Inspection on 30/07/07 for Hirst Villas, 6

This inspection was carried out on 30th July 2007.

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

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

Other inspections for this house

Hirst Villas, 6 15/04/08

Hirst Villas, 6 18/09/06

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:

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Dilston College Of Further Education

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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 Unannounced Inspection 30th July 2007 10:00 Hirst Villas, 6 DS0000000568.V343469.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 Hirst Villas, 6 DS0000000568.V343469.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. Hirst Villas, 6 DS0000000568.V343469.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 Vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th September 2006 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. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Summary: How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service and, staff. The Visit: An unannounced visit was made on 30.7.07. During the visit we: • • • • • • Talked with people who use the service and the staff. Case tracking, this tells us about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the staff about what we found. What the service does well: Admissions to the home are rare; the home makes a full assessment of a person’s needs before deciding if it can meet all those needs. The home draws up detailed plans to meet the care needs of its service users. Their health care needs are also fully assessed and properly met. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 6 The home stores medicines safely, and administers them correctly and safely. Both service users present on the day of the inspection say that staff treat them well and treat them with respect. The home continues to support service users to use a wide range of social activities in the community. One service user has recently been to Paris and two others are going on holiday to Spain. Service users are encouraged to keep in regular contact with family and friends, and they are always made welcome in the home. All are also encouraged to take as much control over their own lives, as they are able, and make their own decisions. Service users were very complimentary about the food, and there is a balanced diet, with a good choice included. Complaints and concerns are taken very seriously and are responded to properly. The home is kept clean, hygienic and free from odours. The Trust is very careful as to how it recruits new staff, and runs all the necessary checks on them to protect its service users. The manager is experienced and the staff and service users said, she is providing very positive leadership to the home and that the home is being run in the best interests of the service users. Service users’ finances are protected by the home’s policies and accounting systems. The health and safety of the service users and of the staff are protected by the home’s policies and systems. What has improved since the last inspection? Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 7 Plans are in place to deliver training, which includes equality and diversity. There are plans to install a mermaid bath hoist, and this will help to promote service users independence. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 8 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 Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are provided with enough information about the service to enable them to make a choice about where they want to live. All service users are appropriately assessed prior to admission into the home. All are provided with a written contract explaining their terms and conditions with the home. 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. However both need to be updated to reflect the current staff and management arrangements. Three service users’ files were checked and each included a full needs assessment. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 10 The 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 and I am happy with the care I receive, the staff are very good at listening to anything I have to say, and they always have plenty of time for me and the others”. The staff member interviewed had had a range of relevant training and experience, and she had good knowledge of each service users care needs. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. Advocacy arrangements continue, as well as family input, to represent service users. Each service user has an allocated key worker, and service users are involved in choosing their key workers. Care plans continue to be drawn up with service users, and these are amended and reviewed on a regular basis. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 12 There are systems in place that will ensure that the placement and the service users plans are reviewed annually. These involve the care managers and the service users 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. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The meals in the home are good, offering both choice and variety. The service users have opportunities for personal development and leisure activities. They are supported to maintain very good links with the community and their relatives and friends. EVIDENCE: Each service user has daily life skills assessment carried out. This is reviewed and updated on a regular basis. All service users participate in this process. Service users use a range of community-based services, which promotes and provides opportunities to learn and use life skills. One service user continues to attend college, she said, “College is good, I have made lots of friends there, and we enjoy nights out together”. The service has its own transport. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 14 All service users will have a holiday abroad this year, one has already been to Paris, and two others are going to Spain. Service users are supported to live a normal life in the community. They are supported and encouraged to be in control of their own lives, to enjoy their own interests and to continue their education. 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. Daily routines promote independence, choice and freedom of movement. Service users are involved in housekeeping tasks. The Home’s menus are based on the known likes and dislikes of the service users. At least two hot meals are provided each day, the service users also help to prepare meals, and help with the food shopping. Service users have access to the kitchen and can prepare snacks for themselves if they wish. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health care of the service users is met and there is good multi disciplinary working taking place. The promotion of health care needs is taken seriously. Medication systems are well managed. Personal support is always provided in the way that service users prefer. EVIDENCE: Privacy and dignity are respected at all times. Service users care records showed that they have access to external health care services. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 16 G.Ps visit when necessary. Service users are referred for specialist health care if appropriate. All service users receive regular health care checks. An occupational therapist has recently visited the home, and she has recommended that the bath should be fitted with a mermaid bath hoist, as this will help to promote the independence of two service users who are both finding it increasingly difficult to use the bath independently. The medication systems were examined for ordering, receiving, administering and disposal. All were found to be well organised. All staff has had accredited medication training. Controlled drugs are not currently prescribed. Should this change; appropriate systems and procedures will be put in place. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good, clear, user-friendly complaints system and service user’s views are listened to and acted upon. Procedures are in place to protect service users from harm, and these are followed. 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 homes investigation and response. The procedure is written in a way that ensures service users fully understand its contents. Service users said that they had been given copies of the procedure and that staff listened to their complaints and dealt with them fairly. The home keeps a record of complaints. Since the last inspection visit, there have been no formal complaints. However, there was one incident involving a staff member, this was dealt with immediately by the manager and the Trust, and appropriately resolved. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 18 The home has a Whistle Blowing policy and the Local Authorities Vulnerable Adults procedures. The home also has a copy of the Department of Health’s document, “NO SECRETS”. Safeguarding adults training is on-going for all staff. The Home keeps detailed financial records on behalf of the service users. Each has an individual bank account. Residents can deposit cash for safe keeping in the home’s safety box and records are kept of accounts. A sample of personal finances records was examined. Transactions were appropriately recorded and had signatures for each entry. There was plenty of evidence of personal spending. Receipts are obtained for purchases and numbered to crossreference to the transaction. Weekly checks of balances and cash are carried out. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 26 27 28 29 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and safe environment for those living there. The standard and decoration within the home is very good. Communal areas and bedrooms are large, and meet the service users needs. All areas within the home are well maintained, clean, tidy and free from offensive odours. EVIDENCE: The home was clean, well decorated and well maintained. The home is in a residential location, near to the main shopping centre of the town. The grounds were tidy, safe, attractive and accessible, and service users have access to a highly attractive summerhouse. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 20 The home has an attractive lounge, dining room and kitchen; all are nicely decorated, and very homely. Service users can see visitors in private in their own rooms. Furnishings and fittings were domestic in design and in very good condition. Lighting was bright and domestic in design. Service users’ bedrooms have privacy locks, opening windows. The rooms were centrally heated and the heating level could be controlled within each bedroom. Radiators and pipes were guarded. All rooms are well decorated and furnished, and highly personalised. 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 clean and free from offensive odours. The laundry facilities are located in the garage and are well organised. The washing machine has the specified programme to meet disinfection standards. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good match of well-qualified staff offering consistency of care within the home. There are robust procedures in place for the recruitment and selection of new staff, which helps to protect service users. The staff receives supervision and this provides them with a good understanding of the service users support needs. EVIDENCE: Staff levels on the day of the inspection met the agreed level. Samples of 4 weeks’ rotas showed the required numbers of staff were on duty: usualy 2 staff between 8am and 9pm with one sleep-in between 9pm and 8am. All the staff were over 18 years of age and those left in charge were at least 21. Training needs of staff are identified in supervision and appraisal sessions. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 22 Over 50 of the staff have completed NVQ level 2 and above, and the Trust has a very good staff training and development programme in place. The Trusts training programme meets The National Training Organisation requirements for the first six months. Staff said they receive three days paid training. The Trust has a rigorous staff recruitment and selection process to ensure that all appropriate checks and references are in place prior to employment. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is supported by the Trust in providing clear leadership throughout the home with staff demonstrating an awareness of their roles and responsibilities. The systems for service users’ consultation are good, and service user’s views are both sought and acted upon. The health and safety of the service users is promoted. The service is aware of equality and diversity and its implications. EVIDENCE: Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 24 The manager has many years experience in senior management within the Trust, however she has yet to be approved as the registered manager by CSCI, and she will need to complete the registered managers award within the next six months, the latter has been delayed due to some health issue, that are now resolved. The staff member on duty was clear about her responsibilities and the service users care needs. She said, “The manager always puts the needs of the service users first, she is a very good manager”. 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 health and safety policy and range of associated procedures. Staff receives training in health and safety and safe working practices (fire safety, moving and handling, first aid, food hygiene, and infection control). The home holds regular meetings to discuss issues, and service users are invited to attend. Servicing and maintenance agreements are in place for facilities and equipment. Risks in the environment and tasks, including safe working practices are assessed and reviewed. All fire safety checks, tests and instructions to staff are conducted at the required frequency and recorded. Accident reporting was suitably recorded. Water storage tanks, gas and electrics are checked annually. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 25 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 3 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 4 25 4 26 4 27 4 28 4 29 4 30 4 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 4 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 1. 2. Refer to Standard YA37 YA1 Good Practice Recommendations The manager must complete the registered managers award within the next six months, and complete an application to become the approved registered manager. Up-date the service users guide and statement of purpose to reflect the current staffing and management arrangements. Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hirst Villas, 6 DS0000000568.V343469.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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