Inspection on 18/07/05 for Ascot Villa

This inspection was carried out on 18th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Ascot Villa 23/05/07

Ascot Villa 20/09/06

Ascot Villa 05/01/06

Ascot Villa 27/01/05

Ascot Villa 23/06/04

Ascot Villa 13/01/04

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

CARE HOME ADULTS 18-65 Ascot Villa 13 Ascot Road Moseley Birmingham B13 9EN Lead Inspector Sarah Bennett Un announced 18th July 2005 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 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 Stationary 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. Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ascot Villa Address 13 Ascot Road, Moseley , Birmingham B13 9EN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 449 9845 Dr Kandiah Somasundara Rajah Vacant Care Home 3 Category(ies) of Learning Disability (3) registration, with number of places Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th January 2005 Brief Description of the Service: Ascot Villa is situated on the ground floor of a three storey Victorian house in a quiet cul-de-sac in Moseley. The upper floors of the property are let to private tenants. There are three single bedrooms, one lounge/dining room and a small kitchen. There is one bathroom with a WC, bath and overhead shower. There is an office. The laundry is situated within a cupboard off the lounge. To the rear of the property there is a large garden. The home provides care and accommodation to three adults who have a learning disability, autism spectrum disorders and challenging behaviour. Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over four and a half hours. Care, staff and health and safety records were looked at. One resident’s records were sampled. A tour of the premises took place. Two residents and three of the staff on duty including the acting manager were spoken to. What the service does well: What has improved since the last inspection? Regular fire drills take place and staff test the fire equipment regularly. The broken lock has been replaced on one of the resident’s bedroom door. Residents care plans state how staff are to support them to meet their needs and achieve their goals. There are regular residents meetings where residents can say what they want to do, what they think about the home and what they want to change. A wider range of leisure activities is being provided for residents to take part in. A new medication cabinet that is easier for staff to access has been provided. Staff have completed the accredited ‘Safe Handling of Medicines’ course so that they know how to give medication correctly and what different medicines are given for. Staff have had training in autism so that they are more able to understand the needs of residents and how to support them. Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 Page 6 All staff have regular supervision sessions with their line manager so that they are clear about their job role and how to support individual residents. 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. Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 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 standard(s) 1, 5 Prospective residents do not have all the information they need to make an informed choice about where to live. Residents have an individual contract that states the terms and conditions of their stay at the home. EVIDENCE: The statement of purpose of the home needed some amendments to the age range of the residents and to the complaints policy. These were amended during the inspection and it now contains all the required and relevant information. The service users guide does not include all the required and relevant information. Staff said that it is in the process of being updated. Residents records sampled included an individual contract. This stated the terms and conditions of their stay at the home and the fees charged. Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 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 standard(s) 6, 8, 9 Residents assessed needs and goals are reflected in their individual care plan so that staff know how to support each individual. Residents are consulted on all aspects of life in the home. Arrangements for ensuring that residents are supported to take risks within a risk assessment framework are not adequate. EVIDENCE: Care plans sampled indicated that the resident had been involved in developing their care plan. The care plan stated how staff are to support the resident to meet their health needs, administer their medication, develop their daily living skills, food to be provided, religious needs and social and leisure activities they choose to participate in. Minutes of residents meetings were seen. These showed that meetings take place regularly and residents say what they think about the home, staff and what activities they would like to be involved in. When residents refuse to have meetings this is recorded. Staff said that they have discussed with residents and sought their views on prospective residents. Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 Page 10 There have been some incidents in the local community where resident’s behaviour has been challenging. Staff have contacted the National Autistic Society and have obtained cards for each resident to carry with them. This explains to members of the public that the resident has autism. Knives were stored in the kitchen drawer. Staff said that knives are not a risk to leave lying around with the current residents. A risk assessment to ensure appropriate action is taken to minimise any risks was not in place. Records sampled included individual risk assessments for residents. These included how risks of going out on their own, shopping, crossing the roads, self-administering medication and behaviours are to be minimised. A risk assessment for the individual resident travelling in the car with staff was dated May 2003 and has not been reviewed since. Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 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 standard(s) 13, 14, 15, 17 Arrangements are in place so that people living at the home experience a meaningful lifestyle. Residents are not offered a healthy diet, which could compromise their wellbeing. EVIDENCE: Residents said that they were ok. Residents said that they are encouraged to look at college courses that might interest them. They were going to do some taster sessions at a local college in cooking, computers and communication skills. A car has been provided so that residents can access the local community. Staff said that this is soon to be replaced by a new minibus. Resident’s records indicated that residents visit their relatives where appropriate and their relatives are welcome to visit the home. Resident’s records indicated and residents said that they go to the post office, shopping for food supported by staff, shopping for personal items, restaurants, the gym and relaxation sessions. Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 Page 12 Records indicated and staff said that residents go to cinemas to watch films that are appropriate to their cultural background. Adequate food was available in the food cupboards, fridge and freezer. Fresh fruit was available. Records of food sampled indicated that residents are not being offered the recommended five portions of fresh fruit and vegetables each day. From nine days sampled there was only one day when five portions were provided. Records did not indicate when fresh fruit and vegetables had been offered but refused by residents. Records indicated that culturally appropriate foods are offered to individuals. Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 Residents receive appropriate personal support and their health needs are met. The arrangements for the management of the medication are adequate to ensure that residents are protected. EVIDENCE: A nurse from the local surgery visited to work with residents and staff on developing individual Health Action Plans. Residents are regularly weighed and a record of this is maintained. Health professionals are involved in the care of residents where appropriate including the GP, practice nurse, psychiatrist and community psychiatric nurse. Records sampled indicated that residents are encouraged to have regular check-ups with the dentist and optician. Where residents refuse to attend these appointments this is recorded. Medication is stored in a locked cabinet. At the front of resident’s medication administration record there is a photograph of each resident. A local chemist provides the medication to the home each week in a ‘Nomad’ pack. Medication administration records cross-referenced with the amount in each pack indicating that medication had been given as prescribed. Records had been signed for appropriately. Assessments are in place and staff were observed encouraging residents to administer their own medication. Copies of prescriptions are kept. Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 Page 14 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 standard(s) 22, 23 The arrangements for making complaints are adequate to ensure that resident’s views are listened to and acted on. Adequate arrangements are not in place to ensure that residents are always protected from abuse and self-harm. EVIDENCE: The complaints policy needed some amendments to ensure that residents are aware that they can contact the CSCI at any time to make a complaint and the telephone number of the CSCI had to be added. This was amended at the time of the inspection. There have been no complaints made about the home since the last inspection. Individual behaviour management strategies stating how staff support residents to manage their behaviour were not in place. A social worker had requested at a residents review that a report be made of the current behaviour management strategies used. Staff said this has not been done. Staff said that extra funding had been requested from Social Services for additional staffing to help the home in managing resident’s behaviour. The acting manager said it is difficult to write a strategy that all staff can use as the behaviour could vary depending on the gender of staff. This must be stated on the strategy and appropriate action taken to ensure that all staff manage residents behaviour appropriately. Discussion took place with the acting manager about appropriate techniques in line with current practice and guidelines about managing resident’s behaviour. The adult protection policy is in line with the Birmingham Multi-Agency Guidelines on the Protection of Vulnerable Adults and a copy of these is available. All staff have received training in adult protection and managing challenging behaviour. Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 Page 15 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 standard(s) 24, 26, 27, 28, 30 Residents live in a homely and clean environment. The limited space prevents it from being comfortable. Resident’s bedrooms suit their needs and lifestyles. EVIDENCE: Resident’s bedrooms were decorated to individual tastes and contained many personal possessions. Staff talked about the plans to extend the vacant bedroom into the sun lounge adjacent to it, which cannot be used as a communal area as you can see through the windows into the bedroom. An en suite facility will be provided. Plans are currently being approved by the City Council Planning Department. Communal areas were decorated to a good standard. Communal space in the home is limited. There is a lounge/dining room, a small kitchen and one bathroom with a WC, bath and overhead shower. To the rear of the home is a large garden that is fenced all round and has grassed areas, shrubs and trees. The laundry is housed in a small room off the lounge. There is a washing machine and tumble dryer. The home was clean and free from offensive odours. Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35, 36 A supported and supervised staff team support residents, which they benefit from. The home’s recruitment policies and practices protect residents. Staff receive appropriate training that enables them to meet individual residents needs. EVIDENCE: Rotas indicated that there are two staff on duty during the day and one waking night staff. The acting manager stated that there are no staff vacancies. Staff records sampled included a completed application form, two written references, proof of identity and a completed medical questionnaire indicating that they are fit to do the job they are employed for. Staff said they have received training in communication skills. The assistant manager said they have just finished their NVQ level 4 and another two members of staff have just started this. The acting manager has completed NVQ level 4. Staff records included completed induction checklist for each member of staff at the beginning of their employment at the home. Staff training records indicated that staff have received training in food hygiene, manual handling, health and safety, fire safety, first aid, infection control, challenging behaviour, Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 Page 17 autism, adult protection and epilepsy. All but one member of staff have completed the accredited ‘Safe handling of Medicines’ course. The acting manager, assistant manager and two staff are going to do a six day course starting in October on ‘Principles and Practice of Working with Individuals with Autism Spectrum Disorders’. The National Autistic Society and St Martins College provide the training. Staff records indicated that staff receive regular, formal, recorded supervision sessions with their line manager. These include discussing the needs and wishes of residents, the performance of individual members of staff and identifying training and development needs. Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Some further development is needed to ensure the health, safety and welfare of residents is promoted and protected. EVIDENCE: The owner has employed consultants to undertake the monthly owner visits. Staff said that the consultants have not yet visited the home. All the portable electrical appliances were tested in June 2005. Fire records indicated that staff regularly test the fire equipment to make sure it is working. An engineer serviced the fire alarm in March 2005. Regular fire drills have been recorded as taking place. Who was involved in the drill, how they reacted to the fire alarm sounding and how long it took to evacuate the building was not recorded. Staff training records showed that not all staff have received fire safety training every six months. Water temperatures are tested weekly and a record of this is kept. Records indicated that they are generally maintained at 43 degrees centigrade. A valid certificate of employers liability insurance was available in the home. Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 Page 19 An engineer tested the gas equipment in July 2004 and stated that it was in a satisfactory condition. The acting manager said this would be checked at the end of July 2005 as required. The accident book was seen and no accidents have been recorded since the last inspection. Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 2 2 x 3 Standard No 11 12 13 14 15 16 17 x x 3 3 3 x 2 Standard No 31 32 33 34 35 36 Score x x 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ascot Villa Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 Page 21 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 1 Regulation 5 (1) Requirement The service users guide must include all the information required in the Care Homes Regulations. A risk assessment for storing knives in the kitchen must be in place. All risk assessments must be regularly reviewed and updated as necessary. Residents must be offered the recommended five portions of fruit and vegetables each day. Behaviour management strategies must be in place for each resident. These must clearly state how individual behaviours are to be managed and what techniques staff are to use to de - escalate behaviours. They must be dated, signed, regularly reviewed and updated as necessary. All staff must receive training in fire safety every six months. Timescale for action 30th September 2005 Immediate & ongoing 31st August 2005 & ongoing Immediate & ongoing 31st August 2005 & ongoing 2. 3. 9 9 13 (4) (a, b, c) 13 (4) (a, b, c), HSWA 1992 12 (1) (a), 16 (2) (i) 12 (1) (a), 13 (4) ( c) (6) (7) 4. 5. 17 23 6. 42 13 (4) ( c), 23 (4) (a, d) 30th September 2005 & ongoing Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 Page 22 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 42 Good Practice Recommendations Records of fire drills should include who took part in the drill, how they reacted and the time taken to evacuate the building. Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Ascot Villa E54 S17109 AscotVilla V240386 180705 UI Stage 4.doc Version 1.40 Page 24 - 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. 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