Inspection on 11/09/06 for Cleeve Villas

This inspection was carried out on 11th September 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cleeve Villas 23/04/07

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

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

CARE HOME ADULTS 18-65 Cleeve Villas 69/70/71 Wilson Street Derby Derbyshire DE1 1PL Lead Inspector Nancy Bradley Unannounced Inspection 11th September 2006 10:00 Cleeve Villas DS0000061805.V311253.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 Cleeve Villas DS0000061805.V311253.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. Cleeve Villas DS0000061805.V311253.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cleeve Villas Address 69/70/71 Wilson Street Derby Derbyshire DE1 1PL 01332 383187 01283 734984 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) Cleeve Villas Care Services Limited Mr Stephen Maurice Kent Care Home 14 Category(ies) of Learning disability (14), Mental disorder, registration, with number excluding learning disability or dementia (14) of places Cleeve Villas DS0000061805.V311253.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No one falling within the category LD or MD can be admitted into Cleeve Villas when there are 14 persons of that category/combined categories already accommodated in the home The maximum number of persons to be accommodated at Cleeve Villas is 14 New Service Date of last inspection Brief Description of the Service: Cleeve Villas is a late Victorian building situated within a few minutes walk of the Derby city centre. The home has fourteen single en-suite bedrooms, including one specifically for the needs of wheelchair users. The communal areas include the dining area, lounge, quiet room, kitchen, bathroom and toilets. The home provides care for service users who have mental health needs and a learning disability and are 18 years of age and over. The home has a qualified psychiatric nurse on duty 24 hours a day, along with trained care assistants. Information on fees was not available, the Registered Manager stated fees are dependant on need. Cleeve Villas DS0000061805.V311253.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection was unannounced and took place over four hours. The inspector spoke with the Registered Manager and care staff. During the site visit the inspector made a tour of the home and spoke with service users. There were nine service users in the home on the day of the inspection. Currently the home has five vacancies. Additionally, time was spent in preparation for the visit, looking at the pre inspection questionnaire. The inspector observed throughout the visit how the staff were meeting service user needs. No family or relatives were present during this visit. Records were examined relating to the service users and the general running of the home. The fees are dependant upon need. Currently two service users maintain their own benefits and seven handle their own financial affairs. From the nine questionnaires sent out three completed ones were returned and all stated they were quite settled at the home. Only one service user was willing to speak with the inspector. What the service does well: What has improved since the last inspection? What they could do better: More management hours are required to ensure the Registered Manager can meet the homes stated purpose, objectives and the needs of the people who live and work there this will enable the manager to effectively achieve: • The arrangement for formal staff supervision. Cleeve Villas DS0000061805.V311253.R01.S.doc Version 5.2 Page 6 • Review of polices and procedures. 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. Cleeve Villas DS0000061805.V311253.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 Cleeve Villas DS0000061805.V311253.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): Standard 1and 2 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service Arrangements are in place to ensure that service users needs are fully assessed and met prior to admission this ensures that all potential service users holistic needs are appropriately met. EVIDENCE: The Commission for Social Care Inspection is in receipt of an amended Statement of Purpose following the variation to conditions of registration. The home now provides care for people with learning disabilities and mental health needs. The individual records of four service users were checked. The majority of the service users who are admitted to the home have their needs assessed via social workers, through the care management system, and consultant psychiatrist. This highlights their additional needs, and the need for additional staffing hours. The assessments then form part of the service user plan compiled by one of the psychiatric nurses. These were comprehensive and up to date and reflected the involvement of service user and significant others. Cleeve Villas DS0000061805.V311253.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): Standard 6,7 and 9 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. There is a care planning and review system in place, which ensures that service users individual needs are met. Service users are supported to achieve an independent lifestyle and participation in all aspects of the life at the home is encouraged EVIDENCE: During the visit care plans of two service users were examined. The care plans have been compiled by the staff on each service user and evidence was seen of care plans being reviewed on a regular basis. Care plans included services users’ individual lifestyle preferences and choices; the interventions prescribed by outside healthcare professionals were appropriate. Daily records are also maintained on each service user. Care plans were personalised however service users do not sign their care plan but are made aware of its content by their key-worker. The home offers a structured multi disciplinary care planning and rehabilitation approach for service users. All service users have access to the Advocacy service should this be required. Cleeve Villas DS0000061805.V311253.R01.S.doc Version 5.2 Page 10 Detailed risk assessments were in place and these included actions to be taken by staff. The Registered Manager recognised the need for these to be updated and reviewed in line with care plans. Cleeve Villas DS0000061805.V311253.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): Standard 12,13,15, 16 and 17 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. There were arrangements in place to enable service users to maintain and develop appropriate relationships. Participate in recreational and social activities both in the home and outside in the wider community needs to be promoted in accordance with service users preferences and wishes. The home provides a well-balanced and nutritious diet. EVIDENCE: The relationships observed between care staff and service users were open and friendly. The service users are encouraged to take pride in their appearance and their preferred style of dress is respected. During the visit the inspector spoke with the care staff about the activities service users were engaged in and the arrangements for these. Previously the home employed a member of staff to arrange suitable activities for the service users. However as the number of service users has fallen the post has been withdrawn. In the questionnaire completed several service users stated they would like more activities in the daytime; the majority of the service uses are fully Cleeve Villas DS0000061805.V311253.R01.S.doc Version 5.2 Page 12 mobile. The care records of four service users provided detailed assessment and care planning information regarding their social, recreational, educational and occupational activities both within the home and outside in the community. Risk assessments on activities do need to be reviewed and updated. The Registered Manager stated that service users are taken on holiday several times a year, however as the service users have complex needs staffing levels are increased which incur extra costs. The daily routine is flexible with service users being supported to make their own decisions about how they spend the day. Service users are encouraged to remain as independent as possible subject to restrictions agreed in their care plan. Service users are encouraged as part of their individual care plan to be involved in cooking, shopping, house keeping and other social events. Service users who wish can have a key to their bedroom. Information on service users’ records indicated that contact with family and friends were appropriate. From examination of the menus and in discussion with the cook the home is providing a healthy well-balanced and nutritious diet. Service users are given a choice of meals and fresh fruit is available. A separate kitchen is available for drinks and to cook some meals with staff supervision. The home is monitoring service users weight. Cleeve Villas DS0000061805.V311253.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): Standard 18,19 and 20 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The health needs of service users’ are appropriately documented ensuring that individuals receive regular health checks. Service users receive personal support in a manner , which promotes, their independence Policy and procedures relating to the receipt, checking and storing of medicines requires reviewing in line with the required standards. EVIDENCE: From records examined and from discussions with staff, this showed that service users’ health and personal needs were being met Service users were generally healthy and records showed that staff promptly contacted the appropriated medical services. All service users attended services within the community including optician, chiropodist, and dentist. However the home needs to record these separately as currently they are recorded in the daily records. The home operates and monitors service users’ medication. None of the service users are able to administer their own medication. All staff have received training on medication training procedures. Cleeve Villas DS0000061805.V311253.R01.S.doc Version 5.2 Page 14 The arrangements for receipt, storage, administration and disposal of medication were also examined and found to be satisfactory. There was a clear audit trail of all medication used at the home. However on examination of the administration of medication records one member of staff had failed to record the medication administered on the day for one service user. The Registered Manager conducted an audit, which confirmed the medication had been given and the records had not been fully completed. The Registered Manager agreed to take this up immediately with the member of staff and contact the Commission for Social Care Inspection to confirm this. Cleeve Villas DS0000061805.V311253.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): Standard 22 and 23 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Arrangements are in place to safeguard service users’ welfare and ensure that their concerns are listened to and acted upon this practice prevents service users being subjected to harm. EVIDENCE: The home has a complaints procedure and a summary of the procedure is included in the service user guide, and is display around the home. The complaints procedure was examined and this requires amending to include the correct details for the Commission for Social Care Inspection. The Registered Manager confirmed that the home had links with the Derbyshire Advocacy Service, and that an independent Advocate had supported the service users in completing the questionnaire for the Commission for Social Care Inspection. Complaints tend to be dealt with at an informal level, which results in the home receiving very few complaints. The home has not received any formal complaints in the last year and the Commission has received no complaints for this service. The homes policy on the protection of adults was examined. This needs to be reviewed and updated to reflect the change of emphasise to the Safeguarding of Adults. From discussions with the Registered Manager and from records examined there has been one reported incident under the safeguarding of adults procedure. This was dealt with in an appropriate manner. Cleeve Villas DS0000061805.V311253.R01.S.doc Version 5.2 Page 16 The Registered Manager reported that all but one staff member had completed the training on Safeguarding of Adults. Cleeve Villas DS0000061805.V311253.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): Standard 24 and 30 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The general standard of the home and the environment was satisfactory providing service users with an attractive and comfortable place in which to live. EVIDENCE: A tour of the home was undertaken and all communal areas were inspected together with the staff facilities. The tour of the home showed that the home is maintained and furnished to a satisfactory standard. Several of the service users bedrooms and en suites were inspected with their agreement. Individual service users’ bedrooms were personalised. As annual maintenance programme for renewal of the fabric and decoration of the premises needs to be produced and implemented with records kept. This will assist with the overall maintenance of the home. As high lightered during the tour of the home the small lounge /quiet room is in need of refurbishment and decorating. Cleeve Villas DS0000061805.V311253.R01.S.doc Version 5.2 Page 18 Service users have access to the grounds outside and patio this area did require attention and a general tidy up, as a number of cigarette ends were visible. The facilities are comfortable and free of unpleasant odours as was the case on the day of the visit. The home has appointed one member of staff to take the lead on infection control and is due to attend the relevant training. Care staff did mention that they are expected to clean when the ancillary staff are on leave, which does distract from the work they do with the service users. These arrangements need to be reviewed. Cleeve Villas DS0000061805.V311253.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): Standard 32,34 35 and 36 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. The home has a recruitment policy in place, which ensure the safety and protects the service users. However this requires strengthening in some areas. Importance is given to the staff training needs. The staff appeared to be well supported in their day-to-day work however this could be further strengthened with the development of a formal system of supervision EVIDENCE: The home operates a key-worker system and the staff spoken with during the visit where aware of the individual needs of the service users. From records examined during the visit all of the staff have attained or are working towards a National Vocational Qualification at level II or level III. A sample of staff records was examined, and although the majority of the information was available staff records do require attention. Staff recruitment records need to meet the requirements under Schedule 2 of the National Minimum Standard for Care Homes for Adults (18–65) 2001. The staff recruitment records did highlight the following issues: • Records of interviews on file for one member of staff. • Copies of birth certificates /passport on file to prove identity. • No copies of qualification certificates on file. • Full employment history. Cleeve Villas DS0000061805.V311253.R01.S.doc Version 5.2 Page 20 • • Documentary evidence of any relevant qualifications Criminal Records Bureau clearance for some staff did not include POVA and POCA. The staff training records were examined. There is a programme of training in place, which includes fire safety, moving, and handling, SKIP and learning to care for people with a learning disability. From discussions with staff training is given a priority in the home and they are encouraged to attend relevant courses. As the home is now caring for people with a learning disability this training needs to continue. Although there is a policy and procedure for the supervision of staff the Registered Manager confirmed that this does not always take place. Staff confirmed that they do have an appraisal and evidence of this was seen on staff personnel records however there was no Personal Development Plan. Cleeve Villas DS0000061805.V311253.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): Standard 37,39 40 and 42 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service Systems are in place to ensure that service users have a voice and their views are listened to this ensures that service users are involved in care planning. EVIDENCE: The Registered Manager has considerable knowledge and experiences in caring for adults with a mental disability and challenging behaviour. He has been with at the home for a number of years. As discussed at the visit the Registered Manager does not have a recognised managers award, which all managers of care homes are required to achieve. The Registered Managers have developed a policy for monitoring care provided by the home. This is conducted jointly with the owner and includes questionnaires and residents meetings. The home is looking to develop this by including families and professionals in the quality audit. Cleeve Villas DS0000061805.V311253.R01.S.doc Version 5.2 Page 22 Samples of policies were examined and has discussed with the Registered Manager several need to be reviewed and updated. The staff have access to all the policies and procedures. A sample of service/maintenance records was examined (including gas and electricity services) and there was confirmation that all the equipment had been properly maintained. Evidence of checks having been carried out was provided to the Commission for Social Care Inspection Systems were in place for the monitoring and maintaining the hot water temperatures. Cleeve Villas DS0000061805.V311253.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 X 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 X 32 X 33 3 34 2 35 2 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 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 X 3 X Cleeve Villas DS0000061805.V311253.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No This is a new service 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 Schedule 2 and 4 Requirement Timescale for action 31/10/06 2 YA35 18 3 YA36 18 All staff employed must comply with the home policy and procedures on recruitment as detailed in Schedule 2 of the National Minimum Standards for Younger Adults 2001 All staff must be given the 31/10/06 opportunity to undertake training appropriate to the work they perform. All staff must have regularly 31/10/06 supervision in line with the National Minimum Standard 36.4 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 2 3 Refer to Standard YA6 YA9 YA24 Good Practice Recommendations Service user and their families should be given the opportunity to sign their care plan. Risk assessments should be reviewed regularly An annual maintenance programme for renewal of the fabric and decoration of the premises needs to be produced and implemented with records kept. DS0000061805.V311253.R01.S.doc Version 5.2 Page 25 Cleeve Villas 4 5 6 7 8 9 10 11 12 YA24 YA34 YA34 YA34 YA34 YA34 YA34 YA37 YA40 Suitable arrangements should be in place to cover when the ancillary staff are not available. When gaps in employment history is investigated this should be formally recorded on interview minutes. All staff should be given a copy of the code of conduct published by the General Social Care Council (GSCC) Staff with a Criminal Records Bureau over three years should have their clearance renewed to include POVA and POCA. The Registered Person should ensure that individual staff interview records are signed and dated. All staff should ensure that they provide copies of all qualifications. The Registered Person should ensure that the full employment history includes the days date month and year of employment The Registered Managers should commence an approved management qualification. All polices and procedures relating to the home should be reviewed and updated. Cleeve Villas DS0000061805.V311253.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Cleeve Villas DS0000061805.V311253.R01.S.doc Version 5.2 Page 27 - 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!