support, autism, active support, food hygiene, fire safety, makaton signing and medication training. Staff who were spoken to also said that they received regular supervision sessions with the manager and that weekly staff meetings were held. 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being managed in a positive and proactive manner. There is a quality assurance system in place. There were no health and safety concerns identified during this visit. EVIDENCE: The new registered manager has now been in post for nine moths and during that time he has made some very positive changes to the way the home is run. He has twenty-one years experience of working with people who have learning disabilities and he holds a RGN (Registered General Nurse) qualification plus a RNMH (Registered Nurse Learning Disabilities) and he has completed diplomas in nursing and management. He has also recently attended a Protection of Vulnerable Adults training workshop for managers. Staff were asked about how they felt the home was being managed and they all responded very positively 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 21 stating that it was being well run and that the manager was very positive and very supportive. Generally staff thought that the home was taking a much more holistic and positive approach in the way that care was being delivered. The home has a quality assurance system that includes seeking feedback from families and friends of the people that live there. Surveys have been sent out to family members. The home also completes a quality assurance return each month for Brighton & Hove Council and this involves checking that performance indicators are being met. Regulation 26 visits are also carried out monthly and these reports have been sent to the CSCI. The information gained from these Regulation 26 visits has clearly indicated how improvements are being made in the home. The inspector recommended that the home should also try to gain feedback from visiting professionals who come into the home such as GP’s and therapists. A thorough health and safety check was made during this inspection as in the past there have been a number of identified issues, which have required attention. A walk around the home indicated that there were no immediate concerns. Door guards have been installed on most internal doors. The home maintains an accident book and this was viewed. Fire drills are carried out three monthly and an emergency evacuation plan has been produced. Emergency lighting and alarms are checked regularly. Three staff members hold full first aid certificates. The manager has trained all staff in infection control and most staff have attended training in manual handling and food hygiene. On two occasions a requirement has been made for the home to produce a fire risk assessment and this has now finally been carried out. 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA32 Regulation 18(1)(a) Requirement That 50 of staff hold an NVQ qualification. Timescale for action 27/05/08 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 YA39 YA24 Good Practice Recommendations It is recommended that the quality assurance tool be expanded to include the views of visiting professionals. It is recommended that the home look into refurbishing the communal bathrooms. 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI 19 Leicester Villas DS0000031913.V333230.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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