Inspection on 25/04/05 for Villette Lodge

This inspection was carried out on 25th April 2005.

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

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

Other inspections for this house

Villette Lodge 28/11/07

Villette Lodge 14/11/06

Villette Lodge 02/09/05

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 Unannounced 25 April 2005 11:00 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 V219745 250405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Villette Lodge Address 1 Edith Street, Hendon, Sunderland SR2 8JS 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) 0191 553 2165 0191 553 2166 Council of City of Sunderland Ms Norma Dougherty Care Home 6 Category(ies) of LD Learning Disability (6) registration, with number of places Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 18th October 2004 Brief Description of the Service: The Home 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 V219745 250405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six hours and was carried out as part of the annual inspection programme. A tour of the building took place and discussions were held with care staff, the Registered Manager, assistant manager and four of the six residents. Three resident care plans, staff training records and incident reports were inspected. What the service does well: What has improved since the last inspection? This is a home that has little to improve on as it offers a good standard of accommodation, support to residents and an active opportunities for people to be involved with something to do through the day and evenings. Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 Page 6 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 V219745 250405 Stage 4.doc Version 1.30 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 V219745 250405 Stage 4.doc Version 1.30 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) 2 and 3 The home offers a very good assessment service, which means people coming into the Home can expect to he helped find the right accommodation when they leave the Home. As there is no timescale for length of stay this can allow people to stay at the Home longer than is necessary, which means the persons needs might not be met as staff are focused on assessment services not on long term care and are dealing with very busy work activities. EVIDENCE: No timescales for length of admission are included in the statement of purpose or service user guide. Two young people had lived at the Home for twelve months and no longer needed an assessment service, for example, one resident had little structured activity and limited or inappropriate intervention were observed therefore difficulties with management of their behaviour is causing concern. Several incident reports have been submitted and police have been called to the Home to assist. At lunch this person prepared three different meals and was offered several options of activities, which seemed difficult for them to understand. The community learning disability nurse had seen the young person some time ago but no referral had been made recently. Two residents had moved from children’s services as they had turned eighteen, therefore staff wondered why assessment of accommodation needs had not been done there so that the young people moved directly in to their own home instead of a halfway situation. This situation also occasionally occurs when Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 Page 9 requests are made from the local health service learning disability treatment unit to take people in to the Home. There had been several changes to the residents since the last inspection as the home had successfully helped people move out to their own Homes with support where needed. One young person was moving out on the day of inspection. They described how they did very little for themselves and were very shy when they came in to the home but now enjoyed going to shops and talking with staff, particularly having fun and playing games with them. During the day people were coming and going from the outreach service, the managers and staff were very busy doing administration and helping one resident prepare to move out the Home, a new person to come in to the home was identified from a waiting list and another came in for an overnight stay as they needed supervision after some treatment. Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 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 standard(s) 6 and 7 People using the service receive a good deal of help from staff during the assessment process, which means their views are taken in to account in their care plan and when making decisions about their lives. This service is well managed and works well. Sometimes the Home can no longer meet the needs of people who have been assessed. EVIDENCE: Individual plans of care are available after an assessment of needs has been completed. The plans are reviewed regularly and show that staff know the service users well. The plans are produced to help service users understand them, with pictures included and staff discussing the plan with them and their relatives where appropriate. The review system is well organised with multidisciplinary help where needed. Staff openly talk and involve residents in their daily living routines and future life plans. The care plan system is a person centred planning system that is used in the Local Authority homes, which looks at what the person’s life has been like, what it is like now and how they want to live in the future. One member of staff explained how they help people make choices; for example, they explain what is an acceptable amount of food to a resident who wants to eat a large amount at breakfast. She said it is sometimes difficult to Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 Page 11 help a resident manage their food intake when they can see others helping themselves to snacks in the kitchen. This was evident as one resident helped themselves to several food items for lunch and became agitated as staff tried to help them decide what to eat and to explain what they were doing was not acceptable. This particular resident had information in their care plan saying they were to be encouraged to eat healthily and although weights recorded did not show great weight gain up until the last recoding in November last year, they looked like they had put on a lot of weight since the last inspection which was also commented on by their parent in their care plan. Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 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 standard(s) 12, 13 and 14 People who use service are helped to continue activities they were involved with before they moved to the Home and to try new activities. Staff have good knowledge of and links with a range of social, educational and employments services therefore the young people at the Home are offered a good range of choices and opportunities. EVIDENCE: Care plans show that residents are involved in a range of activities including college courses, day centres, social events and work placements. One young person has just completed a sponsored bike ride as part of the Princes Trust programme organised at a local fire station. Two other ladies spoke of a jewellery-making course they enjoyed. Some of the women enjoyed going to the hairdressers and beauty therapists to have their hair done and treatments, one lady was proud to show off her pierced ears she had done since moving into the Home and talked of her new hairstyle. Staff assist people to use local services and following a risk assessment some of the residents go out to local shops on their own. One lady came in to the office to show her purchase of cards for a resident leaving the home and a birthday gift for another resident. Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 Page 13 People tend to walk or use public transport to get places but the Home does have a car to use and is waiting for a new people carrier. Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 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 standard(s) 18 and 20 Privacy and dignity is maintained at the Home as residents can keep their personal things locked away and are spoken to in a respectful and acceptable manner. Staff training in how to give medication means that residents are given their medication safely. EVIDENCE: The Home provides single bedroom accommodation and residents are given a key to their room if they are able to take care of it. Care plans show that people are assessed as to the amount of help they need. Bathrooms and toilets are lockable so that people can carry out personal tasks in private. Care staff spoke to people in a respectful and dignified way and interactions were seen to be friendly and supportive. Since the last inspection the Registered Manager has looked at the medication policy with a manager of another home. She said this has been sent to the Commission for Social Care Inspection. At the last inspection concerns were raised about people not being allowed to take their own medication. This is not a problem at the moment as no one at the Home has been assessed as being able to take his or her own medication. The assistant manager said that all staff had now done a twelve week ‘safe handling of medicines’ course. Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 Page 15 Care plans showed that people at the home were seen by a number of different professionals when needed, for example, dentists, opticians and doctors. Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 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 standard(s) 23 Staff are trained to recognise abuse therefore residents at the home should be protected or helped if they experience abuse. However methods to protect residents and uphold their rights from other people living in the Home need to be reviewed. EVIDENCE: All staff have done training in protection of vulnerable adults as part of their induction programme. Some have gone on to attend local training and some are ready to do refresher training, which was raised at the last inspection. A number of incidents have occurred where a resident has hit other residents and staff. One person said they were fed up with this person as they affected their lives, they had all had to move from the room one night when the person was being difficult so they missed TV programmes they liked and they complained they were sometimes woken up by loud music played by this person. Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 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 standard(s) 24 and 30 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. The tidiness of some areas indicate that people might need more help with learning to manage their personal housekeeping skills. EVIDENCE: The Home is nicely furnished and decorated to a high standard and reflects the younger age of the service users. It is bright, clean and comfortable with no offensive odours. External areas are well maintained with access to a garden, patio and B-B-Q area. Problems with the heating system has been going on for some time now and have been raised in several inspection reports. This has affected the hot water supply, leaving one half of the house without hot water for about two months prior to Christmas 2004. Following several reports to the housing association different engineers have been to inspect the system who have said it is in a very poor state and does not meet health and safety regulations. The situation has been mainly left to the home staff to sort out when it needed someone in Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 Page 18 higher management to deal with it. At this point the situation has not been rectified to ensure problems do not continue to occur. Staff help residents to do their laundry if needed. They all have their own days when they can use the washing machine, which tends to be the day they clean and tidy their bedrooms. One persons bedroom was very untidy with things put in inappropriate places, for example, their shoes were on the computer shelf, remote controls on sink and clothing crumpled at bottom of wardrobe. This was their day to tidy their room. Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Staff are well supported with a good range of training opportunities therefore people living at the Home can expect they will be looked after by staff who have the skills to do their job. Some elements of training have not been updated so that staff have confidence in their skills when working with people who challenge the service and therefore people living at the Home with challenging behaviours can be helped appropriately and the other residents can feel safe and comfortable. EVIDENCE: A member of staff said they discussed their training needs during supervision sessions. A training matrix is available, which has a good range of training subjects available for staff to attend. Given the problems with people who present with behaviour that is challenging either due to their learning disability or associated mental health problems, it is disappointing to see that many staff attended this training some time ago. Staff attend fire training during their induction programme and afterwards the managers in the Home do in-house training. The managers have attended certificated external training but care staff do not have certificates to verify Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 Page 20 attendance. The records of training, which is done three monthly shows that staff are given a questionnaire which is the same each time. Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 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 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) 38 and 39 The staff at the Home are very good at involving the residents in day to day decision making about the home and in the care planning process therefore they can expect to be treated in a respectful and equal manner and to have their wishes listened to. The management team are approachable and available for staff, residents and relatives so that people living and working at the Home can feel relaxed about how the Home is run and be comfortable when speaking to senior staff. EVIDENCE: During the day residents and staff freely came in and out of the office approaching the Registered Manager and assistant manager to discuss a range of things, including, how there day had been through to asking advice. Interactions were always seen to be friendly and supportive. Care staff have carry out a good deal of administrative duties and those with more experience and knowledge helped newer staff members. Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 Page 22 Care plans show that residents are consulted and involved an the process and are helped to make decisions about what happens in their lives, equally relatives are involved where the resident wishes them to be. Meetings are held with residents to discuss anything connected to the running of the home. The menu is planned with residents with each person choosing a meal they would like to cook for the evening meal. Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 4 2 x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 4 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 4 4 4 x x x Standard No 31 32 33 34 35 36 Score x x x x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Villette Lodge Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score x 4 3 x x x x B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 3 24 Regulation 14 23(2)(j) (p) Requirement The Home must not provide accommodation to people it can not meet the needs of. The heating system must meet the needs of the Home to ensure heating and supply of hot water is not interrupted. (Previous timescale of 18/10/04 not met) All staff must attend training in the mangement of challenging behaviour. Timescale for action 31/7/05 31/7/05 3. 35 18(1) 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 1 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 timesclae for admission. The fire training provided to care staff should be varied to ensure a good range of issues are covered. 2. 42 Villette Lodge B52-B02 S32750 Villette Lodge V219745 250405 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Baltic House Port of Tyne 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. 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