Inspection on 11/04/07 for Almond Villas

This inspection was carried out on 11th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Almond Villas 13/02/09

Almond Villas 10/01/06

Almond Villas 02/08/05

Almond Villas 11/10/04

Almond Villas 27/04/04

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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 Almond Villas 3-5 Dukes Brow Blackburn Lancs BB2 6EX Lead Inspector Jane Craig Unannounced Inspection 11th April 2007 09:00 Almond Villas DS0000005803.V330591.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 Almond Villas DS0000005803.V330591.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. Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Almond Villas Address 3-5 Dukes Brow Blackburn Lancs BB2 6EX 01254 681243 01254 605038 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) Mrs Marilyn Clarke Mrs Marilyn Clarke Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2006 Brief Description of the Service: Almond Villas is one of a group of three care homes offering 24-hour accommodation, support and rehabilitation programmes for 14 adults with mental health needs. The registered provider and manager for the group is Mrs Marilyn Clarke. A team of managers, each with designated responsibilities, share the day to day management of the three houses. Accommodation at Almond Villas is provided in six self-contained flats. Four flats contain three single bedrooms with a shared lounge, kitchen and bathroom; the other two are single person flats. Communal areas, including a group/training room, counselling room/quiet lounge and laundry are housed in the basement. The offices and staff facilities are also on this floor. Almond Villas is a detached, converted property located in a residential area close to Blackburn town centre. There is a small patio/garden area at the front entrance. There is no parking at the house but street parking is available approximately 100 yards away. The main road into Blackburn, with a bus stop, shops and other amenities is within easy walking distance. Information about the home is given to prospective residents during their trial visits. Copies of Commission for Social Care Inspection reports are available on request. At 11th April 2007 the weekly fees ranged from £632.00 to £1,016.72. There were extra charges for personal toiletries, newspapers and magazines. Residents also made a contribution to activities not included on their programme. Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Almond Villas on the 11th April 2007. At the time of the visit there were 13 residents accommodated. The inspector met with most of the residents and talked to six about their experiences of living in the home. Some of their comments are included in this report. Three residents and five visitors/relatives returned comment cards before the inspection. The majority of their views about various aspects of the home were very positive. Discussions were held with the registered provider/manager and six other members of staff with various roles in the home. A tour of the premises took place and a number of documents and records were viewed. This report also includes information submitted by the home prior to the inspection visit. What the service does well: The process for assessing and admitting new residents was very thorough. This meant that prospective residents had enough information to help them decide whether Almond Villas was right for them and staff knew that they would be able to provide the right care. Residents were involved in planning their own care and drawing up their weekly programmes, which meant that they could make decisions about what care they received and what they did with their time. A resident commented that they felt that they were in control. Almond Villas provided a safe environment where residents were encouraged and supported to engage in rehabilitation programmes in preparation for independent living. One resident said, “staff know we all want a place of our own and they are helping us towards it.” Staff encouraged residents to be as independent as possible. If they were safe to do so residents went out on their own, otherwise staff went with them. They helped residents to form new friendships and to keep in touch with their family. Staff also gave practical help with transport arrangements for residents whose family lived out of the area. Staff made sure that residents had information about how to stay healthy. They helped residents to make and keep appointments with healthcare professionals. Where possible residents were supported to handle their own medication in preparation for independent living. Staff organised and managed medicines well. Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 6 None of the residents had any complaints about the home but all said they knew who to speak to if they did. They were confident that staff would be able to help them if they had any concerns. Residents and relatives said that staff had appropriate skills and experience to provide care. One resident said that staff, “know their jobs and really understand about all our problems,” another said, “staff are excellent, very professional.” The manager made sure that new staff had thorough checks before they started work at the home. This provided protection for residents. new staff went through a thorough induction training programme. Other staff also had good opportunities for training. This meant that the staff team were knowledgeable about the residents’ needs and the best way to support them. The registered person and the rest of the team responsible for managing the home were very experienced and well qualified. The staff and residents said the managers were knowledgeable, supportive and professional. Residents and staff were consulted about what they thought about the home. Any new ideas or suggestions for improvement were listened to and acted upon. When asked what they felt the home does well, four out of five relatives made very positive comments. One relative wrote, “the care home does everything well,” another wrote, “the needs of the residents are always put first.” What has improved since the last inspection? What they could do better: Staff should receive refresher training in all the health and safety topics in order to protect residents and themselves. None of the relatives who completed surveys had any suggestions for improvements. Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 7 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. Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 8 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 Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 9 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): 1 and 2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The admission process ensured that prospective residents had enough information to make a decision as to whether the home was suitable for their needs and staff had a clear understanding of the resident’s needs and how they were to be met. EVIDENCE: Residents were generally referred to Almond Villas several months before their discharge from hospital. During this time they were visited and assessed by a member of the management team. Assessment information was obtained from all appropriate sources and communicated to the staff team before the resident was admitted. The resident, their family and health care professionals were fully involved in the process. The prospective resident also had trial visits and short stays at the home. They were given a service user’s guide to back up verbal information given to them during the assessment process. There was also a welcome pack, put together by the service user’s forum, which included frequently asked questions and descriptions written by other service users about their experiences of living at Almond Villas. Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 10 Most residents were happy with the gradual admission process. One said that it helped him to get to know the routines and staff. Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 11 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning process enabled residents to be involved in setting their own goals and ensured that staff were provided with sufficient information to help residents to meet their needs. Residents were supported to maximise their independence by taking responsible risks and making decisions about their own lives. EVIDENCE: Care plans for two residents were looked at as part of the case tracking process. A new resident had drawn up his trial care plan with a senior member of staff and he was asked to check that it was right before it was shared with other staff. Residents said they could see their care plans at any time. One said, “Care planning meetings are very good – they help you look at what’s not right and how you can make it better.” A member of staff said they were thinking of starting a care planning group to help residents take ownership of their plans. Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 12 The second plan had also been drawn up with the resident and outlined their short and long term goals. Staff directions were clear and focused. Plans were reviewed and updated as and when any changes occurred and all residents had a formal, multi-disciplinary review at least every six months. Service users who completed surveys perceived that they did not always get to make decisions about what they did each day. Staff said that this was because they had an agreed weekly programme to follow in accordance with their rehabilitation programme. Another member of staff said that there were some minor restrictions for residents’ safety. Those residents spoken to said they were happy with the level of choice and decision making. One said, “I feel in control,” and another said, “They don’t act as if they are in charge of you.” A member of staff said, “They make decisions about everything. Everything is geared to their lives from how they want their room set out to activities, routines, and plans for the future.” All residents had a care plan to assist with decision-making. There was a policy on risk taking and risk management. All files contained risk assessments and detailed risk management strategies specific to the resident. Any limitations or restrictions were agreed by the resident, staff and other professionals involved in their care. Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 13 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 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents were supported by staff to engage in a lifestyle of their choosing, whilst working towards independent living. EVIDENCE: All residents drew up weekly plans with their key worker. The plans included one to one time, time spent on domestic tasks, a mix of therapeutic and recreational activities and leisure time. All but one of the residents said they enjoyed the activities. They gave examples of recent groups such as, health and safety, fire prevention, anger management, gym, football and badminton. One resident explained that they received certificates for some and said, “So if we go somewhere else we can show what we have done.” One member of staff said that most of the groups were recreational or educational so that when residents moved into a place of their own they would have some interests and abilities and wouldn’t end up isolated and staying in Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 14 bed all day. Another said that there was as broad a range of activities as possible so as to make everything accessible and no-one was excluded. Residents planned, shopped for and prepared their own meals as part of their rehabilitation programme. Residents were happy with the cooking and domestic arrangements. One said, “Even if you can’t cook you wouldn’t starve – they will help all you need.” Another said, “It’s the best way to work – staff know we all want a place of our own and they are helping us towards it.” One resident said they had done an NVQ 1 in cooking and were talking to their key worker about doing a level two. Residents said their rights were upheld. One said, “if you want privacy just go into the bedroom. No one disturbs you there. Staff knock if they want you.” They said staff were respectful and this was apparent in the way that staff spoke with and about residents. Residents who completed surveys said staff treated them well. Most relatives indicated that the service supported people to live the life they chose. One wrote, “the staff work very hard trying to ensure that residents have the best standard of life they can cope with. There was an open visiting policy. Residents were also supported to keep in touch with their family and friends. One said that staff helped him to work out buses so that he could go home regularly. Four out of five relatives indicated that the home helped the resident to keep in touch with them. One wrote that if they could not pick their relative up then the staff would give them a lift. They also indicated that they were kept up to date with important matters, although staff said that information would only be shared in accordance with the resident’s wishes. Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 15 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ personal and healthcare needs were clearly identified and met by staff, with support from the multi-disciplinary team. Staff handled and administered medication in accordance with robust policies and procedures. EVIDENCE: None of the residents required physical assistance with personal care. Some needed prompting and supervising to ensure that their personal care needs were met and care plans contained information about the type and level of support they needed. Residents received very good emotional health care. All plans took into account residents’ individual mental health needs and included triggers and signs of relapse and clear strategies for staff to support them through any changes. Residents had regular contact with other members of the multidisciplinary team and regular CPA reviews. The majority of relatives who completed surveys indicated that the home met the needs of their relatives. One wrote that they did this “extremely well.” Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 16 All residents had a care plan with regard to health care checks or monitoring of ongoing physical health needs. The records showed that any new healthcare needs were identified and addressed. A new resident was registered with a GP on the day of admission and part of their plan was for staff to assist them to identify other professionals such as a dentist and optician. Residents were happy with the support they received. One said, “Staff help with appointments and check ups which means I don’t have to worry about forgetting.” Another said, “staff prompt me – it takes the pressure off.” Staff said that residents were encouraged to take responsibility for their own health care when they were able to do so. There were several health information and promotion leaflets on display on the resident notice board and periodically staff facilitated groups to encourage a healthy lifestyle. There was a full set of medication policies and procedures. All residents had an individual medication procedure on their file, which outlined any special needs. Care plans contained a current list of medicines and information about effects and potential side effects for staff to monitor. There were records of homely remedy medication and medicines handed out to residents going on leave. Records of medicines received, administered and returned were complete. The systems to assist staff to audit the medicines not included in the monitored dose system were not clear and would require staff to look back to when the medication was initially dispensed. Residents were supported to self medicate in stages, which concluded with them storing and administering their own medication. As previously required there were records of risk assessments and random checks in place. Residents confirmed that staff, “Check periodically to make sure you are doing it right.” Medication was stored safely and access was restricted to staff who had received training in handling medication. Residents who administered their own medicines had lockable storage in their rooms. Residents who monitored their blood glucose levels had individual lancing devices. The manager was aware of the recent alert and had passed this information on to other staff. Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 17 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents knew how to make a complaint and were confident that their concerns would be dealt with appropriately. Staff had a thorough understanding of adult protection issues ensuring that any allegations would be investigated. EVIDENCE: There was a clear complaints procedure in the service user’s guide and on display on the residents’ notice board. There had been no complaints since the last inspection. All residents who completed surveys indicated they knew who to speak to if they were not happy and they knew how to make a complaint. Those spoken with during the visit all said they would be able to go to staff if they had any complaints and they all thought that staff would sort them out. Most of the relatives who completed surveys said they knew how to make a complaint and indicated that the service would respond appropriately if they were to raise concerns. One relative wrote, “There has not been any need to raise concerns, the care is so good.” Staff had access to written guidance about safeguarding adults. They received training during their induction and then attended the course run by the local authority. Training was updated every two years. Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 18 An allegation of financial coercion made by a service user against a member of staff was investigated in accordance with advice from the adult protection team. On investigation the resident involved could not remember making the allegation and categorically denied any abuse. Staff said they would report any suspected abuse straight away. They were aware off who to report to both internally and outside the home. One member of staff said, they would report to the manager or to CSCI if it was not acted upon. Another said, “bad practice wouldn’t be tolerated by the team.” Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents were satisfied with the environment, which suited their needs and lifestyle. The standard of cleanliness and hygiene was satisfactory. EVIDENCE: The plan for redecoration and refurbishment of the house continued. The latest plan included points for action and completion dates. All bedrooms and communal areas in some flats had been redecorated. Some new flooring had been laid and four shower rooms had been refurbished. Both staircases had been re-carpeted. Residents said the location and layout of the home suited them. One said they liked being in a flat, much better than just a bedroom. Comments about the environment ranged from “alright” to “really nice”. Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 20 There were some minor repairs outstanding. For example, a leak in the laundry had caused damage to the floor and there was an offensive odour in the room. There was a plan to renew the flooring in the next two weeks. The home was generally clean and tidy at the time of the inspection. Residents were responsible for domestic tasks in their own flats. Staff monitored the standard of cleanliness and provided support where necessary. Residents were satisfied with the level of domestic tasks expected of them as part of their rehabilitation programme. Residents who completed surveys indicated that the home was always or usually fresh and clean. Staff received infection control training within their induction programme and the aim was to provide update training annually. Residents covered infection control & universal precautions within a recent health and safety group. One resident had put information about handwashing on display in the flat as a reminder for his flatmates. Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 21 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 and 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Recruitment practices safeguarded residents. Residents were supported by a competent and qualified staff team in sufficient numbers to meet their individual needs. EVIDENCE: The duty roster showed that staffing levels were completely flexible to meet the needs of the residents. In addition to the core numbers, extra staff were rostered to provide supervision for one to one and group activities. Residents said they liked the key worker system that was in place. One of the management team took responsibility for staff training. Training needs were identified through a training needs analysis, supervision and appraisal. The induction training programme had been revised to meet the 12 week common induction standards. The training included discussions, self study and shadowing. Some aspects of the foundation programme were still in place in order to give new staff add-on training in certain topics, such as mental Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 22 health. New staff were mentored by their line manager and there was an assessment of competency at the end of the training. The content of the training exceeded the recommendations of the common induction standards. All staff received training in safe working practice topics during their induction. The aim was to provide update training annually at a level relevant to the member of staff. For example all lone workers had full first aid training whilst others had awareness. However, refresher training in moving and handling, infection control and food hygiene was not up to date for all staff. Staff said opportunities for training were very good. A number of other courses relevant to the resident group were available. For example, drugs awareness, and residential care and rehabilitation. A number of staff had recently attended a three day course on dual diagnosis which they all said was informative and useful to their day to day work. 54 of staff had achieved NVQ level 2. Residents made very positive comments about the staff. Their comments included, “staff are excellent, very professional,” “they all know their jobs – really understand about all our problems” and “very respectful.” The majority of relatives indicated that staff had the right skills and experience to look after people properly. Their comments were also complimentary. One wrote that staff did, “far, far more than the normal requirements,” and another stated, “staff are employed who want vulnerable people to have a better life and they work very hard at this.” There was a low turnover over staff and no agency use. The files of two new employees showed that all pre-employment checks were carried out. Staff commenced their induction programme but were not able to work without supervision until their full CRB disclosure had been returned. This was recorded on staff files. All the required information and documents were present. Residents who were involved in the service user forum (a group of resident representatives) had input into the recruitment of new staff, either by formal or informal interview. Staff received group supervision approximately every month. They said they found the group very useful because it increased discussion and gave more opportunities for sharing ideas. Staff also had the option to request one to one supervision at any time. Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 23 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 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from a safe and well managed home. There was a high level of consultation which enabled residents, staff and other stakeholders to contribute to service development. EVIDENCE: The registered person managed the home on a day to day basis. A management team, who each took responsibility for a different area of the service, supported her. In addition to holding three nursing registrations, the registered person was qualified to NVQ level 5 in management. She also held qualifications in therapy and counselling and undertook short courses to keep her clinical and managerial skills up to date. Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 24 The rest of the management team were also appropriately qualified and experienced. The registered person and the management team were fully conversant with their roles and responsibilities. They took a proactive approach to ensure that the service continued to develop and evolve. Staff said the home was very well run. One member of staff said that the operational manager was one of the best managers he had ever had, that she was always accommodating and had time for everyone. Residents confirmed that the management team were very efficient and approachable. There were excellent quality monitoring systems in place. The home held three external awards for quality, one of which judged the service as excellent. The groups of homes had also been given an award by their employment consultants for being employers of excellence. Annual surveys were sent out to residents, relatives, staff, and referrers. Residents could also complete a questionnaire relating to their admission experience. Results of surveys were evaluated and action plans drawn up to address any shortfalls. Surveys seen at the time of the inspection were all very positive. Residents also had opportunities to make their views known during the weekly house meetings or in their one to one sessions. One resident said that staff were, “Always asking if everything is ok and if anything could be better.” There were team meetings every week. Staff said they were able to discuss ideas and make suggestions for change. One said, “You can get ideas into practice quite quickly.” There were also several internal systems for monitoring the quality of the service, including audits of systems and records. The service had an identified health and safety manager who liaised with external health and safety consultants. There was a full set of policies and guidelines available to staff. Servicing and testing of the fire system, equipment and alarms was up to date. All staff and residents had received fire safety training and been involved in practice drills. Residents had also been involved in a recent health and safety group. Certificates were available to evidence maintenance of installations and equipment in the home. There were risk assessments to cover all aspects of the environment and safe working practices. Open storage of potentially hazardous items was reassessed when a new resident was admitted or when there were any changes to a resident’s individual risk assessment for selfharm. Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 25 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 3 2 4 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 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 4 33 34 35 36 3 4 X 3 X LIFESTYLES Standard No Score 11 12 13 14 15 16 17 X 4 4 X 3 4 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 DS0000005803.V330591.R01.S.doc Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Almond Villas Score 3 4 3 X 4 X 4 X X 3 X Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 YA20 Good Practice Recommendations The registered person should review the systems for recording medication carried over from the previous month to ensure that there is a clear and simple audit trail. The programme to update awareness training in moving and handling, infection control and food hygiene should be completed. 2. YA35 Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Almond Villas DS0000005803.V330591.R01.S.doc Version 5.2 Page 28 - 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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