Inspection on 15/05/06 for Coldwell Villa

This inspection was carried out on 15th May 2006.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coldwell Villa 21/05/07

Coldwell Villa 18/05/05

Coldwell Villa 27/07/04

Coldwell Villa 04/05/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 71 Mersea Road Coldwell Villa Colchester Essex CO2 7QR Lead Inspector Ray Burwood Key Unannounced Inspection 15th May 2006 09:30 71 Mersea Road DS0000017742.V298748.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 71 Mersea Road DS0000017742.V298748.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. 71 Mersea Road DS0000017742.V298748.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 71 Mersea Road Address Coldwell Villa Colchester Essex CO2 7QR 01206 547588 N/A 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) The Essex Autistic Society Manager post vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 71 Mersea Road DS0000017742.V298748.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 5 persons) 23rd August 2005 Date of last inspection Brief Description of the Service: The home is owned and managed by the Essex Autistic Society (EAS). The home provides accommodation and care for up to 5 adults with learning disabilities. The property is located within walking distance of Colchester town centre, pubs, a post office, public transport and other amenities. The home was opened in 1994 and is a two storey family-sized house. The accommodation is domestic in style and scale. All five bedrooms are single with each bedroom having a wash hand basin. Toilets and bathrooms are shared. A small, well maintained garden is to the rear of the property, with garden furniture and a small pond. The range of monthly fees supplied to the Commission for Social Care Inspection (CSCI) on the 15th May 2006 and charged by the Society is currently between £1,035.60 and £1,201.78. There are additional charges for activities during the evenings and weekends. Individual service users meet all personal clothing, and items such as magazines and haircuts. Holidays for service users are staffed accordingly with appropriate ratios. Staffing, transport, and food expenditure between 9.00am and 5.00pm are met by the Society. Information about the service, including inspection reports, are made available to prospective service users through a pack containing information about all of the services provided by the Society, the Statement of Purpose, a current Newsletter, and literature regarding the Societies Jigsaw Study Centre. 71 Mersea Road DS0000017742.V298748.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was undertaken on the 15th May 2006 with the assistance of the Acting Manager, service users and staff. The site visit was carried out between the hours of 11.00am and 4.00pm. A tour of the premises, examination of service users’ and staff files was undertaken as part of the site visit. Also, a range of information from the preprepared inspection record contributed to the overall report. A total of 24 standards were inspected with twenty-two being met. Discussions with service users were undertaken during the site visit together with observations of service user’s engaged in household routines and activities. All service users were able to communicate well and explained their experiences as good, both in the home and in the community. Since the home’s last inspection, the Acting Manager had applied to the Commission for Social Care Inspection (CSCI) to become the Registered Manager of “Coldwell Villa” and another small home close by. The home currently has one vacancy due to the transfer of one service user to another home within the Essex Autistic Society. What the service does well: The service provides a committed key-work system and a good communication network with other professionals. Service users are supported well by the home in accessing a wide rage of activities and hobbies. Appropriate activities are identified for one service user who is less able to participate in educational activities. All of the service users spoken with during the site visit were complimentary about living in the home and the support given to them by the staff. 71 Mersea Road DS0000017742.V298748.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. 71 Mersea Road DS0000017742.V298748.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 71 Mersea Road DS0000017742.V298748.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home has appropriate transitional and admission arrangements which clearly link service user’ needs and wishes to the service provided. EVIDENCE: Because of the length of time the current group of service users have been together at the home, original needs assessment documentation have been archived. The Society has commenced a programme of re-assessing all of the current service users in all of its homes who have been accommodated for many years, and whose needs and aspirations may have changed within that period. The assessment of individuals is extended to cover all aspects of their needs, and involves consultation with families, friends, agencies, and professionals involved in the lives of prospective service users. Documentation for assessing prospective service users are kept in the home with guidance contained in the Societies information manuals. 71 Mersea Road DS0000017742.V298748.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Care planning systems are clear and comprehensively detailed, ensuring that service users needs and wishes are met. EVIDENCE: Care plans sampled were well detailed with service user involvement in the care planning process. Plans outlined service users’ contact arrangements with friends and family, social, recreational, and educational preferences. Plans also contained management guidelines and appropriate risk assessments based on the initial assessment process and subsequent changing of individual needs. Care staff spoken with confirmed their awareness and understanding of care plans and their responsibilities associated with key-worker duties. Service users spoken with discussed their involvement in decision making within the home and the assistance of staff or advocates being available should they need it. 71 Mersea Road DS0000017742.V298748.R01.S.doc Version 5.2 Page 10 During the site visit the Acting Manager voiced her concerns about a service user who was placing himself at risk in the community through his association with people known to management and staff at the home. Discussion with the service user confirmed his involvement with the couple and the amount of time he spent with them. The acting Manager was advised to notify people with a professional interest and refer the case to the appropriate organisations for investigation. All of the current service user group manage their own financial affairs and have bank accounts. Service users’ meetings are now going ahead since the arrival of the Acting Manager with consultation and proposals regarding changes in the home discussed. Records seen of meetings indicated that they were service user led. One service user has requested more regular meetings now that there is a manager in the home. 71 Mersea Road DS0000017742.V298748.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Links with the community are good and support and enrich service users’ social and educational opportunities. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets their tastes and choices. EVIDENCE: Individual service users timetables were made available by the Acting Manager, which reflected a full programme of events for the week. On the day of the site visit the programme of activities confirmed the movements of service users and staff supporting them. Care plans sampled during the site visit contained evidence of activity planning and recording. This evidence included the likes and dislikes of service users. 71 Mersea Road DS0000017742.V298748.R01.S.doc Version 5.2 Page 12 Three of the service users living in the home attend the local educational college and the Essex Autistic Jigsaw Study Centre where they participate in the following classes: • • • • • Horticulture. Life skills. Music. Computing. Creativity Workshop. One service user, who does not access the local education college, attends the Essex Autistic Jigsaw Study Centre and appropriate social and leisure activities in the community. Overall, service users access a wide range of educational, social and leisure pursuits. One service user attends the local Buddhist centre for meditation classes and is about to commence employment one day a week at a shop in the town. Another service user attends a monthly social skills group in London. One service user is a member of a local music band. All service users spoken with were happy with the support given in accessing a wide range of opportunities individually or as a group. One service user whose hobby is antiques explained how he is supported by staff in visiting different antique centres. Family contact is maintained through visits from family members and relatives to the home. One service user spends the weekends with his family. Contact for other service users is maintained through telephone calls, e-mails, and correspondence. Two service users who do not have families have friends in the town and socialise with them. The home had an open door policy on visitors, with service users having the option of receiving visitors in their own room or in the home’s lounge area. The home operates a four weekly rotational menu that was seen to be varied and included alternatives. The main meal of the day was taken at night and flexible to meet service users needs associated with evening activities. The home had a rota system for service user to assist with the preparation and cooking of food. The Acting Manager was aware of the need to promote house rules and daily routines that recognise service users abilities and disabilities, ensuring that any changes are agreed with service users. Service users were observed to be involved in housekeeping duties and had access and freedom of movement in the home. Service users had keys to their bedrooms. All service users contributed to the site visit, explaining their experiences within the home and the community. 71 Mersea Road DS0000017742.V298748.R01.S.doc Version 5.2 Page 13 71 Mersea Road DS0000017742.V298748.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Evidence reflected that the health and emotional care needs of service users are managed effectively. EVIDENCE: Since the home’s last inspection one service users health and emotional needs had been assessed by professionals, including the Societies own Clinical Psychologist, and found to have deteriorated, culminating in a number of incidents that affected the running of the home and the anxieties of other service users. Another placement was highlighted within another Essex Autistic Society home with the move taking place before this site visit. The home currently has one vacancy. None of the service users at the home administer their own medication. Systems and appropriate training qualifications are in place to ensure the safe administration by staff. 71 Mersea Road DS0000017742.V298748.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home’s Complaint, Whistle Blowing and Adult Protection policies were adequate to help ensure service users were protected from abuse. However, unnecessary risks to the health and safety of service users should be identified and responded to. EVIDENCE: The home’s complaints policy and procedures were in place and included the stages and timescales relating to complaints. One service user spoken with said he would know how to make a complaint if it was necessary. During the site visit the Acting Manager outlined an ongoing complaint from a neighbour that involved a service user who has been found on their premises opposite the home on numerous occasions. The Acting Manager and the Director of Adult Services are currently addressing the complaint. The manager agreed to keep the Commission informed of any developments. As previously reported under Standard 9 the protection of a service user was discussed with the appropriate measures taken by the Acting Manager following the site visit. 71 Mersea Road DS0000017742.V298748.R01.S.doc Version 5.2 Page 16 Staff are undertaking refresher training associated with the de-escalation of incidents and restraint procedures. Staff spoken with indicated that the level of training they receive should take account of more serious incidents occurring. Some of the home’s staff had completed their Adult Protection training with the remainder of the team booked onto a training course in May 2006. 71 Mersea Road DS0000017742.V298748.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The standard of the environment within this home is good, providing service users with an attractive and homely place to live. EVIDENCE: The environmental standards of the home are good and provide service users with a homely, comfortable and safe place to live. The home offers access to local amenities and has a people carrier if service users wish to make use it. The premises are safe and accessible to all service users and meet the requirements of the local fire service and environmental health department. Laundry facilities are domestic in nature and are accessed by service users as part of their daily and independence programme. 71 Mersea Road DS0000017742.V298748.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34,35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service user’s benefit from a well qualified, competent, and supervised staff team. The home operates a robust recruitment process that helps to protect residents living in the home from abuse. EVIDENCE: The staffing situation in the home has changed since the last inspection with a new manager now in post. She has applied to the Commission for Social Care Inspection (CSCI) to become the Registered Manager of the home and also to manage another small home in the same area. One new member of staff has been employed recently making the number of full-time staff eight, plus the Acting Manager. Additional cover for sickness and annual leave is drawn from the Societies bank staff. The number of staff hours provided for the home is in excess of the hours required using the Residential Forum guidance. 71 Mersea Road DS0000017742.V298748.R01.S.doc Version 5.2 Page 19 The home currently has three staff members who have a National Vocational Qualification (NVQ) Level 2 or above. This represents 37.5 of the total staff team. A further three members of staff have completed modules from the Learning Disability Award Framework (LDAF) and are working towards completing the Foundation Course. All staff had completed their induction training, or in the case of new staff, are undertaking the course. Three staff files were sampled, including the new member of staff, in respect of the home’s recruitment process. All three files examined were seen to include the documentary evidence required under Regulations. Discussions with the Acting Manager and staff, together with records seen, indicated that supervision of staff is taking place for all staff by the Acting Manager. Records were also in place for projected supervision sessions throughout 2006/7. The Acting Manager was advised to ensure that staff carrying out supervision should be suitably trained. 71 Mersea Road DS0000017742.V298748.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The Acting Manager is well supported by the senior staff in providing clear leadership throughout the home, ensuring the health and safety of service users, staff, and visitors to the home. EVIDENCE: The Acting Manager of the home, who has applied to the Commission for Social Care Inspection to become the Registered Manager of Coldwell Villa and another small home close by, has many years experience of working with people with autism. Her experiences includes a care background and more recently as a manager for the Essex Autistic Society. Discussions with staff during the site visit regarding the management and changes to the service were positive, with staff feeling very supported. 71 Mersea Road DS0000017742.V298748.R01.S.doc Version 5.2 Page 21 Management training has been highlighted for the Acting Manager to commence as soon as a provider becomes available, possibly later in 2006. The homes quality assurance report is contained in the organisations Quality Assurance Audit and Report undertaken by “Autism Accreditation” on behalf of the Essex Autistic Society. Although grouped with other homes, the report is specific to Coldwell Villa. Further development in the Quality Assurance system is outlined in the homes recent Action Plan, and includes confidential questionnaires to parents, and meetings with parents and advocates. Quality assurance survey forms are in place in Widget format for all service users to complete Surveys and questionnaires to other interested parties and stakeholders are sent out from Central Administration, with the results contained in the above report. The Acting Manager was advised to look at carrying out surveys amongst other professionals and stakeholders who support the home, and who may not be known to Central Administration personnel. Maintenance and associated records/checks evidenced through the site visit and pre-inspection questionnaire. There were no concerns or health and safety issues presenting in the period between the last inspection and the site visit. Monthly visits to the home by the Adult Services personnel, confirmed that there were no current health and safety concerns. 71 Mersea Road DS0000017742.V298748.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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 X 34 3 35 3 36 3 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 2 X 3 X X 3 X 71 Mersea Road DS0000017742.V298748.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 YA23YA23 Regulation 13 (4)(c) Requirement The registered person must ensure that any unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. The registered person must ensure that the manager of the home has the appropriate qualifications to manage the home or has commenced the training within the timescale for action. Timescale for action 31/07/06 2 YA37YA37 9 (2)(b) 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA32YA32 Good Practice Recommendations The registered person should ensure that the appropriate number of staff (50 ) achieve National Vocational Qualification (NVQ) Level 2 or equivalent. 71 Mersea Road DS0000017742.V298748.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 71 Mersea Road DS0000017742.V298748.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!