Inspection on 05/01/06 for Ascot Villa

This inspection was carried out on 5th January 2006.

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 found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ascot Villa 23/05/07

Ascot Villa 20/09/06

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 5th January 2006 01:15 Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 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.V277102.R01.S.doc Version 5.1 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.V277102.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ascot Villa Address 13 Ascot Road Moseley Birmingham West Midlands B13 9EN 0121 449 9845 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 James White Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the manager undertakes appropriate training in Autism and forwards confirmation of completion to the Commission no later than December 2005 18th July 2005 Date of last inspection 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. Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was conducted by one Inspector over four hours. This was the second of the statutory inspections for this home for 2005/2006 and not all of the National Minimum Standards were assessed. To get a full picture of the home it is advised to read this report in conjunction with the report from July 2005. At this inspection time was spent observing interactions and support from staff. A tour of the home was made. Service users records, risk assessments and a number of Health and Safety records were inspected. The Inspector had the opportunity to talk with service users, members of staff and the Business Manager. What the service does well: What has improved since the last inspection? The service users guide has been updated to include all the necessary information so that prospective service users can make an informed choice about whether or not they want to live at the home. Risk assessments have been reviewed and updated so that staff know how to make sure that all the risks to service users are minimised. There was evidence that more fresh fruit and vegetables are being offered to service users so their diet is healthier. All staff and service users have had fire safety training so they know what to do if there is a fire. They also know ways to prevent a fire from starting. Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 Page 6 Behaviour management guidelines for service users are available so that all staff know how to respond to service users behaviour in the same way. This avoids confusion for the service user. The vacant bedroom has been refurbished and an en suite shower and toilet provided. This will give more privacy for the service user who lives in this bedroom. The other bathroom will only need to be shared by two service users. 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 DS0000017109.V277102.R01.S.doc Version 5.1 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.V277102.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individuals needs and aspirations are assessed. EVIDENCE: The service users guide has been updated to include all the required information. Each service user has a copy of it. The current service users have lived in the home for some time. At previous inspections their records have been sampled to ensure that an assessment has been carried out before they move in to make sure that the home can meet their needs. The service users guide refers to the assessment process being carried out before a prospective service user is admitted to the home. Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 Service users are supported to make decisions about their lives. Adequate arrangements are in place to ensure that service users are supported to take risks within a risk assessment framework. EVIDENCE: Service user said they could make decisions about what they eat, wear, buy and what places they go to. Service users records sampled showed that they make decisions about their day-to-day lives. Staff were observed supporting service users to make decisions about where they want to go and what they want to eat and drink. Since the last inspection service users risk assessments have been reviewed and where things have changed they have been updated. A risk assessment has been put in place for storing knives in the kitchen to ensure that service users are protected from harm. Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 16, 17 Service users take part in activities appropriate to their age. Service users rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet. EVIDENCE: Service users said that they have been given the opportunity to try out college courses but are not doing any at the moment. They spend their day doing activities that they choose to do. These include going for walks, shopping, restaurants, the gym and using the computer. Service users are expected to take part in shopping for their food and helping to prepare their meals. Service users daily records sampled showed that they are regularly involved in household chores. Service users said that they are expected to clean their bedrooms and keep them tidy. If they are not able to do this they have to allow staff to enter their bedroom once a week to support them to clean it and change their bed linen. They said that sometimes they need the support from staff but prefer to do it themselves when they can. Staff were observed knocking on service users bedroom doors before entering. Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 Page 11 Service users food records sampled showed that a variety of food is offered including fruit and vegetables. Service users talked about their diet and the need to have a healthy diet. They said that they have seen a dietician who has given them advice about healthy eating. They have also attended a training session with the staff about healthy eating. The service user spoke to staff about how staff could support them to lose weight and the staff agreed to this. Fresh fruit was available. Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Service users receive appropriate personal support and their health needs are met. The arrangements for the management of the medication are generally adequate to ensure that service users are protected. EVIDENCE: Staff were observed talking to service users and reassuring them when they had anxieties. One service user was concerned that the meat they had in their sandwich at lunchtime was out of date. Staff found the tin and showed them that it was not out of date, which reassured the service user. Service users were well dressed according to their age and the activities they were doing. Service users records sampled showed that they are regularly weighed. Their weight has been stable over the last year. When they refuse to be weighed this is recorded. Service users records showed that the psychiatrist regularly reviews their medication. Medication is stored in a locked cabinet. Lloyds Pharmacy provide the medication for the home in blister packs for each week. Staff try to encourage service users to administer their own medication and individual care plans are in place for this. All medication administration records (MAR) had been signed for. The MAR cross-referenced with the blister pack indicating that Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 Page 13 medication had been given as prescribed. In the medication cabinet there was a bottle with one tablet in it that was labelled, “ spoilt, unused tablets.” Any spoilt or unused tablets must be put in an envelope labelled with the name of the medication, the dosage and the service users name so that it is clear what it is and can be disposed of appropriately. The Business Manager said that there are small envelopes provided for this and that staff need to be reminded to use them. Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 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 the following standard(s): 22, 23 Adequate arrangements are in place so that service users feel their views are listened to and acted on. Adequate arrangements are in place to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: The complaints policy includes all the required information and details of how to contact the CSCI. The Business Manager said there have been no complaints since the last inspection. One of the service users spoke to staff about their views of the food that was bought, as they were concerned that it was not always healthy food to support them to have a healthy diet. They worked out strategies of how staff could support them to eat food that was healthier. Staff agreed to follow these strategies and suggested practical ways of how they could be carried out. A requirement was made at the last inspection for individual behaviour management guidelines to be put in place so that staff know how to manage service users behaviour and deal with it in a consistent way. These have been developed and are detailed. All staff were involved in developing them, which gave them an opportunity to suggest ways of how they manage individual’s behaviour. The guidelines included clear examples of responses to the individual and of things that should not be said so as to avoid them becoming anxious. They were dated and are to be reviewed at least every six months. Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 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 the following standard(s): 24, 26, 27, 28 Adequate arrangements are not in place to ensure that service users live in a homely and comfortable environment. EVIDENCE: Since the last inspection the vacant bedroom has been refurbished and en suite facilities provided. A shower with a thermostatic regulator has been fitted to prevent the risk of service users scalding themselves. There is not an extractor fan in the en suite and this is required to ensure that there is adequate ventilation. One service users bedroom was seen. This was personalised. The service user spoke about how staff support them to keep it clean. The kitchen units are worn and in need of replacing. There are several different types of tiles on the kitchen wall that have been replaced at different times. These need replacing so that they match. A representative from a company visited during the inspection and gave a quote for the kitchen to be refurbished. There were some holes in the lounge wall where one of the service users had pulled off the whiteboard. A new table and chairs have been provided in the dining room. The fire door of the laundry room was not closing properly. The home was warm and clean. Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35 Service users are supported by an effective staff team who have received the appropriate training to meet their individual needs. EVIDENCE: Over 50 of the staff have achieved NVQ level 2 or above. Rotas indicated that there are two staff on duty during the day and one waking night staff. The Business Manager said that there is a vacancy for one full-time member of staff as one member of staff who is pregnant has been moved to the other home where there are fewer risks. The Business Manager said that they have interviewed to fill this vacancy and are waiting for Criminal Records Bureau (CRB) check and references before the person can start working at the home. Three members of staff have attended a six - day autism course. They have put together a training pack from this to deliver to all staff. They are also buying some training videos from the National Autistic Society to use to train staff. The service has recently achieved the ‘Investors in People’ standard. The Business Manager said they have received a grant for £2,500 from the Birmingham Chamber of Commerce to provide training for staff. They hope to use this to provide specialist training for staff in autism. Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 There have been several changes of managers, which is not of benefit to the service users. Arrangements are generally adequate to ensure that service users are confident that their views underpin all self-monitoring, review and development by the home. Arrangements are generally adequate to ensure that the health, safety and welfare of service users is promoted and protected. EVIDENCE: Since the last inspection the manager has left. This has caused anxiety for one of the service users. An acting manager is in post, they will decide at the end of January 2006 whether or not they would like to continue as the manager and make an application to be registered with the CSCI. The Commission is concerned about the retention of managers at the home and the owner’s ability to recruit a suitable manager who meets the required criteria. Since 2002 there have been five managers. Two of the managers did not submit an application for registration to the CSCI. One of the managers was refused registration by the CSCI, as they did not have the adequate skills and Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 Page 18 knowledge to be a registered manager. The last manager was registered in August 2005 and left in October 2005. The Business Manager said that in the past they have improved the quality of the service by asking service users for their views. They aim to ask the service users to complete a survey again in the near future. Consultants are employed by the owner to undertake the Regulation 26 visits. They visit the home monthly and a report of their visit is available as required. These visits include asking service users and staff for their views of the service provided. The Gas Safety record was displayed in the office. This indicated that a Corgi registered engineer tested the gas equipment in July 2005. They said that it was not to current standard but was safe to use and made some recommendations. The Business Manager said that these recommendations have now been met. Fire records showed that an engineer serviced the fire equipment in March 2005. There was a fire drill in November 2005 as part of the fire safety training with all staff and service users. Staff test the fire alarm and emergency lighting weekly to make sure they are working. The door closure on the fire door of the laundry room was broken. An Environmental Health Officer visited in October 2005 and stated, “hygiene practices were good at the time of the inspection”. They recommended that a fly screen be fitted over the kitchen window and this is required. The home has a minibus that service users use to access the community. There was a valid certificate of insurance and MOT for this. An electrician completed the five –year electrical wiring installation test in November 2002 and stated that it was in a satisfactory condition. Staff regularly test the water temperatures and these range from 38 – 42 degrees centigrade. The recommended safe level is below 43 degrees centigrade to prevent service users from being scalded. The floor in the vacant bedroom slopes upwards. The Business Manager said that this had been looked at during refurbishment and the slope minimised as much as possible. They said that one of the service users has been using the shower in the en suite and the slope had not been a problem to them. However, a risk assessment must be in place to ensure that any risks of falling and tripping are minimised. This must be updated when a service user is identified to move into the bedroom to ensure that any risks to the individual are minimised. Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 Page 19 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 2 28 2 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 1 X 2 X X 2 X Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No 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 YA20 Regulation 13 (2) Requirement Timescale for action 05/01/06 2. YA42YA24 3. 4. 5. 6. YA24 YA24 YA24 YA37 7. 8. YA42 YA42 Any medication to be disposed of must be put in an envelope and labelled with the name of the medication, dosage and the service users name. 16 (2) (j) A fly screen must be fitted to the kitchen window as recommended by the Environmental Health Officer. 23 (2) (p) An extractor fan must be fitted to the en suite of the vacant bedroom. 16(2)(g) The kitchen units must be 23(2)b,c,d replaced. The tiling in the kitchen must be replaced. 23(2)(b,d) The holes in the lounge wall must be filled and the wall repainted. 8, 9 The manager’s post must be recruited to. An application for registered manager must be received by the CSCI. 13(4)(a, The door closure on the fire door b,c) from the laundry room must be 23(4) repaired. 13(4)(a, A risk assessment must be in b,c) place for the area of the floor in the vacant bedroom that slopes. 31/03/06 28/02/06 30/04/06 31/03/06 28/02/06 07/01/06 31/01/06 Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 Page 21 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 YA39 Good Practice Recommendations Service users should be asked on their views of the service by asking them to complete the survey again. Ascot Villa DS0000017109.V277102.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Birmingham 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 DS0000017109.V277102.R01.S.doc Version 5.1 Page 23 - 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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