Inspection on 31/10/05 for Hirst Villas, 6

This inspection was carried out on 31st October 2005.

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 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 18/09/06

Hirst Villas, 6 25/04/05

Hirst Villas, 6 06/12/04

Hirst Villas, 6 09/06/04

Similar services:

22 Sandown Road

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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 Announced Inspection 31st October 2005 09:30 Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 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.V249330.R01.S.doc Version 5.0 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.V249330.R01.S.doc Version 5.0 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) Northgate & Prudhoe NHS Trust Mrs Shelagh Burgess Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th August 2002 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 homes front and rear gardens are landscaped and easily accessible. Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second annual announced inspection visit. It took place over 3 hours during the morning and early afternoon. The inspector spoke to two service users separately, three members of staff and the homes registered manager. Time was spent looking at the homes policies and procedures and the service users care records. What the service does well: 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. Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 Page 6 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.V249330.R01.S.doc Version 5.0 Page 7 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): 1235 The homes statement of purpose and service users guide will provide prospective service users with sufficient information to enable them to make an informed choice about the home. Prior to admission all service users needs were appropriately assessed. All service users are provided with a copy 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. One of the service users interviewed confirmed she had been given a copy of the guide. Which are available in a range of formats. The standard contract contains a range of information required by the standards. One service user interviewed confirmed she had a copy of her individual contract. The service users’ file checked included a copy of a full needs assessment. This was carried out by the referring social worker. The assessment contained a range of appropriate information and the service user interviewed confirmed she was involved in drawing up both these initial assessments and the home’s subsequent service user plan. Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 Page 8 Two service users interviewed said their needs were met and they were happy with the care offered to them. Staff had had a range of relevant training and experience. Admissions to the home are very rare, however the home does have appropriate admission procedures in place. Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 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 8 10 The service users care plans are holistic and cover all aspects of health, personal and social care. The service users are consulted about their individual care needs and are treated with dignity and respect at all times. EVIDENCE: There was evidence of a comprehensive assessment in the service users’ care plans. There is also a comprehensive risk assessment of service users. There was evidence of advocacy arrangements, as well as family input. Each service user has an allocated key worker. Care plans are drawn up with service users. There is evidence that plans are amended and reviewed on a regular basis. Self-advocacy is promoted, service users can access a range of external agencies that promote independence, and any rights that are restricted are linked to risk assessments. Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 Page 10 Each service user receives support from staff to manage their finances. Both service users said that they are able to make decisions for themselves, the service users are aware of their individual records that are kept and that they are secure and confidential. Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 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): 11 13 14 16 17 Staff play a key role in supporting service users to live fulfilling lives outside as well as within the home. There is a high priority to ensure that each service user is provided with the opportunities for personal development and independence and integration into community life and leisure activities. The menus are balanced varied and healthy. EVIDENCE: Each service user has a practical life skills assessment carried out and this is reviewed and updated every six months, all service users participate in this process, and their relatives are invited to attend. The service users said that they have access to a range of community-based services, which promote and provide opportunities to learn and use life skills. There was evidence that each service user has the opportunity to participate in community-based activities, including education and training. The staff team liaise closely with external agencies in order to monitor each service user progress. Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 Page 12 The service users said that they are supported to maintain very close links with their families. All are able to choose who they want to see and when. There was evidence that daily routines promote independence, choice and freedom of movement. Two of the service users are involved in housekeeping tasks. The Home’s menus are based on the known likes and dislikes of the service user and the menus promote healthy eating. At least two hot meals are provided on a daily basis. Service users have access to the kitchen and are able to prepare snacks for themselves if they wish. The service users that I spoke with said that the food was very good and that she helps with the food shopping. Nutritional assessments are completed for all three-service users. A range of special diets can be catered for. Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 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): 19 20 21 All service users health care needs are identified and fully met. Staff have been trained to administer and handle medication. Staff training is needed in order to deal with ageing, illness and death, appropriate policies and procedures will need to be developed. EVIDENCE: The service users said that privacy and dignity are respected at all times. No service users currently have or require any technical aids or equipment inside the home. There was evidence within the service users care records that they have access to external health care services. G.P.’s visit when necessary, and service users are referred for specialist health care if appropriate. All service users receive regular health care checks. The records and the procedures for the administration of medication were examined; these appeared to be appropriately detailed. The medication systems were examined for ordering, receiving and administering and disposal. All were well maintained. All staff had received medication training. Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 Page 14 The staff will require training relating to ageing, illness and death/palliative care and appropriate procedures should also be made available. The service users wishes relating to aspects of standard 21 are recorded, and where appropriate their relatives have been consulted to aid this very sensitive process. Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 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 The Health Care Trust have clear procedures that enable service users to make their views known and reassure them that appropriate action will be taken. The service users were confident that the homes manager and staff take their views seriously. EVIDENCE: The home does have a complaints procedure, it contains details of how to contact the CSCI to make a complaint, that complaints would be responded to and that complainants would not be victimised. One service user interviewed confirmed that she had been given a copy of the procedure and that staff listened to her concerns and dealt with them fairly. The home does keep a record of complaints. In the last twelve months there have been no complaints received. The home has a Whistle Blowing policy procedure as well as, the Local Authorities Vulnerable Adults procedures. The home also has a copy of the D.H. “NO SECRETS” for further information. The Home maintains detailed financial records on behalf of the service users; each has an individual bank account. There was evidence of personal spending and receipts are kept. Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 Page 16 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): These standards were not inspected during this inspection visit; all standards were met during the last inspection carried out on 5.4.05. EVIDENCE: At the previous inspection visit the home was extremely well maintained and provided a very comfortable and safe environment for the service users. Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 Page 17 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): 31 32 34 35 36 The staff team have the qualities, training and support required to meet the assessed needs of the service users. The staff team are highly motivated and competent; they understand the purpose of the home and the key values that underpin the standards. Staff recruitment is well managed and appropriate checks are carried out. Staff receive regular supervision sessions. EVIDENCE: Staff levels on the day of the inspection continue to meet the agreed level. Samples of 4 weeks’ rotas were checked and these stated the required numbers of staff were on duty at all times. The staff interviewed confirmed that the Trust has a thorough recruitment process which includes obtaining two written references, obtaining full employment histories and checking gaps in these, a criminal records check, medical checks, obtaining proof of ID and of any qualifications. During the last twelve months there have been no changes to the staff team. The training needs of staff are identified via supervision and appraisal sessions. Staff receive a minimum of three days paid training. Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 Page 18 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 38 39 42 The home has a confident and skilled manager she promotes an atmosphere of openness and respect. A quality assurance system operates that seeks the views of service users, relatives and other professional involved with the home. The health and safety of the service users is safeguarded and protected. EVIDENCE: The registered manager has many years experience in senior management and is working towards a level 4 National Vocational Qualification in management and care. In the last year all of the staff team have attended several courses to keep themselves up to date. The staff team are very organised and are aware of their responsibilities. The service user interviewed spoke positively about the manager and the staff saying “they were very kind and helpful”. Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 Page 19 The home does have a quality assurance system, which seeks the views of service users, via meetings and questionnaires. Service user and relative’s meetings also take place regularly. The home also has an annual development plan. The service user interviewed confirmed that she felt involved in the process and that it had improved the quality of care offered. The manager said others are asked for their views of the home eg – GP’s, District Nurses and advocates are sent questionnaires. Service users are informed when inspections take place and have access to inspection reports. These are also summarised and discussed in service user meetings. Copies are on display for relatives/others to see The records inspected were found to be appropriately completed, these included the fire log book, accident book, personal allowance records, Health and Safey manual, and information which verified that appropriate maintenance contracts for the home are in place. Finance records have previously been forwarded to the CSCI to verify that the home is viable. Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 x 3 Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 3 12 x 13 3 14 3 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hirst Villas, 6 Score x 3 3 2 Standard No 37 38 39 40 41 42 43 Score 3 3 3 x x 3 x DS0000000568.V249330.R01.S.doc Version 5.0 Page 21 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. 1 Standard YA21 Regulation Requirement Timescale for action 01/06/06 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. 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 Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 Page 22 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 Hirst Villas, 6 DS0000000568.V249330.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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