Inspection on 23/05/07 for Ascot Villa

This inspection was carried out on 23rd May 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ascot Villa 20/09/06

Ascot Villa 05/01/06

Ascot Villa 18/07/05

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 West Midlands B13 9EN Lead Inspector Sarah Bennett Unannounced Inspection 23rd May 2007 11:05 Ascot Villa DS0000017109.V335257.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 Ascot Villa DS0000017109.V335257.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. Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ascot Villa Address 13 Ascot Road Moseley Birmingham West Midlands B13 9EN 0121 449 9845 0121 247 8760 lornastreasure@yahoo.co.uk 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) Dr Kandiah Somasundara Rajah Vacant post (Afia Walker – Acting Manager) Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2006 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 of which has an en suite, 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 small room 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. The CSCI inspection report is available in the home for anyone who wishes to read it. The fees charged per week range from £1550 - £1948.50 as stated in the pre-inspection questionnaire. Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a completed pre – inspection questionnaire. One inspector carried out the unannounced fieldwork visit over one day. This was the homes key inspection for the inspection year 2007 to 2008. The staff on duty and the Acting Manager were spoken to. The inspector met with both of the people living in the home and time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. What the service does well: What has improved since the last inspection? Staff have had training in physical intervention so they and the people living there can be safe if someone is behaving in a way that they or others can get hurt. Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 6 All staff have had training in how to prevent abuse so that they know how to keep the people living in the home safe. A fly screen had been fitted to the kitchen window as recommended by the Environmental Health Officer to make sure the kitchen is kept clean. The valves on the taps had been adjusted to make sure that the temperature of the water is not too hot or cold. A Manager has been recruited who has the experience of working with people who have Autism Spectrum Disorders and of supervising staff. They will be able to support the staff to meet the needs of the 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. The summary of this inspection report can be made available in other formats on request. Ascot Villa DS0000017109.V335257.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 Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home or choosing whether or not to live there have the information so they know what the home provides and how their needs can be met there. Each person has an individual contract so they know the terms and conditions of their stay at the home. EVIDENCE: Records of the people living in the home included a service users guide to the home. This included the relevant and required information so that people living there or choosing whether or not to live there know what the home provides. It had been updated when there had been a change of staff. There was a vacancy for one person and no people had been admitted since the last inspection. Therefore, the standard relating to assessment was not assessed at this inspection. Records sampled included a contract between the person and the home. This stated the terms and conditions of the person’s stay at the home and the fees Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 9 that they were charged. It had been signed by the person to state that they agreed with the terms and conditions. Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 10 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, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have the information they need so they know how to support individuals to meet their needs and achieve their goals. People living in the home are supported to make decisions and choices about their day-to-lives. People are supported to take risks within a risk assessment framework so ensuring their safety and well being. EVIDENCE: The Manager has devised a new care plan and assessment tool, which included a detailed assessment of the persons needs, their skills and includes their individual behaviours. They plan to use this to improve the tool already in place. Records of the people living in the home included an individual care plan. These were not that detailed but included enough information for staff on the support the person requires. The new care plan template would be more Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 11 detailed so that staff have further and clearer information on how to support each person to meet their needs and achieve their goals. The Manager said that the people living in the home choose not to have meetings, as due to their previous experiences of meetings when they may have been experiencing ill health they feel threatened by the term meeting. They do have informal discussions about the things they want to do, choosing furniture and the decoration for the home and what they want to eat and these are documented. Records included individual risk assessments for each person. These stated how staff are to support each person to reduce the risks of there being a fire, when using gym equipment, when taking their medication, the risks of some of the behaviours they display or have displayed in the past, being exploited by other people, staying out all night, over eating and going out on their own. All risk assessments had been regularly reviewed and updated where necessary where there had been changes in the person’s needs or their behaviour. The daily records of one person said that they had been out two days before without informing staff and when they came back they said they had been asking strangers for money. The Manager said that a risk assessment for this behaviour, which the person had not displayed before was being developed. Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 12 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, 14, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that people living in the home experience a meaningful lifestyle. People are offered a healthy diet and they choose what they eat. EVIDENCE: Records sampled of the people who live in the home showed that people go to local shops to buy magazines, go to buy takeaways and go shopping for food. One person went out shopping with a member of staff for food in the morning and also went to the barbers to get their haircut. Both people walked to Kings Heath and back with two members of staff in the afternoon and went to a café for a drink. Some records sampled stated that staff had asked people if they wanted to go out but they had refused and chose to stay in bed instead. Records sampled stated that the people living in the home help to prepare meals, wash up, do their laundry and clean their bedrooms so increasing their Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 13 independence skills. Some records stated that people spent time chatting to staff so encouraging their social skills and giving them an opportunity to make choices and talk about how they are. Records showed that the people living in the home are supported to celebrate their birthday in the way that they choose to and with the people that they want to. Records showed that people are supported to maintain contacts with their family and friends through telephone calls, visits to the home and visits to their homes. One person said and records showed that they had requested to have some culturally appropriate food and this is now being provided and the person is helping to prepare this. Food records and menus sampled showed that a varied and nutritious diet is offered that is appropriate to the cultural background of the people living there. They included the recommended five portions of fruit and vegetables each day. One person went shopping with a member of staff and bought a variety of fresh fruits. The fridge/freezer was well stocked. Shopping is done daily so that people living in the home have an opportunity to go and choose the food they want but there were supplies of basic food stuffs so a meal could be provided if for any reason they did not get out shopping. Ascot Villa DS0000017109.V335257.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are sufficient to ensure that the health and personal care needs of the people living in the home. The management of the medication protects the people living there so ensuring their well being. EVIDENCE: People living in the home were dressed appropriately to their age, gender, the weather and the activities they were doing. One person went to barbers in the morning with a member of staff to get their haircut. Staff praised them for doing this and told them how nice it looked so helping to raise their self esteem. Each person had a health action plan that was produced using pictures so making it easier to understand. A health action plan is a personal plan about what a person needs to stay healthy and what healthcare services they need to access. The plan included how staff are to support them to meet their health needs and included a section on sexuality. This showed that discussion around this had taken place with the person, indicating that the holistic needs of the Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 15 people living in the home are met. The Dietician had been involved with one person to help them to lose weight. They had stated what their target weight should be, although they had not yet achieved this records showed that they were supported to follow the advice of the Dietician. Staff had regularly monitored the person’s weight. Records showed that the people living in the home had their medication regularly reviewed and they had regular health check ups. Staff support people to manage their own medication as much as they are able to. One person orders their own repeat prescriptions. Both people administer their own medication with staff support so encouraging them to be as independent as possible. The medication is stored in a locked cabinet, as it had been assessed that it is not safe for people to store their own medication. Each person had a list of homely remedies that they can safely take with their prescribed medication if for example they have a cold or are in pain. The Deputy Manager, the pharmacist and the GP had signed these. Lloyds Pharmacy supplies the medication in blister packs. They do regular audits to ensure that medication is being given to people as it is prescribed so ensuring their well being. Medication Administration Records (MARS) had been signed appropriately indicating that medication had been given as it is prescribed for the person. Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that people living in the home feel their views are listened to and acted on. Arrangements are generally sufficient to ensure that people living in the home are protected from abuse, neglect and self-harm. EVIDENCE: There is a complaints procedure that makes it clear how people can make a complaint about the home. The pre-inspection questionnaire stated that there had been no complaints received by the home. Since the last inspection there had been one complaint received by the CSCI regarding the restraint of one of the people living there by staff in February 2007. This was investigated by the CSCI at the time the complaint was made. This found that the restraint was necessary due to the person putting themselves and others at risk of harm. Staff had used the physical intervention techniques they had learnt on training by a training company that had been accredited by the British Institute of Learning Disabilities (BILD). Staff received foundation training in managing challenging behaviour using de-escalation techniques with physical intervention as a last resort in October 2006. The trainer recommended that staff receive further training because of the needs of the people living in the home. Staff had this training in April 2007. Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 17 An inventory of one person’s belongings was in place so it was clear what the person owned so if anything was to go missing it would be easier to identify when they last had it. The person had refused to sign it. One person handles their own money and goes to pay their own rent. The Manager said that a relative of the other person looks after their money on their behalf. Individual behaviour management guidelines stating how staff are to support the person to manage their behaviour appropriately reducing risks to themselves and others were in place. These had not been reviewed for nearly two years. They need to be reviewed as records showed that for one of the people some of their behaviours had changed since then. The Manager said that they are going to put a physical intervention record in place. A policy with guidelines on physical intervention was seen that was in line with the Department of Health (DOH) guidelines on physical intervention for people with a learning disability. All staff had training in adult protection and the prevention of abuse in 2006 so they know what to do if there is an allegation of abuse and how to stop abuse happening. Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 18 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, 27, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, comfortable and safe for the people who live there. EVIDENCE: Space in the home is limited. Each person has their own bedroom; the vacant bedroom also has an en suite shower and WC. There is also a small bathroom, small kitchen, small laundry and a lounge/dining room. The home was well decorated and furnished in a contemporary style reflecting the age of the people that lived there. Staff said that new sofas were to be delivered the next day and the people living in the home had chosen these. So the sofas can be brought in, as space in the hallway is limited the lounge window has to be taken out. The window frame is worn and in need of repair so this and other window frames are to be Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 19 replaced. A new TV cabinet had also been ordered, which one of the people living in the home had chosen. The garden was well maintained and staff said that the gardener had recently cut the grass. Staff said that the people living in the home enjoy spending time sitting in the garden. There was hand wash and hand towels provided in the bathroom so minimising the risk of cross infection. The home was clean and free from offensive odours throughout. Since the last inspection a fly screen had been fitted in the kitchen, as recommended by the Environmental Health Officer to prevent the risk of infection or contamination of food. Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 20 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, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements for staffing, their support and development are generally sufficient to ensure that individual’s needs are met. The recruitment practices are not sufficient to ensure that suitable people are employed and the people living in the home are protected. EVIDENCE: The majority of staff have NVQ level 2 or above in Care. Two staff are currently undertaking NVQ 2. This exceeds the standard that at least 50 of staff achieve this qualification so ensuring that staff have the skills and knowledge to meet individual’s needs. One member of staff has started doing NVQ level 3 and another is doing NVQ level 4. Since the last inspection two male staff had been employed. The people living in the home are men so this means that the gender of the people is better reflected in the staff team. Staff meeting minutes showed that there had been four meetings in the last year. There should be at least six staff meetings each year so that staff know Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 21 how to meet individual needs and are aware of any changes going on in the home. Staff said that another meeting is due soon as they were aware that there had not been sufficient meetings. There were no staffing vacancies. The pre-inspection questionnaire stated that one member of staff had left since the last inspection for personal reasons. However, they now work bank shifts at the home as and when needed to cover sickness or holidays. Two records of staff were sampled. These included a photograph of the person, the required recruitment records and evidence that a Criminal Records Bureau (CRB) check had been undertaken so that suitable people are working there. However, for each of the two members of staff their second reference was not from the person they had stated on their application form but from a friend or relative. The Manager had only recently started working at the home so was not sure why the references had not been sought from the previous employers. The reasons for this need to be explored so that suitable references are provided to ensure that suitable people are employed. The pre-inspection questionnaire stated that one member of staff had their CRB in June 2003. CRB’s need to be reapplied for after three years to ensure that people are still suitable to be employed. Staff training records sampled showed that staff had undertaken accredited training in the ‘Safe handling of Medicines,’ Physical Intervention, Adult Protection and the Prevention of Abuse and Fire Safety. New staff had completed an induction when they first started working at the home so they were informed how to support the people living there to meet their needs. The Manager and Deputy Manager are booked to do training in the Mental Capacity Act in June 2007 so they will have knowledge of how this will impact on the people living in the home. The Manager is going to do a six - day course on autism in Lancaster starting in September to ensure she has updated knowledge to meet the needs of the people living in the home. The Manager said that she is arranging further training in managing challenging behaviour for all staff to attend as she had identified that staff need further training in this because of the needs of the people living there. For one member of staff their records showed that they had regular formal, recorded supervision sessions. Records of these showed that their performance was monitored and had improved so that the needs of the people living in the home are met. The other records sampled showed that the member of staff had only received one supervision session when they first started working at the home over six months ago. Staff should have at least six formal, recorded supervision sessions each year so that they know how to support the people living in the home and their training and development needs are identified. Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements ensure that the people living in the home benefit from a well run home. Arrangements are in place so that the people living there are confident that their views underpin all self-monitoring, review and development by the home. Arrangements are sufficient to ensure that the health, safety and welfare of the people living in the home is promoted and protected. EVIDENCE: The previous Acting Manager did not feel they could take on the Registered Manager post so they are now Deputy Manager of the other home operated by the same Provider. There is also a Deputy Manager in this home. A new Manager had been in post since 1st May 2007 and has started their Registered Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 23 Managers Award. They have several years experience in a supervisory position in a variety of care settings including working with people who have Autism Spectrum Disorders (ASD). They are going to apply to the CSCI to be the Registered Manager for this home and another operated by the same Provider in the same road. There is a Deputy Manager in post in each of the homes. The Manager demonstrated a good understanding of Quality Assurance. She talked about auditing all areas of the home, it’s systems and records to see how things are working, are they effective and if not how can they be changed to improve the service. She was aware that audits needed to be analysed to provide feedback and implement new systems where necessary. A consultant employed by the Provider visits the home monthly to undertake an audit as required under Regulation 26 to ensure the home is meeting the required standards. This includes seeking the views of the people living in the home. The Manager had put in place a new checklist for testing the fire equipment. These included what needed to be checked daily, weekly, monthly, three monthly and annually. These were in line with the Government guidelines on fire safety risk assessment for care homes. The Manager said that these would be linked to the Quality Assurance system. Records showed that an engineer had recently serviced the fire alarm to ensure it was maintained and would work if there were a fire. An electrician completed the five – yearly test of the electrical wiring certificate in November 2002 and stated that it was in a satisfactory condition. The Manager was aware and it was stated in the pre-inspection questionnaire that this would need doing again this year to ensure the wiring remains in a satisfactory condition. The home has a minibus for which valid insurance and a MOT was seen. Staff test the water temperatures weekly to make sure they are not too hot or cold for the people who live there. Records showed that these were maintained within safe limits. Staff test the fridge and freezer temperatures three times a day to ensure that food is stored safely. Records showed that the freezer temperatures were within safe limits. The temperature of the fridge was a little warmer than it should be and was between 6 to 8 degrees centigrade. The recommended safe temperature is 0-5 degrees centigrade. The Manager said that she would ensure that this was adjusted. Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 24 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 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 2 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 25 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 YA34 Regulation 19 (1) c Requirement Timescale for action 30/06/07 2. YA34 13 (6) Appropriate references must be sought for all staff to ensure they are suitable to be employed to work with the people living there. A further Criminal Records 31/07/07 Bureau (CRB) check must be undertaken for all staff after three years of their previous check. This is to ensure that staff remain suitable to be employed to ensure the safety of people living in the home. 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 YA23 Good Practice Recommendations Individual behaviour management guidelines should be reviewed so that where a person’s behaviours have changed they can be supported to manage them safely. There should be at least six staff meetings per year so that staff know how to meet the needs of the people living DS0000017109.V335257.R01.S.doc Version 5.2 Page 26 2. YA33 Ascot Villa 3. YA36 there and are kept up to date with any changes. All staff should receive at least six formal, recorded supervision sessions each year so that their performance is monitored and their training and development needs are identified. This will ensure that they are able to meet the needs of the people living in the home. Ascot Villa DS0000017109.V335257.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Ascot Villa DS0000017109.V335257.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. 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!