Inspection on 14/11/06 for Villette Lodge

This inspection was carried out on 14th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Villette Lodge 28/11/07

Villette Lodge 02/09/05

Villette Lodge 25/04/05

Villette Lodge 18/10/04

Villette Lodge 13/05/04

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 Villette Lodge 1 Edith Street Hendon Sunderland SR2 8JS Lead Inspector Gillian McCabe Key Unannounced Inspection 14 & 29th November 2006 09:30 th Villette Lodge DS0000032750.V309117.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 Villette Lodge DS0000032750.V309117.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. Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Villette Lodge Address 1 Edith Street Hendon Sunderland SR2 8JS 0191 553 2165 0191 553 2166 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) Council of City of Sunderland Norma Elizabeth Dougherty Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Nil Date of last inspection 2nd September 2005 Brief Description of the Service: Vilette Lodge is registered to provide personal care to six adults with learning disabilities. The Home specialises in emergency care and assessment, with a view to making recommendations regarding more permanent accommodation. Nursing care is not provided. However there are good links with primary health care and specialist teams. Villette Lodge is a purpose built, six bedroom detached bungalow within its own grounds. The layout of the Home is suitable for the stated purpose. It is well furnished and tastefully decorated. Car parking is available in an enclosed rear yard or to the front of the home on the street. The Home is within easy reach of Sunderland City Centre via public or private transport. Fees for the service are £692.91 per week. Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over two days in November 2006 and was a scheduled unannounced inspection. The inspection included a separate look at the pre-inspection questionnaire (completed by the manager) and any comment cards received from residents and/or their relatives. A tour of the building took place, and a sample of residents and staffing records were looked at. A sample audit of the homes system for receiving, storing, administering and disposing of medication also took place. Time was spent talking with residents throughout the day and meeting one visiting relative. Time was also spent talking with the homes manager, assistant manager and members of staff working at the home. The judgements made in the report are based on the evidence available to the inspector during the inspection and the pre-inspection questionnaire completed by the manager. What the service does well: Staff members encourage everyone to be involved in the running of the home and work closely with residents to make sure support is given to do this. Residents are supported to make and keep links with the local community, friends and family members. One visiting relative described staff as ‘Very good’ and ‘Helpful’. Resident’s comments about the service include ‘The staff are great, they will do anything to help’. ‘Villette Lodge is a lovely place and I am in no hurry to move, but I would like a place of my own’. ‘Villette was good, I liked going to the pub. I also started going to a garden centre, which is good.’ ‘It’s canny’ Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 6 The home has a very warm and welcoming atmosphere and is generally well maintained. The furnishings are of good quality and individual bedrooms are decorated to a good standard. 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. Villette Lodge DS0000032750.V309117.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 Villette Lodge DS0000032750.V309117.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): 2. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to the service. There have been several admissions into the service since the previous inspection. Overall, the service does consider carefully the needs assessment for each prospective resident before agreeing admission. However on one occasion a prospective resident was admitted into the service without requirements regarding assessment, individual planning and conditions of registration being met. EVIDENCE: The home has an admission procedure in place outlining the process prior to admission. Admissions to the service usually only take place if the service is confident it can meet the needs of the prospective resident. However on one occasion a person moved into the service as an emergency admission without any reference to a full needs assessment or consideration of any specialist care that may have been required. Staff did not have access to any care management assessments or profiles prior to the person moving in which is vital to ensure the person receives the correct amount and level of support and care. The person was also over 65years of age, which is older persons category and the service was at the time only registered young adults 18 – 65 category. The service had applied for a variation to the service registration however this was carried out after the person was admitted into the service. Time was spent Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 9 talking with the assistant manager about the importance of pre admission being properly coordinated and the implications of breaching the Care Home Regulations. The assistant manager confirmed that pre admission is usually coordinated and prospective residents are given the opportunity to visit the service to meet residents and staff prior to moving in. As part of the pre admission process, members of staff will also explain the pre admission procedure with prospective residents prior to their admission. This ensures that any prospective residents fully understand the homes terms and conditions before moving in. As part of case tracking two residents files were looked at and one contained a comprehensive assessment. The manager and staff confirmed that the information gathered is used to form the basis of individual care or support plans, which are subject to regular evaluations. The service has a generic agreement known as ‘Your Home’ giving details of the terms and conditions of the placement. The agreement is produced in written words which some residents may have difficulty in understanding. Space is available in the contract for prospective residents or their advocate to write their signature to say that they agree with the terms and conditions however one contract was not signed by the prospective resident or their advocate. A representative from the City Of Sunderland also signs the agreement. The contract also provides space for details of individual fees that are paid by the prospective resident. However, details of fees were not recorded in individual contracts. This kind of information is required by regulation 5 of the Care Homes Regulations 2001 and is important to ensure that residents know what they are paying or expected to pay for. Villette Lodge DS0000032750.V309117.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, & 9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents support plans are in place, which generally reflect individual needs, wishes and aspirations. This ensures that staff always give the correct level and type of support when it is required. Residents are consulted on and participate as much as possible in the running of the home. This helps to promote independence and inclusion. Residents are supported to take some risks within a planned framework as part of an independent lifestyle. However guidelines are not always followed to ensure the correct level of support is given to minimise any potential risks. EVIDENCE: Support plans are in place for all residents. Upon admission, each person is allocated a key worker who has responsibility to start the assessment process in partnership with each resident. The support plans are completed in two separate parts, part one of the support plan is started as soon as a person moves into the home. This part of the plan is used as a working tool and Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 11 focuses on gathering information on what the person can currently achieve and the support a person may need to achieve any new skills. Part two of the plan focuses on future aspirations of the individual. The support plans at Villette Lodge follow the principles of person centred planning and most plans are presented in a format that can be accessed and understood by each resident. Members of staff spoken with at Villette Lodge have a thorough knowledge of resident’s needs, wishes and aspirations and are able to support residents with the ongoing development of support plans. Support plans for one person showed information regarding records of important life events, people involved in the persons life, routines that the person likes to keep, dislikes the person may have, issues relating to mental and physical health, mobility and dietary requirements and details about how the person likes to communicate. Records were also in place giving details how a person prefers to be supported with a particular area of care for example, information about the type of products a person likes to use when bathing were documented. Some parts of this persons plan were incomplete, although the deadline date for completion had passed. It is important that the support plan is completed fully to ensure the right kind of information and support is available and provided. Views of residents are fundamental to the operation of the service. Residents are encouraged and supported with developing skills in decision-making and also with acknowledging their rights and responsibilities on a daily basis. For example, this can be carried out by supporting residents to choose how to plan their day, planning meals and choosing what they want to watch on television. Risk management plans are in place, which identify particular areas of risk for each person and how the person needs to be supported to carry out the risk as part of an independent lifestyle. One persons plan showed details of how support is needed for road safety. Record show that risk management plans are evaluated and details of how a person has progressed are recorded. One person using the service has a risk management plan in place for using the kettle. Information regarding the type of support that is needed is clearly documented in the risk management plan. However during the second visit to the home, the person was observed carrying out the task without the necessary support outlined in the risk management plan. It is vital that risk management plans are followed correctly to enable a person to remain safe whilst promoting an independent lifestyle. Time was spent talking with the person’s key worker and the assistant manager about how to address this. Villette Lodge DS0000032750.V309117.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 & 17 Quality in this outcome area is good. This judgement has been made using evidence gathered both during and before the visit to this service. Residents are supported and assisted to lead active and fulfilling lifestyles by having regular community presence and accessing a range of community facilities. Routines in the home are resident focussed, and changed to meet individual needs when necessary. Meals provided are healthy, varied and attractively presented in a relaxed and unrushed manner. Plans are in place to incorporate a choice of two evening meals to enable residents to have more choice. EVIDENCE: Members of staff at Villette Lodge actively encourage and support residents to access and become involved in meaningful activities of their own choice. Some residents access various groups in the community as well as various leisure and recreational facilities. One resident attends a day service where activities are accessed. Some residents are supported to use public transport to access Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 13 facilities such as the Winter Gardens and various shows at the Empire Theatre. Staff are also committed to the principles of inclusion and promoting good relationships with members of the community. All activities are planned on a weekly basis with residents. Relatives and friends are encouraged to visit the service at any reasonable time throughout the day and evening. One visiting relative said how happy he was with the service provided for his relative although he expressed concerns about his relative’s future. Residents are encouraged to participate in the domestic routines of the home. Staff and residents are involved in devising a daily plan which identifies various tasks such as setting and clearing the table, washing the dishes and preparation of communal meals as part of promoting independence. The weekly plan also identifies choice of meals for each day although residents may change their mind about what they want to eat. Mealtimes are usually around the same time each day to suit individual needs. Residents are supported and encouraged to prepare snacks and beverages independently and with support throughout the day. Several residents were observed helping themselves to hot beverages and snacks during the course of the inspection. There are no restrictions on food in the home and members of staff try to encourage healthy choices as part of healthy eating. One resident talked about how she like to have a treat occasionally and talked about the food provided in the home, her comments included ‘The food is alright’. ‘I can have what I want’ Another resident said ‘You get plenty to eat here’ Examples of meals included in the homes menu include spaghetti bolognaise, fish, potatoes and vegetables, pasta bake, salad and garlic bread. Deserts are available but not recorded in the homes menu. Fresh fruit is available each day. Villette Lodge DS0000032750.V309117.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 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents health care needs are identified and arrangements are in place to ensure they are promoted and met. Robust arrangements are in place to ensure medication is managed well, which promotes the health & well being of residents. EVIDENCE: Comprehensive health profiles are in place giving details of all healthcare professionals involved in each persons health needs. Regular appointments are seen as important and there are systems in place to make sure residents appointments are not missed. Records show that appointments and check ups have been made with professionals such as Chiropodists, Dentist, Optician, Psychologist and G.P. Members of staff confirmed that close contact is maintained with relevant healthcare professionals when necessary, staff support residents with attending to healthcare needs and actively seek advice from health care professionals where necessary. This ensures residents physical and emotional wellbeing is well monitored. Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 15 A sample audit of the homes medication procedures for administration, disposal and storage of medication was carried out. All records looked at were complete and signed appropriately. Sample initials of staff responsible for administration were kept in the medication file and weekly audits are carried out to ensure no mistakes are being made. The assistant manager confirmed that all staff responsible for handling medicines in the home have completed training in Safe Handling Of Medicines, which means all staff have the skills necessary to be fully competent in handling medicines. Villette Lodge DS0000032750.V309117.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 & 23 Quality in this out come area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Villette Lodge has robust procedures in place to ensure residents are protected from harm and to address any complaints or concerns about the service. EVIDENCE: The complaints procedure is produced in written and pictorial format and residents spoken with said they knew what to do if they had any complaints about anything. The assistant manager discussed the homes complaints procedure and how complaints are dealt with and monitored. Records show complaints received into the service are recorded and handled well following the correct procedures. Villette Lodge has a policy and procedure in place, which set out the values, and principles that underpin the homes approach to the protection of residents. This ensures that all residents are protected from harm. All staff have completed training around MAPPVA procedures. Staff are also aware of whom to contact in the event of an alert. Written guidance of the procedures to follow are displayed in the office for all to access. The service is clear when incidents need external input and who to refer the incident to. Residents spoken with during the inspection said they would ‘tell the staff’ if they had any concerns. Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this out come area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents live in a comfortable and warm environment, which is generally well maintained however there are some environmental issues that need attention to ensure the home remains a comfortable place to live. EVIDENCE: Villette Lodge is clean and tidy and residents spoken with confirmed they are happy staying there. One resident said ‘Villette Lodge is a lovely place and I am in no hurry to move, but I would like a place of my own’. Two residents gave a tour of their own rooms and talked about the new chairs that had been purchased and also the combination television and DVD players. One resident said Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 18 ‘My room is nice’ All bedrooms are nicely decorated and residents have their own personal pictures and belongings displayed. The home has sufficient bathrooms and toilets to meet the needs of residents using the service however the bath/shower room has ongoing problems with ventilation and the base of the shower has black residue around the floor, which cannot be removed following regular cleaning procedures. The showerhead is also broken. Repair work has been completed in the homes second bathroom due to a leak, but paintwork has not been finished and plasterwork has been left bare. These issues need to be addressed quickly to enable residents to continue to bathe in a relaxing and comfortable environment. The service has a maintenance file in place for reporting faults, which gives details of all issues reported to Nomad Housing for attention. Staff at the home have reported these issues on a number of occasions to Nomad Housing but they have yet to be resolved. Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before a visit to this service. The service recognises the importance of training and delivers where possible a programme that meets statutory requirements. However training records were difficult to assess to determine if all mandatory training had been carried out. The service has good recruitment procedures that clearly define the process to be followed. EVIDENCE: The manager carries out a yearly training needs analysis for the team, which identifies staff training that is required. The needs analysis is forwarded to the departmental training section where individual training is planned. Some courses have been planned for staff to attend but cancelled due to low turnover of staff requiring this particular area of training. Which means some staff are still waiting to attend various courses. Some staff have completed training in courses about human rights, safe handling of medicines and understanding learning disabilities. Staff spoken with talked about training completed in Intensive interaction, which involves learning about eye contact, facial expressions, personal space, and techniques to use to promote positive interaction. Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 20 The service has training records in place for staff however details of training courses completed are difficult to assess due to the way in which training files are organised. Time was spent talking with the assistant manager about organisation of training files. Two staff files were looked at as part of the inspection and all necessary employment checks and clearances prior to employment had been carried out. This ensures that only suitable staff are employed to support the people who use the service. Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of residents are regularly sought and listened to, and used to shape improvements in the way the home is run. The team work effectively with the manager to ensure Villette Lodge is a safe and pleasant place to live. EVIDENCE: The manager has been in post for a number of years and has the required qualifications and experience to run the home and meet its stated aims and objectives. She is supported by an assistant manager and a team of seven residential officers who work together to provide a good service. The home has a positive approach towards measuring the quality of its provision, which includes gathering the views of everyone who uses the Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 22 service. One member of staff talked about tenants groups that are held regularly to discus any issues relating to the accommodation and service provided. Copies of the minutes are given to residents that do not attend the group to ensure they are informed of all discussions that are held. Staff at Villette Lodge also have regular in house meetings where residents have the opportunity to discuss any concerns or complaints they may have regarding the service. Minutes of each meeting are circulated and produced in written and pictorial format to make it easier to understand for people who may have difficulty in reading written words. As part of quality monitoring the service also receives monthly visits from the departments performance and governance section. Checks are made on aspects of the service such as the environment, staffing issues, records and residents. Reports of internal checks carried out however are not always forwarded to CSCI each month as required under regulation 26 of Care home regulations. The homes manager and staff also take responsibility for carrying out regular safety checks in the home making sure that everything is working, as it should. As a result residents are offered a good standard of support in a safe environment. Fire records kept in the home are up to date and any accidents that had occurred in the home are recorded appropriately. The home continues to notify CSCI of any incidents or accidents under Regulation 37. Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 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 4 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 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 2 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 24 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 YA3 Regulation 14(1) Requirement The registered manager should not provide accommodation to service users prior to the needs of the service user being fully assessed. Contracts must include fees payable and must be signed by residents or their representative. The service user contract/statement of terms and conditions requires further development in order to make it more accessible to people who may have difficulty understanding the written word. Risk management plans must be reviewed and/or revised regularly, and followed correctly to minimise potential risks. Ventilation in bath/shower room must be adequate. All staff must attend training in the management of challenging behaviour. (Previous timescale of 31/10/05 not met) Regulation 26 reports must be forwarded to CSCI on a monthly basis. Timescale for action 30/11/06 2. 3. YA5 YA5 5(1) 17 (2,3) 5(1) 17(2,3) 31/12/06 31/03/07 4. YA9 14(2)(a) 30/11/06 5. 6. YA24 YA35 23(2)(p) 18(1)(i) 31/12/06 31/03/07 7. YA39 26(5)(a) 30/11/06 Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 25 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 YA1 Good Practice Recommendations The Registered Provider should review the Statement of Purpose to ensure it is clear about the service provided at the Home and consider adding an approximate timescale for admission. Staff training files could be better organised to make it clear if staff have completed all necessary training. 2. YA32 Villette Lodge DS0000032750.V309117.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South Shields Area Office St Nicholas Building St Nicholas Street Newcastle NE1 1NB 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 Villette Lodge DS0000032750.V309117.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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