Inspection on 18/09/06 for Hirst Villas, 6

This inspection was carried out on 18th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hirst Villas, 6 15/04/08

Hirst Villas, 6 30/07/07

Hirst Villas, 6 31/10/05

Hirst Villas, 6 25/04/05

Hirst Villas, 6 06/12/04

Hirst Villas, 6 09/06/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hirst Villas, 6 6 Hirst Villas Bedlington Northumberland NE22 5QQ Lead Inspector Jim Lamb Key Unannounced Inspection 18th September 2006 11:00 DS0000000568.V299761.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 DS0000000568.V299761.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. DS0000000568.V299761.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hirst Villas, 6 Address 6 Hirst Villas Bedlington Northumberland NE22 5QQ 01670 - 531799 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) Northumberland, Tyne & Wear NHS Trust Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000000568.V299761.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st October 2005 Brief Description of the Service: Hirst Villa is a small residential care home providing personal care and accommodation for three female service users with learning disabilities. The home is located in a residential area of Bedlington. There is good access to all local amenities and transport links. The home provides very comfortable and spacious facilities for the service users. The homes front and rear gardens are landscaped and easily accessible. Fees for the home range from £270 to £409. Information about the service and previous inspection reports is available in the home. DS0000000568.V299761.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection visit. The inspection lasted four hours and involved discussion with two support workers and one of the service users. Two service users care records were inspected together with other records relating to the running of the home. Two staff training files were also seen. What the service does well: What has improved since the last inspection? What they could do better: To provide staff with a greater knowledge and awareness of equality and diversity issues, it is recommended that training be arranged within the next six months. This training will enhance their awareness relating to: race, gender, age, ethnicity, sexuality, disability and belief. The staff team still require death, dying and palliative care training, and this is outstanding from the last inspection visit. DS0000000568.V299761.R01.S.doc Version 5.2 Page 6 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. DS0000000568.V299761.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 DS0000000568.V299761.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 and 5 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to the service. Prospective service users are provided with enough information about the home to enable them to make a choice about where they want to live. The service users needs are assessed prior to admission. All are provided with a contract to inform them of the homes terms and conditions. EVIDENCE: Details of the extra charges, and what these are for, are in the contract given to service users and are agreed prior to their admission. The homes Statement of Purpose and the Service Users Guide both contained the full range of information required. These are available in pictorial formats. Admissions to the home are rare. The last admission to the home was over five years ago. Two service users’ files were checked and each included a full needs assessment. They contained a range of appropriate information. The service users are involved in drawing up both these initial assessments and the home’s subsequent service user plans. DS0000000568.V299761.R01.S.doc Version 5.2 Page 9 The two service user plans checked by the inspector were comprehensive, and listed details of service user’s needs and actions taken by the staff to meet these needs. One service user Said, “ All my needs are met. I don’t have to worry about anything”. Two care plans were checked and two staff interviewed, which confirmed that a range of specialist services was provided to service users. Both support staff present had a wide range of relevant training and experience. DS0000000568.V299761.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 and 9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. There is a consistent care planning system in place to provide staff with the information they need to meet the needs of the service users. Service users are able and supported to make decisions about their lives. EVIDENCE: There are comprehensive assessments in the service users’ care plans. There is also a comprehensive risk assessment of service users. These have been agreed and signed by service users and their representatives. There are advocacy arrangements, as well as family input, to represent service users. Each service user has an allocated key worker. Care plans are drawn up with service users. Plans are amended and reviewed on a regular basis. DS0000000568.V299761.R01.S.doc Version 5.2 Page 11 One of the service users said, “I am always involved and I have agreed with what is written down”. There are systems in place that will ensure that the placement and the service users plans are reviewed annually. These involve the service users, their care managers and their representatives. Service users can use a range of external agencies that promote independence. Any rights that are restricted are linked to risk assessments. Each service user receives support from staff to manage their finances. The manager acts an appointee for one service user; the DSS and the service user’s Mother, who lives abroad, have agreed this. Regular audits of service users finances are carried out. The records checked were found to be accurate. The service user said, “ I am always able to make decisions for myself, and the staff always listen to me. They are all very good and provide me with lots of help”. DS0000000568.V299761.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 and 17 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to the service. Links with the community are very good and support service user’s social and educational opportunities. The meals are good offering both choice and variety and catering for special dietary needs. EVIDENCE: Each service user had a skills assessment carried out. These are reviewed and updated on a regular basis. All service users participate in this process. Service users use a wide range of community-based services, which promotes and provides opportunities to learn and use life skills. They are supported to live a normal life in the community, and are supported and encouraged to be in control of their own lives, to enjoy their own interests and to continue their education. DS0000000568.V299761.R01.S.doc Version 5.2 Page 13 The staff team continue to liaise closely with external agencies in order to monitor each service user’s progress. All service users are supported to maintain very close links with their families. They can choose who they want to see and when. One service user said, “I see my nephews and nieces all of the time. They often visit me and I also visit them”. She said, “ I go to a day centre every Tuesday and Saturday and I have lots of friends there. I also visit church every Sunday”. Daily routines continue to promote independence, choice and freedom of movement. Two of the service users are involved in housekeeping tasks. One said, “I enjoy helping out around the house, I help with the laundry and ironing and dusting and polishing, it keeps me busy. I also help with the gardening which is great”. The meals are based on the known likes and dislikes of the service users. At least two hot meals are provided each day. The meals are varied and well balanced. There are no longer any formal menus as the service users decide independently what they would like to eat on a daily basis. A record is kept of what meals they have had. The service users are also involved with the food shopping. The service users have access to the kitchen and can prepare snacks for themselves if they wish. One service user said “ the meals were very good. I can choose what to eat and when and I like helping to prepare meals with the staff”. DS0000000568.V299761.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 and 21 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The health care needs of the service users are met. The systems for the administration of medications are good and the records demonstrate that the service users medication needs are met. The health care needs of the service users is being met. EVIDENCE: Service users currently do not have any moving and handling needs. They need minimal help with personal care tasks, such as bathing and dressing. Privacy and dignity are respected at all times. One service user said, “we are treated the same and always with dignity and respect”. The service users do not currently need any technical aids or equipment. Service users care records showed that they have access to external health care services. DS0000000568.V299761.R01.S.doc Version 5.2 Page 15 G.Ps visit when necessary and service users are referred for specialist health care if needed. All service users receive regular health care checks. The staff team still require training on ageing, illness, death and palliative care. This is outstanding from the previous inspection visit. The medication systems were examined for ordering, receiving, administering and disposal. These are well managed. Five staff have had accredited medication training, and training is being arranged for one other member of staff. Controlled drugs are not currently prescribed. Should this change, appropriate systems and procedures will be put in place. The dispensing pharmacist continues to offer good support and advice. DS0000000568.V299761.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to the service. There is a good complaints system in place with evidence that service users views are listened to and acted upon. EVIDENCE: There is a complaints procedure. It contains details of how to contact the CSCI to make a complaint, if complainants are not happy with the manager’s investigation and response. The procedure is written and produced in pictorial format to ensure service users fully understand its contents. All complaints are investigated within 28 days. In earlier inspections, service users said that they had been given copies of the procedure and that staff listened to their complaints and dealt with them fairly. One service user said, “ I will always tell staff if I am unhappy about anything because I know they will sort things out for me”. A record of complaints is kept. Since the last inspection visit there have been no complaints received. There is a Whistle Blowing policy and a copy of the Local Authorities Vulnerable Adults procedures. There is also has a copy of the Department of Health’s document, “NO SECRETS”. DS0000000568.V299761.R01.S.doc Version 5.2 Page 17 There are detailed financial records kept on behalf of the service users. Each has an individual bank account. Receipts of personal spending are kept. DS0000000568.V299761.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 26 27 28 29 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Through good maintenance and planning this is a very homely and comfortable environment for service users. EVIDENCE: The home was clean, extremely comfortable, well decorated and well maintained. The grounds were tidy, safe, attractive and accessible. In the rear garden the service users have access to a spacious well-furnished summerhouse. Furnishings and fittings were domestic in design and in very good condition. The lighting throughout the home was bright and domestic in design. All bedroom doors have privacy locks and each service user keeps their own key. The bedrooms are all very spacious and very highly personalised. They exceed the minimum size required. DS0000000568.V299761.R01.S.doc Version 5.2 Page 19 The rooms are centrally heated and the heating level could be controlled within each bedroom. Radiators and pipes were guarded. There was emergency lighting throughout the home. Water is stored at over 60°C. Valves at water outlets ensure water is provided close to 43°C to prevent scalding. The home was very clean and free from offensive odours. The laundry facilities are well organised and the washing machine has the specified programme to meet disinfection standards. DS0000000568.V299761.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 and 35 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The procedures for the recruitment of staff are robust and provide safeguards to offer protection to the service users. The deployment and numbers of staff are sufficient to meet the needs of the service users. EVIDENCE: Staff levels on the day of the inspection met the agreed level. The rotas showed the required numbers of staff were on duty: 2 staff between 8am and 9pm with one sleep-in between 9pm and 8am. The Trust also operates an out of hours on-call system. This is a safeguard for staff and service users after 9pm at night. All the staff were over 18 years of age and those left in charge were at least 21. The staff team are very experienced and have been employed by the Trust for many years, three of them for over 20 years. The training needs of staff continue to be identified in supervision and appraisal sessions. The Trust continues to operate a very good training and development DS0000000568.V299761.R01.S.doc Version 5.2 Page 21 programme for all employees. The staff continue to receive paid training. Although staff recruitment files are not kept in the home, the staff confirmed that there is a rigorous staff recruitment and selection process to ensure that all appropriate checks and references are in place prior to employment. Service users are involved in the recruitment of staff. They meet all potential employees and their views are considered prior to selection. The staff turnover is low. The majority of staff has worked for the Trust for many years. DS0000000568.V299761.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 and 42 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service The home has a new manager. She provides guidance and direction to staff to ensure the service users receive consistent quality care. The practices in the home promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: A new manager has recently been appointed, but is not yet registered. She has over 20 years experience and is a qualified nurse. She has commenced NVQ level 4 in management. Both staff on duty were clear about their responsibilities and they were very knowledgeable about each service users personal, health and social care needs. DS0000000568.V299761.R01.S.doc Version 5.2 Page 23 The staff spoke positively about the new manager saying she had encouraged both staff and service users to contribute to the development of the service. Service users are told when inspections take place and they are shown inspection reports. These are also summarised and discussed in service user meetings. Copies are available for relatives and others to see. There is a good quality assurance system in place. Service users are consulted and their views are sought and acted upon. Relatives and professionals are also consulted. The Trust has developed a range of policies and procedures which have been linked to the National Minimum Standards. The records inspected were found to be appropriately completed. These included the fire log book, accident book, personal allowance records and Health and Safey manual. There are appropriate maintenance contracts in place. Water storage tanks, gas and electrics are checked annually. DS0000000568.V299761.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 4 2 3 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 4 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X 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 X X 3 X DS0000000568.V299761.R01.S.doc Version 5.2 Page 25 Yes 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 YA21 Regulation Requirement Timescale for action 01/12/06 12, 13, 18 Staff require training for ageing, dying and death/palliative care. Procedures need to be developed and made available to staff in the home. Outstanding since June 2006 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 YA32 Good Practice Recommendations Provide staff with equality and diversity training to enhance there awareness of diversity issues. DS0000000568.V299761.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 DS0000000568.V299761.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. 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