Inspection on 16/02/07 for Kingswalden Villa

This inspection was carried out on 16th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kingswalden Villa 16/01/09

Kingswalden Villa 30/01/08

Kingswalden Villa 06/02/06

Kingswalden Villa 22/08/05

Kingswalden Villa 13/01/05

Kingswalden Villa 07/06/04

Kingswalden Villa 12/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Kingswalden Villa 40 The Baulk Biggleswade Bedfordshire SG18 0XS Lead Inspector Mr Ian Dunthorne Unannounced Inspection 16th February 2007 10:00 Kingswalden Villas DS0000014921.V330765.R02.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 Kingswalden Villas DS0000014921.V330765.R02.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. Kingswalden Villas DS0000014921.V330765.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kingswalden Villa Address 40 The Baulk Biggleswade Bedfordshire SG18 0XS 01767 318674 F/P 01767 318674 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) www.hft.org.uk Home Farm Trust Mr Ian Chambers Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Kingswalden Villas DS0000014921.V330765.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th February 2006 Brief Description of the Service: Kings Walden Villas is one of five registered care homes within Bedfordshire that are managed by Home Farm Trust. HFT is a nationwide provider for people with learning disabilities. Kings Walden Villas is situated in a residential area of the market town of Biggleswade, and is a short distance from the local HFT headquarters and day care facility in Shefford. The home is within walking distance of the towns shops, public houses, cafes, bus and rail links. A leisure facility with swimming pool is a short car journey away. The home does not have off road parking. The building was originally used as a private domestic dwelling. It has been sympathetically converted to retain its homely environment, and provides single accommodation to eight adults with learning disabilities organised on two levels. Communal space consists of toilet and bathing facilities, a lounge, dining room and kitchen. In addition, at the rear of the property is an all weather conservatory that leads to a small-enclosed garden. Within the garden, is an outbuilding that is used for combined storage and laundry purposes. The home is not currently adapted to accommodate people with physical disabilities. Information regarding the home’s range of fees and the manager’s figure provided in the pre-inspection questionnaire in January 2007 stated that the monthly fee ranged from £2098.40 to £2609.78. Any additional fees not included were also specified and that they would incur an additional charge. Kingswalden Villas DS0000014921.V330765.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over four hours during the afternoon & evening and it was unannounced. Prior to the inspection time was taken to review the information gathered since the last inspection and plan this inspection visit. This report also includes feedback from relatives and visitors obtained from postal comment cards. The inspection included a tour of the communal areas and several bedrooms, inspection of certain records, discussion with staff and the person in charge, discussion with service users, their relatives and observation of the routines of the home. The method of inspection was to track the lives of several service users. This was done by speaking to them about the service they receive, observing their life in the home, talking to staff and relatives and reviewing their records. What the service does well: What has improved since the last inspection? What they could do better: Some of the things that the home could do better include: Kingswalden Villas DS0000014921.V330765.R02.S.doc Version 5.2 Page 6 • Making sure that service users or their families are involved in preparing information about them, to help the home meet their needs. Then checking the information regularly and making any changes needed to it. Assessing, monitoring and reviewing service users health and diet. Providing enough training for staff, which would help them understand and meet some of the needs of the people living at the home. Making sure that there are enough staff working during the weekend evenings, to support and safeguard the service users. Asking for the views of service users and others about what they think of the home and any suggested ideas for improvement. Then producing a plan, showing how they will act upon those views and carry the plan out. • • • • 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. Kingswalden Villas DS0000014921.V330765.R02.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 Kingswalden Villas DS0000014921.V330765.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided information about its facilities and services, which were supported by needs assessments to enable prospective service users to make an informed decision about admission to the home. EVIDENCE: Six out of seven of the respondents to the surveys sent to the service users, said that they felt they were given enough information about the home to make an informed choice about whether to live there. The homes service user guide was available in a suitable format for some of the service users intended and provided information to enable prospective service users to make an informed choice about where to live. Service users and relatives who were spoken with as part of the inspection supported that evidence. There was evidence that the home had assessed the needs of a prospective service user and demonstrated that the method and system for doing so provided a satisfactory form of assessment. The method of assessment involved the service user, the family and other individuals referred to as part of the service users care management process. Kingswalden Villas DS0000014921.V330765.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user plans contained satisfactory information, however further development was needed to ensure both the plans and risk assessments were reviewed and updated at regular intervals. To ensure they accurately reflected service users changing needs and associated risks to enable the home to meet those needs and minimise risk to service users. EVIDENCE: A sample of the service user’s plans and supporting documentation were examined and found to contain suitable and sufficient information to help meet their changing needs and personal goals were identified and reflected in their individual plan. A suitable keyworker was allocated for each service user. The plan was made available in a format the service user could understand and a person centred planning (pcp) approach was used successfully. However, there were some areas that required further development. There was evidence that the plans had been reviewed, although this had not been achieved at suitably regular intervals; not all service user plans demonstrated evidence that the Kingswalden Villas DS0000014921.V330765.R02.S.doc Version 5.2 Page 10 service user together with their family, friends and / or advocate as appropriate had been consulted and several had not been dated or signed by the staff member completing the information to validate them. All respondents to the postal comment cards said they either always or usually made their own decisions about what to do each day. There was evidence from speaking with service users and records examined that service users were assisted as necessary to make decisions about their daily lives. An advocacy alliance service visited service users at regular intervals once monthly and service users were supported by staff to participate if they wished. Staff were observed communicating in ways appropriate to each individual service user, to enable them to make an informed decision in a way the service user could understand. It was evident by observation, that service users were offered the opportunity and participated in the day to day running of the home and contributed towards any proposed changes within the home, to influence any decisions reached. One service user said, “this is our house & the staff are here to support us, but we must take responsibility and look after the house ourselves and take jobs in turn”. The home had a notice board for service users, which provided information in a suitable format about various activities, services, policies and procedures. There was evidence that service users were consulted about all aspects of life within the home at service user meetings that were held regularly. There were risk assessments in place as part of the homes risk assessment strategy to enable service users to take risks supported by staff, however some had limited value because several of those examined had not been regularly reviewed, dated or signed and some risks on ‘Health Action Plans’ had not been identified. There was no evidence that service users who were self-administering their own medication had been risk assessed to ensure their safety, see also ‘Personal & Healthcare Support’ section of this report. A risk assessment identifying the hazards to individual service users, of the external laundry and its associated equipment and chemicals in a separate out building was also absent, see also ‘Conduct & Management of the Home’ section of this report. Kingswalden Villas DS0000014921.V330765.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home and staff support the service users to pursue meaningful leisure activities, education, relationships & community links. However further development was required, to ensure that service users nutritional needs were assessed, monitored & reviewed to ensure that their health and wellbeing was maintained. EVIDENCE: The home was supporting two service users who wished to develop and improve their independent living skills, as they wished to be supported to live independently eventually. The home supported service users to attend college and many were also supported by the home to regularly visit a resource centre, which provided planned educational and training activities; also a local leisure centre, library, cinema and access a range of holistic natural therapies provided locally. The Kingswalden Villas DS0000014921.V330765.R02.S.doc Version 5.2 Page 12 internet was also provided and used by service users within the home for educational as well as leisure purposes. The home’s notice board for service users displayed information about local activities. Service users were able to access and use local public transport facilities available close to the home; one service user used public transport to travel to college each day. Service users were supported by the home to pursue their own interests and hobbies. One service user had been supported by their keyworker to visit a local radio station as they wished to pursue this interest and another service user visited a holistic therapist locally when they wished to. One relative spoken to said that service users are supported by the home to attend and pursue their interests in any local external clubs and activities available. Two service users had indicated in their postal comment card responses that they would like to be supported with activities at the weekend; this evidence was supported by some service users who were spoken with. Evidence examined suggested that the cause for a reduction in staff supporting service users with weekend activities, was as a result of a lower staff ratio as opposed to during the week see also ‘Staffing’ section of this report. There was evidence that the home supported service users to maintain family links and friendships inside and outside the home, in accordance with their wishes, which included intimate personal relationships. This evidence was supported by responses within service user surveys and service user plans which identified sexuality and relationships. Staff were observed knocking on service user’s bedroom doors before entering and waiting to be invited into their bedrooms. Those service users who wished to were supported to keep their own room keys. Service users responsibility for housekeeping tasks was specified within a rota devised by the homes service users. One service user explained that each service user took it in turn to complete a task, which they believed was fair and the tasks rotated at regular intervals. Service users were observed during a mealtime enjoying well prepared and presented, home cooked and appetising food in suitably sized portions and the menu’s examined supported this. Although the menu’s were not in a suitable format to enable all service users to make an informed choice. Not all service users had the opportunity to be involved in devising the fortnightly menus, however service user’s who were supported by staff to undertake the food shopping were rotated to include all service users. There were no set mealtimes as such, as the service users preferred the flexibility and this also suited their individual evening activities. Service users were observed being supported by staff to clean and tidy up after the meal. There was evidence that not all service users nutritional needs were being assessed at regular intervals, therefore risk factors associated with weight change were not being monitored. Kingswalden Villas DS0000014921.V330765.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The systems for the administration of medication were satisfactory. However further development was needed to ensure that service users who wished to self-administer their own medication, were assessed by the home to do so, to safe guard the health and well being of service users. EVIDENCE: Service users spoken to said they enjoyed living at the home and that they felt supported by the staff. Records viewed suggested service users received personal support in the way they preferred and most were encouraged to maximise their independence. This was supported by observations and discussions held with service users. Each service user had a key worker, who they were each able to identify and those service users spoken to said they were happy with the support from them and the relationship they had developed with them. All respondents to the service users surveys said that they were treated well by staff. One service user said “the staff always speak nicely to me and they are helpful, I like living here and the best thing about it is my keyworker” Kingswalden Villas DS0000014921.V330765.R02.S.doc Version 5.2 Page 14 There was evidence that the home accessed outside healthcare professionals and services as required; in order to support and meet the healthcare needs of the service users. Further development was required to ensure that the health action plans for individual service users were completed in full by the home and reviewed. Service users had been supported to complete medical consent forms. One service user was supported by the home to manage their medical condition and although a service user plan was in place to support this, an associated risk assessment was absent. In addition the associated service user plan had not been signed by the service user or their representative to acknowledge their consultation and agreement. The home had ensured that care staff were trained in medication and the procedures implemented suggested that service users safety was being maintained in most areas. Staff observed supporting service users with and administering medication to service users appeared competent and confident. However there was no evidence that those service users self-administering their own medication had been assessed to do so by the home. Kingswalden Villas DS0000014921.V330765.R02.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. 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 arrangements for protecting service users were good and the home maintained an effective approach to complaints within a satisfactory system. This helped to ensure service users were protected from abuse and to feel that they views were listened to and acted upon. EVIDENCE: The home had a satisfactory complaints procedure that ensured service users felt their views were listened to and acted upon. The complaints procedure was produced in a format appropriate for service users to understand and access. There had been two internal complaints since the last inspection both between service users, evidence demonstrated that they were managed in a way that ensured the service users involved were listened to and their views acted upon which complied with their policy and evidence of the process was recorded. Relatives spoken to were aware of the home’s complaints procedure and felt comfortable and confident to use it and that they would be listened to. All respondents to the postal comment cards said they knew how to complain and who to speak to if they weren’t happy, this evidence was verified by those service users who were spoken with during the inspection. The home had a Protection of Vulnerable Adults (POVA) policy in place, which included whistle blowing and staff spoken to demonstrated they were aware of the procedure. Most staff had also attended abuse awareness training, which included POVA; POVA training was also included and formed part of the homes induction process for staff. Since the last inspection there had been no Kingswalden Villas DS0000014921.V330765.R02.S.doc Version 5.2 Page 16 notifiable incidents at the home in accordance with the POVA policy and guidance, which required reporting to CSCI. The homes policies and practices regarding service users money and financial affairs were generally satisfactory and protected service users from abuse. There was evidence that the home was about to introduce a revised policy for the management of service users money and finance, to improve and ensure robust practices were followed. Kingswalden Villas DS0000014921.V330765.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home was satisfactory. However some areas appeared ‘tired’ and further development was needed to improve infection control practices to maintain a pleasant and safe environment for service users. EVIDENCE: The home provided a homely environment; the building had been sympathetically converted from private houses. The location and layout of the home were suitable to meet service users individual and collective needs. The home was close to local amenities and transport if required. The local fire service or environmental health department had not visited the home since the last inspection. The home had built a level patio to ensure the safety of service users when they walk to the out building for laundry purposes since the last inspection. Kingswalden Villas DS0000014921.V330765.R02.S.doc Version 5.2 Page 18 Most service users spoken to were happy with their individual bedrooms and they had free access to them, one service user said they had chosen the decoration themselves with the support of the home and their family. Service users had been encouraged to bring or choose their own furniture and those bedrooms observed had been personalised to reflect their needs and lifestyle. Toilets and bathrooms were safe and suitable for their intended purpose and were in appropriate locations. Each were lockable and maintained service users privacy, however staff were able to override this feature in an emergency. The decoration in some toilets and bathrooms appeared ‘tired’ and in need of redecoration. The home appeared clean and generally free from offensive odours, service users, care staff and night staff were responsible for ensuring this was maintained. However some communal toilets and bathrooms within the home, had a communal towel in as the only facility to dry your hands on after washing them. This was not an effective infection control system that was consistent throughout the home. In addition a communal bathmat was in place in one bathroom, which also presented a slip and trip hazard. Kingswalden Villas DS0000014921.V330765.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing numbers to meet the needs of the service users were satisfactory during the week, however this was not always the case at weekends. Therefore the health, safety and wellbeing of service users was being compromised placing them at potential risk during some weekend evenings. EVIDENCE: Staff spoken to identified varied training which they had undertaken at the home and this was supported by evidence in their training records. There was evidence that some staff had received specialist training to support them to meet the needs of the service users. The percentage of staff qualified at nvq (national vocational qualification) level 2 or 3, fell below the minimum required level of 50 . Staffing level numbers within the home were maintained to meet the appropriate ratio based upon the needs of the service user during the weekdays. However staffing level numbers fluctuated based on how many service users were in the home, they sometimes reduced at the weekends particularly if several service users had gone away; this then impacted upon service users social activities at weekends, see ‘Lifestyle’ section of this report. Kingswalden Villas DS0000014921.V330765.R02.S.doc Version 5.2 Page 20 In addition there was evidence that as a result, staff numbers were regularly falling below the ratio required during some weekend evenings, which was disappointing to find as this was made a requirement at the last inspection. The homes recruitment process’s and practices were unable to be inspected, as the manager was not present, therefore access to the necessary information was not available. However, there was evidence that the home maintained a low turnover of staff and agency staff usage. Evidence from speaking to staff and examining the homes training records supported that there was no training and development plan in place for the team as a whole. In addition although staff had received varied training, several had not received any training for some time, records indicated some had not received any training in the past twelve months. Staff spoken to supported that they received regular supervision. Kingswalden Villas DS0000014921.V330765.R02.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. 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. Service users’ views were sought but there was no evidence that this changed how the home was run. Some aspects of the homes health & safety, safe working practice procedures and risk assessments, needed further development to ensure service users & staff would be protected from the risk of harm. EVIDENCE: The manager was not present during this inspection. However there was evidence that the manager was qualified, competent and experienced to run the home. Developing and maintaining an effective quality assurance system within the home, was set as a requirement at the last inspection and had still not been Kingswalden Villas DS0000014921.V330765.R02.S.doc Version 5.2 Page 22 fully complied with. There was evidence that the manager had made some progress since the last inspection but had yet to complete the full quality monitoring cycle, which could then be maintained systematically. Some aspects of the homes health & safety safe working practices, required some improvements to protect service users from potential risk or harm. See ‘Environment’ section of this report. Various records were examined to support adequate compliance with safe working practices, regarding health & safety including generic risk assessments for the home and various tasks. The home used a traffic light hazard warning system for storage and control of substances hazardous to health (COSHH). A risk assessment identifying the hazards to individual service users, of the external laundry and its associated equipment and chemicals in a separate out building was also absent and the generic risk assessment regarding laundry process’s, did not identify all the potential hazards and was insufficient. Kingswalden Villas DS0000014921.V330765.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 X 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X X 2 X Kingswalden Villas DS0000014921.V330765.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 YA6 Regulation 15 (1) Requirement All service user plans must be reviewed on a regular basis and changes made where necessary and service user plans must be prepared in consultation with the service user or their representative. Timescale for action 30/04/07 2. YA9 3. YA17 13 (4) (a), (b), (c) & 15 (2) (b) 12 (1) (a) & 13 (4) (c) Risk assessments must be 30/04/07 reviewed by the home at appropriate and agreed intervals. People who use the service must have their nutritional needs assessed by the home and reviewed at regular intervals, including risk factors associated with weight. People who use the service and wish to self-administer their own medication, must be assessed to do so by the home. 30/04/07 4. YA20 13 (2) & 13 (4) (b) & (c) 18 (1) (c) & (i) 30/04/07 5. YA32 & YA35 Training must be provided for 30/06/07 staff by the home, which is appropriate for the work they are to perform. Arrangements must be made for DS0000014921.V330765.R02.S.doc 6. YA33 18 (1) (a) 30/04/07 Page 25 Kingswalden Villas Version 5.2 7. YA39 24 (1) sufficient numbers of staff to be on shift at all times especially on weekends when all the service users are in the home. The ratio must be 6:1 for service users of medium care needs. This is a requirement set on the previous inspection. The organisation must review the staffing level and respond with a plan on how to address this shortfall identified by staff and service users too. Previous timescale not met: 31/03/06 Arrangements must be made for a quality monitoring system to be implemented within the home, which reflects effective monitoring of the care provided. This was a requirement set on the previous inspection, but was still not met. Extended time scale is now set. Previous timescale not met: 31/03/06 30/06/07 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 YA30 Good Practice Recommendations Disposable hand towels should be provided in communal toilets and bathrooms, to ensure effective infection control practices are not compromised. Kingswalden Villas DS0000014921.V330765.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Kingswalden Villas DS0000014921.V330765.R02.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. 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