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Inspection on 21/06/06 for Cherre Villa Care Home

Also see our care home review for Cherre Villa Care Home for more information

This inspection was carried out on 21st June 2006.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There continue to be very good outcomes for service users at Cherre Villa. Service users are clearly encouraged and supported to make decisions and take an active role in the running of the home. Social activities and meals are both well managed and provide daily variation and interest for people living in the home. The principles of care are well understood and put into practice at Cherre Villa. Service Users rights are recognized and promoted in every aspect of the care provision at the home. There was evidence of this was in the routines of the home and in the friendliness of staff with Service Users. Service Users have a good quality of life, with plenty of activities, and are supported by a well-trained staff group. Service Users are involved both in the decision-making and in the running of the home.

What has improved since the last inspection?

Service users welfare has been further promoted by the system of paying for staff costs on days out has been changed so that service users are not paying for these costs. Staff also said that service users now have new beds and that the bathroom has been retiled. The back door behind the kitchen area was locked and the key was now being kept in the lock at the time of the inspection so that fire access is not blocked. This now follows fire safety instructions the Registered Owner had given to staff.

What the care home could do better:

To update the Fire Risk assessment to cover all identified issues. Ensure that service users privacy is fully respected at all times by installing a privacy lock to the bathroom and replacing a glass segment in a service user`s bedroom so that people cannot directly look in.

CARE HOME ADULTS 18-65 Cherre Villa Care Home 168 Fosse Road South Leicester Leicestershire LE3 0FR Lead Inspector Keith Charlton Unannounced Inspection 21st June 2006 15:45 DS0000006436.V300279.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 DS0000006436.V300279.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. DS0000006436.V300279.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cherre Villa Care Home Address 168 Fosse Road South Leicester Leicestershire LE3 0FR 0116 223 9374 0116 223 9374 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) Miss Hema Malini Patel Miss Hema Malini Patel Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000006436.V300279.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 14th February 2006 Brief Description of the Service: Cherre Villa is registered to provide care for three adults with learning disabilities. The home is situated close to Leicester city centre and within easy reach of a range of local amenities. Service users are accommodated in one single and one shared bedroom. In addition to their rooms, service users have access to a lounge and a large kitchen / dining room. There is a paved area to the rear of the property. Cherre Villa is run as a small family home. Service users attend colleges and day centres during the day. They have access to a range of leisure and recreational activities both within the home and in the local community. DS0000006436.V300279.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involved selecting one service user and tracking the care received through looking at their records, discussion with the service user, care staff and observation of care practices. Where communication for some Service Users is difficult, their choices and informed decisions are dependant to some extent upon the consistency of staff, service users relationships with staff, and the quality of communication. The quality of care in this respect may be established by the Inspector through observation of interactions between staff and Service Users. The inspection took place between 3.45pm and 6.45pm. Planning for this inspection included reviewing the previous inspection report and the service history. The Commission for Social Care Inspection has not received any complaints from the last inspection. There were three service users present at the time of the inspection with a staff member. Some statutory records were not available for this inspection visit so the inspector returned and completed the inspection with the Registered Manager on 27/6/06. What the service does well: There continue to be very good outcomes for service users at Cherre Villa. Service users are clearly encouraged and supported to make decisions and take an active role in the running of the home. Social activities and meals are both well managed and provide daily variation and interest for people living in the home. The principles of care are well understood and put into practice at Cherre Villa. Service Users rights are recognized and promoted in every aspect of the care provision at the home. There was evidence of this was in the routines of the home and in the friendliness of staff with Service Users. Service Users have a good quality of life, with plenty of activities, and are supported by a well-trained staff group. Service Users are involved both in the decision-making and in the running of the home. DS0000006436.V300279.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000006436.V300279.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 DS0000006436.V300279.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users needs and aspirations are fully assessed prior to moving into the home. EVIDENCE: The Statement of Purpose was viewed – this is a detailed document outlining the services of the home. The Registered Manager is reviewing this information to make it more user friendly with photographs/symbols so that all service users can more easily understand it. This home has a stable group of service users who have resided there for a number of years. There was evidence on a file inspected that staff had completed a full assessment for service users prior to admission. DS0000006436.V300279.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Good systems are in place to ensure service users are consulted in all aspects of their lives, enabled and supported by staff, to meet their individual needs and choices in order for them to achieve independent lifestyles. EVIDENCE: Service users said that they had Care Plans and were involved in setting them up so that staff understood what was needed for them. The staff member spoken to said the Registered Manager encouraged staff to read Care Plans to be aware of the care needed for each service user. Service users have comprehensive care plans and risk assessments, which are reviewed. One service user also said he has a Person Centred Plan, which he had done himself and he said that he was now a person centred trainer so that he could help people understand that everyone was an individual with different needs and wishes. DS0000006436.V300279.R01.S.doc Version 5.2 Page 10 Service user meetings are held monthly and are documented in detail. The records sampled showed that Service Users views are sought in all areas of their lives at the home, and there was evidence that staff responded to Service Users wishes. Service Users are enabled to attend their reviews if they wish to do so. Service Users are aware of the records kept about their care and said they were aware of their rights to see them. The Registered Manager stated that she will action issues such as service users interviewing prospective staff and being part of staff meetings, if they wish to attend. The Inspector observed the staff member on duty sensitively supporting Service Users to make decisions about food choices for tea, clothes, choices for going out and what activities were available. Service Users files showed that risk assessments are undertaken to enable them to lead active and independent lifestyles and to be protected from unreasonable risk. Two service users are able to go out on their own and one service user chooses to go to town every day on his own or to meet friends. DS0000006436.V300279.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users lifestyles are promoted and respected by the service. EVIDENCE: DS0000006436.V300279.R01.S.doc Version 5.2 Page 12 Service users have the option of going to College or activities in the community. One service user chooses not to follow a programme and this choice is respected by staff. One service user said he enjoyed his computer sessions during the week. Service users spoken to said they liked going out and they go on holidays abroad - and are asked where they want to go on holiday, e.g. to Florida, which they really enjoyed. On the evening of the inspection service users who wanted to go were going to club with a disco. A service user and staff from the sister home visited to invite service users to this night out. There was evidence of a good range of activities that service users talked about – arts, music, cooking, going out to activities – drop in centre, ten pin bowling, cinema and local pubs etc. Service users are supported in helping in the kitchen with supervision as necessary. This was observed and also detailed in the service user meeting notes. The staff member said that service users use a range of community facilities including local shops, pubs etc. The staff member on duty was observed talking with service users positively and with respect. Service users had free access to the kitchen in accordance with risk assessments and helped themselves to drinks if they were able. Records showed meals are varied and service users said they helped plan the menu. A service user said that he goes shopping for his own clothes. Service users stated that they spend time in the city centre, visiting friends and family. At home service users watch TV, listen to music and relax. Service users said that they saw their families at the weekend and their friends can visit them if they want to. Service Users are enabled to have social contact with Service Users at the Registered Owner’s other local home and with others in the community through their day placements. A staff member said a service user goes to temple through his family taking him and he celebrates other religious activities, e.g. Diwali. Service users said that they ‘’loved the food’’ and never had any complaints about it. Food records showed that service users had a choice for each meal. The staff member was observed to be offering service users a choice for tea. DS0000006436.V300279.R01.S.doc Version 5.2 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 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. Service Users health and personal care needs are well met. EVIDENCE: Service users said that if that were not well then they could see a GP if they wanted. They said staff were always available to talk to and help them if they had any problem. There is a section in the Care Plan which details all medical appointments and check ups on an individual basis - from GPs, dentist, optician etc. Service Users personal and healthcare needs were recorded in their records together with the outcomes from their visits to healthcare professionals. Accident records were checked – there has only been one issue in the past year. Recording did not specify how this injury occurred – this needs to be included as known. Only one service user needs help with his personal care. Staff said that he is able to do as much as possible for himself and chooses what clothes he wants to wear. DS0000006436.V300279.R01.S.doc Version 5.2 Page 14 The staff member was observed to be working with service users in a positive and friendly way and understood that service users wanted to chat and be around them for company. No service user is able to self medicate. Only one service user has prescribed medication – he is not able to self medicate so staff supply it to him. He said he liked staff doing this for him. The staff member said that she had received medication training from the pharmacist. Medication records were checked and found to be generally good. The medication is kept securely locked away. DS0000006436.V300279.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected from abuse though generally robust protection procedures. EVIDENCE: Service users said that they would tell staff members if they were unhappy with anything and they said it would be sorted out. There are no complaints records though there was evidence in the Incident Book as to a relative being unhappy as to the clothes worn by her brother. It was recommended that the Registered Manager begin a complaints book so that this information can be easily accessed. This complaint was appropriately dealt with. The complaints procedure is clearly displayed in the kitchen and contains information as to how to contact the Commission should a complainant be dissatisfied with the home’s response though it also refers to a previous registration body and does not give the option of going to the Commission for Social Care Inspection first. The Registered Manager said she would make amendments to the procedure and that it would be a more user-friendly document for service users. There are service users meetings held where all people are invited to attend and share their views about the home. Records of these meetings are available for staff and service users to refer to. DS0000006436.V300279.R01.S.doc Version 5.2 Page 16 The staff member on duty was asked about the understanding of whistle blowing procedures, and demonstrated a good understanding of the protection of service users from abuse. DS0000006436.V300279.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Cherre Villa is a homely, clean, safe and comfortable environment for service users though some aspects of privacy need to be reviewed. EVIDENCE: Service users said that they liked the home and their bedrooms. One service user said it would be nice if there was also a shower as well as a bath to give him a choice. The Registered Manager said this would be carried out. Areas of the home toured were clean, odour free and comfortable. The Inspector looked at two bedrooms and service users said that they had arranged and furnished them as they wished and that apparent shortfalls in furnishings were documented in records as being of their choice. The Registered Manager said a service user is to go shopping with a staff member to obtain an easy chair of his choice. DS0000006436.V300279.R01.S.doc Version 5.2 Page 18 The outside area is in need of tidying and repair. There were old mattresses, which were due to be taken away shortly. Planned improvements to this area were recorded in the maintenance book – the need for a new patio, painting of walls and pot plants. The back exit now has the key stored in the door enabling access in case of fire. A privacy lock is still needed for the WC/bathroom. The Registered Manager asked the maintenance man to action this. A lock to the office/sleeping in area is also needed to protect the privacy and potential safety of staff. The Registered Manager said she would check with the Fire Officer as to whether this could be done, as this room may be a designated fire escape route. There were missing glass panes to a window in a wall of a service user’s bedroom, which allowed anyone to look in thereby compromising this service user’s privacy. The Registered Manager said this would be attended to. DS0000006436.V300279.R01.S.doc Version 5.2 Page 19 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): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The deployment, number, support and training of staff appear sufficient to meet the current needs of service users. EVIDENCE: The rota indicated one member of staff on duty when service users are at home. The staff member on duty confirmed this. This appeared sufficient to meet the needs of current service users. One member of staff sleeps overnight. There is an on call system so that additional staff can quickly respond if needed. Staff are trained and a number of staff have completed a National Vocational Qualification level two or above in care. The staff member spoken to said the Registered Manager emphasis staff training on a number of important care topics. The inspector looked at the induction package which covers key issues – service user rights, the philosophy of care etc. Staff receive one to one support on a regular basis from the Registered Person. DS0000006436.V300279.R01.S.doc Version 5.2 Page 20 The organization and atmosphere at the home again indicated a smoothly running establishment. Policies and procedures were available to staff and sampled procedures demonstrated the commitment to good practice at the home. Staff spoken to said that the Registered Manager asks that staff read the Policies and Procedures of the service, so that care is consistently delivered. Staff records were mostly complete though the Registered Manager was asked to ensure that the Protection of Vulnerable Adults check was not destroyed before being seen by an inspector, to check this had been received before employment commences. DS0000006436.V300279.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home promotes the Health and Safety of service users. EVIDENCE: DS0000006436.V300279.R01.S.doc Version 5.2 Page 22 Both service users and staff spoke highly of how the Registered Manager runs the home. The Staff Meeting notes seen are detailed and comprehensive and focus on ensuring staff are aware of service users changing care needs. Service users have been asked as to their views on the way the home is run through a Quality Assurance survey. The Registered Manager has analysed the results of the survey and included this in the home’s information for current and prospective service users. Service user monies were checked and found to be in order – records detailed running balances, receipts and signatures and money was checked on every shift to ensure it was always correct. Fire records showed that testing of fire bells was generally up to date and there are regular fire drills. The fire risk assessment is in place though needs to be completed, e.g. emergency action plan, training etc. The Registered Manager has not arranged the fitting of radiator covers as assessed as needed to protect service users from heat injuries and there was no Risk Assessment to indicate service users were not at risk. The hot water temperature was measured and found to be over 46c – which was not within the National Minimum Standard of 43c. The Registered Manager is to Risk Assess this to ensure service users safety from scalding. Health and Safety Policies and Procedures are in place (though the Risk Assessments for safe working practices were few in number and need to be extended to cover all areas of known risk – the Registered Manager said this would be followed up) and the staff said they are encouraged to read them. DS0000006436.V300279.R01.S.doc Version 5.2 Page 23 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 X 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 3 X 3 3 X DS0000006436.V300279.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000006436.V300279.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 DS0000006436.V300279.R01.S.doc Version 5.2 Page 26 - 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!