Inspection on 02/09/05 for Villette Lodge

This inspection was carried out on 2nd September 2005.

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 3 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 14/11/06

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 Sharon McDowell Announced Friday 2 September 2005 13:30pm nd 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 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 Stationary 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 B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 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 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 only 6 Category(ies) of LD Learning disability (6) registration, with number of places Villette Lodge B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25th May 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. Villette Lodge B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place at 13:30pm until 19:00pm. During the course of the inspection discussion took place with the Registered Manager, two care staff, four residents and one relative. The inspector shared the evening meal with the residents and staff. A range of documentation was reviewed including two residents individual care plans, staff training records, minutes of house meetings and some maintenance records. A pre-inspection questionnaire was submitted to the Commission for Social Care Inspection prior to the inspection by the Registered Manager, which gives details, such as, staffing numbers, policies available, complaints and accidents. One relative comment card and six service users comment cards were returned to the Commission for Social Care Inspection, which give their views about the Home. What the service does well: There is a strong sense of partnership between the service users and staff at the Home. Service users are treated with dignity and respect. There is a family atmosphere evident with a lot of fun going on alongside a good deal of support to service users, enabling them to maintain and develop new skills and confidence in their abilities. The care planning system is well developed and demonstrates that service users are involved in planning their future. Service users are proud of their care plans and see them as being their property and proudly want to show what they have done to help develop their care plan. Villette lodge offers a very comfortable, clean and well maintained home and is in keeping with the age group of the service users living there. Villette Lodge B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 Page 6 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 B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Villette Lodge B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 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 standard(s) 1 Whilst the Home provides and excellent assessment service it is being used as a transitional placement and some service users are being placed there because there is no where else to go therefore this might not be in the best interests of the service user. The Home’s statement of purpose does not accurately reflect the service provided therefore prospective service users might not have the information they need to make a decision about staying at the Home. EVIDENCE: As detailed the in the previous report, residents had moved from children’s services as they had turned eighteen and it is planned for further young people to move in to the Home under these circumstances. Staff are concerned why assessment of needs had not been done in their previous home so that the young people can move directly in to their own accommodation instead of a transitional halfway situation. This use of the service is not detailed in the statement of purpose therefore the document is not an accurate reflection of the service provided at the Home. Villette Lodge B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 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 standard(s) 9 Service users are supported to take risks within a risk management framework. Therefore service users are able to remain safe and have their independence promoted. EVIDENCE: Risk assessments are contained in the service users individual care plan. One service user explained there risk assessments for travelling, staying in the Home on her own and going to the shops. Another service user had risk assessments for going to the shops, making hot drinks, using money and crossing roads. The risk assessments are completed in great detail and include information about the benefits of the activity against the risk and, for example, when going out of the Home, guidance to staff what to do if the service user is not back within a given time. One service user explained how they were keeping pictures and receipts of activities as evidence of what they had been involved with. Villette Lodge B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 Page 10 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 standard(s) 16 & 17 Service users rights are respected and routines in the Home encourage them to make decisions and take responsibility for some of their actions. Service users can expect to be supported by staff in their daily lives. Service users are involved in the planning of menus and a good deal of freedom is afforded them in their choices. However, whilst this means they can make independent choices they are not given appropriate support to choose healthy options, which might affect their health and well-being. EVIDENCE: Service users are encouraged to be independent therefore participate in routine activities in the Home, for example, they take care of their own bedrooms, tidying, hovering and laundering their clothes. Each day a specific task is allocated to a service user, for example, cooking, washing the dishes or setting the table for meals. Staff support them in these tasks if required and this all contributes to the assessment process. One service user was keen to show off her bedroom as it had been a little messy at the previous inspection and they had now managed to tidy it up. Villette Lodge B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 Page 11 Staff were seen to be very interactive with residents, which the residents openly enjoyed as they talked to each other and ‘had a laugh’. No area of the Home is ‘out of bounds’ and residents freely come and go around the Home including the office, which again signifies how comfortable relationships are in the Home. Service users assist with the food shopping for the Home. Each service user chooses an evening meal, which they are then responsible for cooking for the other service users and staff who eat their meals with them. Service users are free to help themselves to food. At this inspection and previous inspections there does not appear any restrictions on food despite a number of the service users being overweight. One service user had stated in their personal profile that they would like to follow a healthy eating plan and to see a dietician, which they did do. However there was no care plan or information available to guide staff how to help them with this aspiration. During the evening meal, which was a choice from the fish and chip shop, there was a relaxed family atmosphere, with lots of chatter and good humour. Villette Lodge B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 Page 12 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 standard(s) 19 Service users generally receive good support from care staff to ensure their physical health care needs are met. EVIDENCE: Service users individual care plans demonstrate a good level of knowledge has been gained by staff and documented about each person’s health care needs. There is a specific section in the care plan for medical history and physical health, which are completed in-depth. A range of healthcare professionals are involved in the lives of the people accommodated in the Home, for example, GPs and community nurses. Service users are fully involved in the care plan process and one service user spoke about some of their health care needs and was fully aware of the treatment they required. Concern has been raised in the previous section about the dietary needs of residents and the affect this might have on their health and well-being. Villette Lodge B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 Page 13 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 standard(s) 22 The Home has an open culture and a good complaints procedure, which means service users, can let people know if they are unhappy about something. EVIDENCE: One of the service user explained how they are involved with a tenants group that meets to discuss any issues relating to their accommodation, for example at one of the meetings the issue of neighbourhood watch was raised. This service user said ‘I like living at Villette Lodge, better than my last home as the staff listened to me and are nice’. There are house meetings with written minutes available. However these are not currently produced in any other format to enable people who cannot read to know what happened at the meetings. A service user spoke about a couple of concerns they had raised at the house meeting, which staff had dealt with. They also helped make sure there was a complaints form in each service users bedroom and they were able to locate the complaint procedure in the office. The complaint document is available in picture format to try to make it accessible to more people. Villette Lodge B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 Page 14 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 standard(s) 24 The home is generally well maintained and is reflective of the age group of people accommodated. The layout and design of the Home offers a good standard of accommodation and is in keeping with local housing. Villette Lodge offers a very comfortable home for people to live in. EVIDENCE: This standard was assessed at the previous inspection. However some issues were raised as detailed below. Since the last inspection a new boiler has been fitted. This should now rectify the longstanding problem with heating and hot water supply in the Home. There has also been new lighting and new flooring fitted in some of the rooms, which one of the service users was keen to tell about the workmen being in the Home. Some of the service users complained about the heat at night. Some electric fans have been purchased, which the Registered Manager said will be purchased for all the rooms. There is a problem with opening the windows overnight as they are linked into the alarm system therefore the service users cannot have fresh air in their rooms. Villette Lodge B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 The Registered Provider has a good range of training opportunities available to staff. Therefore there is sufficient competent staff to meet the needs of the service users currently accommodated. EVIDENCE: This standard was assessed at the previous inspection therefore only follow up issues were reviewed during this inspection. Following the previous inspection some staff have been booked on a training course for challenging behaviour, which is essential to give staff the skills to deal with service users who might present with these specific difficulties. The staff training matrix remains difficult to retrieve information easily as it is densely populated with information. Villette Lodge B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The Home is maintained in a satisfactory manner to ensure the health and safety of the service users accommodated. EVIDENCE: One of the service users was bale to show the fire safety plan in their care plan and confirmed they had taken part in the fire drill practices. Again the fire training records for staff are not easy to obtain information about staff attending the required training sessions as directed by the fire authorities. A file is available with certificates of maintenance checks on equipment and services in the Home, for example, electrical equipment, fire extinguishers and alarm system and gas installation. Accident reports are completed and are compliant with the data protection act. Villette Lodge B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 Page 17 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 2 x x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x x x x x 3 2 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Villette Lodge Score x 2 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 Page 18 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 YA1 Regulation 4&6 Requirement The Registered Provider must review the Statement of Purpose to ensure it is clear about the service provided at the Home. The Registered Manager must ensure the service users are enable to make healthy nutritional choices. Fire training records must identify that staff have attended the required number of fire safety training sessions. Timescale for action 31/12/05 2. YA17 12 & 16(2)(i) 23(4) 31/10/05 3. YA42 31/10/05 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 YA22 Good Practice Recommendations The Registered Manager and staff should consider producing the house meetins minutes in alternative formats to the written word to enable service users to access them. The staff training matrix should be simplified to enable easy retrieval of information. 2. YA35 Villette Lodge B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Baltic House Port of Tyne, Tyne Dock South Shields NE34 9PT 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 B52 B02 S32750 Villette Lodge V202336 2 Sep 2005 Stage 4.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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