Inspection on 28/11/07 for Villette Lodge

This inspection was carried out on 28th November 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Villette Lodge 14/11/06

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 Mr Clifford Renwick Key Unannounced Inspection 28th November & 12th December 2007 09:30 Villette Lodge DS0000032750.V352300.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.V352300.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.V352300.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.V352300.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One person over 65 years of age may be admitted in the learning disability category LD(E) 14th November 2006 Date of last inspection 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 £693.00 - £893.00 per week. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • Information we have received since the last visits in November and 2006. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The provider in the annual quality assurance assessment (AQAA) submitted information to confirm what they are doing in the home. The Visit: An unannounced visit was made on the 28th November and an announced visit on 12th December 2007. During the visit we: • • • • • • • Talked with people who use the service, staff, and the assistant manager. Observed life in the home. Looked at information about the people who use the service & how well their needs are met. Looked at other records, which must be kept. Checked that staff had the knowledge, skills & training to meet the needs of the people they care for. Looked around all of the building to make sure it was clean, safe & comfortable. Checked what improvements had been made since the last visit. We told the assistant manager what we had found. The people who reside in this home prefer to be known as “residents”; therefore this term of reference is used throughout the report. At the time of the second visit the manager was on holiday. 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. Surveys received from residents stated, Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 6 “The staff are fair and honest” “They arrange things for me if I want to go out” “The staff are helping me to move on and find my own flat” Surveys from relatives and an advocate confirmed the following, “The staff have the right experience and skills to look after people properly” “The home meets the needs of the residents” “The home responds appropriately and promptly if you raise concerns” There is a good atmosphere in the home. What has improved since the last inspection? What they could do better: Some of the window restrictors in bedrooms are not working and must be repaired or replaced. Door closures where they are not fully working must be repaired or replaced. Both bathrooms require decoration where plastering work has been carried out and any remedial works such as small holes in the bedroom wall should be filled in before decorating takes place. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 7 The written care plans must be updated to include the actions that are being carried out by staff to demonstrate how they are supporting residents to lead an active lifestyle. The commission must be notified without delay of any incident that occurs which can effect the well being of any resident. Staff training files could be better organised to make it clear what training staff have completed. The terms and conditions of residence require some minor revision with more detail being included as to why someone may be asked to leave the service. 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. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 8 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.V352300.R01.S.doc Version 5.2 Page 9 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): 2&5 Quality in this outcome area is good. We have made this judgment using a range of evidence, including a visit to this service’. Good arrangements are in place to ensure that resident’s needs are assessed prior to moving into the home. This ensures staff can meet their needs and the home is the right place for them. Each resident has an individual contract that sets out the terms and conditions of residence. This ensures that residents are aware of what services they will receive in the home. EVIDENCE: The home has an admission procedure in place outlining the process prior to admission. Admissions to the service only take place if the service is confident it can meet the needs of the prospective resident. 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. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 10 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 three residents files were looked at and both contained a comprehensive assessment. The assistant 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. Each file contains a range of information about the fees to be paid, by whom and how. Though the weekly fee is the same the individual contribution that each resident must pay will vary depending upon what benefits they receive. Discussion with residents confirmed that they know what they have to pay each week and they refer to this as “their rent”. Each resident is responsible for paying his or her rent every week at the local authority housing office. Receipts are kept in their files. Discussion with the deputy manager confirmed that if there was a need the current written contract could be devised in other formats to e.g. pictorial, but at present this had not been required. Some of the wording in the contract (terms and conditions) requires minor revision and this was discussed with the assistant manager. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 11 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 & 9 Quality in this outcome area is good. We have made this judgment using a range of evidence, including a 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. Some updating is required to reflect the daily tasks that residents are engaged. 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 there is not always sufficient detail in the risk management plan. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 12 EVIDENCE: Support plans are in place for each resident and in discussion they confirmed that they agree and discuss their care plans with staff. Each resident has a key worker and residents stated that they are actively involved in supporting them with their care plan. Three support plans were looked at during the visit. One risk assessment that related to a resident staying alone in the home did not contain enough information about a particular area of risk. Though discussion with staff confirmed that they were aware of any potential risks and had appropriate strategies in place to deal with this. There is also some joint work being carried out with probation services but this is not fully reflected in the support plan or the risk assessment. There is a good range of personal information in each care file both pictorial and written. And residents confirmed that they had been supported by staff to put this information together. The support plans varied in how they recorded information on activities and tasks that residents are involved in. Some were up to date and another did not accurately reflect what is happening now. The residents confirmed that they attend monthly residents meetings and they use these meetings to discuss all aspects of living in the home. In both individual and group discussion with residents they confirmed that they are encouraged to make decisions on a daily basis. And they are actively involved in planning their daily routines. Discussion held with staff confirmed that they have a good knowledge of individual residents needs and what support is required. Staff confirmed that the views of the residents are an important aspect of their work and this is used to influence and develop the services that are offered. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 13 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): 12, 13, 15, 16 & 17 Quality in this outcome area is good. We have made this judgment using a range of evidence, including a 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. Residents are involved in the choice of meals and encouraged to take part with meal preparation. This helps to promote their general health and well-being. EVIDENCE: Discussion with residents confirmed that they maintain contact with relatives and friends and this is supported by staff. During the visit one resident was Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 14 helped by staff to visit his mother, with the staff member providing the transport. Relatives and friends are encouraged to visit the service at any reasonable time throughout the day and evening. Due to some previous problems with contact for one relative of a resident staff have implemented some restrictions on unsupervised access and this is recorded in the care plan. Surveys received form relatives and one advocate confirmed how happy they are with the services provided. The residents confirmed that they go out when they want and some who have formed friendships go out together. Two of the residents spoke about a recent trip they had went on together to South Shields using public transport. They said that it was “very handy” having a bus pass as it enabled you to get out and about. As it was getting near Christmas some of the residents had been shopping for presents for their relatives. They had also made preparations to go out with staff for a Christmas meal to a local pub. 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. As previously stated in this report some residents have a weekly activity plan in the care file and this confirmed that people go swimming, to the cinema, shopping and two people attend day services. One resident is also involved in a drama group and as such as extra opportunities for getting out and also travelling to other areas. Another person is working in a horticultural environment as a way of gaining work experience. In discussion with the residents they confirmed that they go shopping with staff for the weekly foodstuffs. The residents also confirmed that they are involved in planning the meals with staff. There are no restrictions on the food you can eat but residents confirmed that the staff encourages you to eat healthy meals. As a result staff offer guidance to the residents on healthy eating and there are some limitations on having repetitive meals. One resident said that he prefers this structure otherwise he would “ eat pies all of the time”. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 15 Menus for the evening meals are on display in the kitchen and one of the residents had been involved in writing these up on the computer. The meals on display are varied and offer a good choice to the residents. Breakfasts and lunch times are less structured with residents being encouraged to help themselves to food from the kitchen. Lunch was taken with the residents on both visits and this was an enjoyable experience. It offered the opportunity to have a chat with both staff and residents during the meal in a relaxed setting. Throughout the visit residents were observed making snacks and refreshments and making good use of the kitchen. It was clear from the discussion that the people who are currently living in the home are very satisfied with the home and the services it provides. All of the residents who were spoken to were very positive about the future and said that staff were helping them a lot. Comments made by residents were, “The staff are great” “You get a lot of help from the staff” “This is a nice home” The staff too is positive and spoke of the work they are doing to support residents as part of their preparation for moving back into the community. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 16 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 good. We have made this judgment using a range of evidence, including a visit to this service’. There are good arrangements in place that promote the health and well being of the residents. This includes identifying their healthcare needs and plans being formulated to meet those needs. Medication is administered following good practice guidelines and regulation that 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. Information in residents care files confirmed that regular appointments and check ups have been made with professionals such as Chiropodists, Dentist, Optician, Psychologist and G.P. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 17 Discussion with 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. Residents will also go to see the doctor on their own unless they specifically request that staff accompany them. At present staff take responsibility for administering prescribed medication to residents. One resident did self medicate until recently and due to changes in behaviour this responsibility had to be dealt with by staff. A note on the care file confirmed that this was being monitored for one month and would then be reviewed. Medication records are in good order and staff follow all of the appropriate guidance when dealing with medicines. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 18 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. We have made this judgment using a range of evidence, including a visit to this service’. Information about making a complaint is clear and accessible. This contributes to residents’ and relatives’ views and concerns being voiced. It also ensures any complaints are dealt with promptly. Appropriate systems are in place to protect vulnerable people against abuse and all staff receives training, so they can identify any signs of abuse and protect residents. 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 deputy 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. Residents spoken with during the inspection said they would ‘tell the staff’ if they had any concerns. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 19 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 “Safeguarding Adults” known in the local authority as “alerter training”. This ensures that they are aware of what to do and who to contact in the event of an alert being made. Written guidance of the procedures to follow are displayed in the office for all to access. A recent alert had been dealt with by staff promptly and correctly and involved holding a strategy meeting with other professionals. Work in this area is ongoing and is being dealt with under “Safeguarding Adults “ procedures. However a delay in notifying this incident (9 days after in the initial alert) to the commission meant that the strategy meeting had been held before the commission had received notification of the incident. Consequently this meant that a representative of the commission did not have the opportunity to be involved with the strategy meeting. This was discussed with the assistant manager who was advised of the requirement to notify any incident to the commission as soon as possible. Following this discussion it was felt that there had been a minor breakdown in communication between management staff in the home that believed the appropriate notification had been made. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 20 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 & 30 Quality in this outcome area is good. We have made this judgment using a range of evidence, including a visit to this service’. Residents live in a comfortable and warm environment, which is generally well maintained this ensures the home remains a comfortable place to live in. EVIDENCE: All communal areas were viewed and four residents accompanied me to look at their rooms. In two bedrooms the lighting was dull and following discussion with staff immediate steps were taken to replace light shades and bulbs. This resulted in better illumination. Staff confirmed that the housing association who are responsible for the maintenance of the building will be carrying out decoration as well as fitting a new lounge carpet. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 21 Staff also confirmed that since the housing association merged with another company there had been improvements in the timescales for completing maintenance works. Some decoration is required in bathrooms where plastering has been carried out and some minor works are required. A maintenance file is kept and used to record any works that need doing. Once work has been completed a record is kept and this enables staff to monitor how repairs are being dealt with and within what timescale. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 22 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, 34 & 35 Quality in this outcome area is good. We have made this judgment using a range of evidence, including a visit to this service’. Staff receive training appropriate to their work, which ensures that staff follow good practice guidelines at all times. However details of training courses completed are difficult to assess due to the way in which training files are organised. 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. This ensures that all staff undergoes mandatory training. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 23 Discussion with staff and the assistant manager confirmed that training workshops on mental health had been carried out with a Community Psychiatric Nurse as well as an “outreach team”. Staff have also completed training in how to deal with behaviours that challenge. The training file that is used to record the training undertaken by staff is not clear. You have to spend a lot of time searching through the file to see who has done what training and when. This was noted at the last inspection and time was spent talking with the assistant manager about organisation of the training files. Since the last inspection one new person has commenced work in the home, 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.V352300.R01.S.doc Version 5.2 Page 24 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 good. We have made this judgment using a range of 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. A person who is competent and experienced is managing the service and this ensures that the residents’ health, safety and welfare are promoted. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 25 EVIDENCE: Regular monthly visits are carried out by a representative of the Local Authority as part of the ongoing quality assurance process. Checks are made on aspects of the service such as the environment, staffing issues, records and residents and a report is made available to the manager. Copies of these reports are available for examination. Regular monthly residents meetings are held and these are used to develop the service. 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 these confirm that staff are receiving regular fire instruction and taking part in fire drills. A fire risk assessment for the building is in place that meets the guidelines of the Fire Rescue Service. Records of any accidents that have occurred in the home are recorded appropriately. And these demonstrate that staff takes appropriate actions to deal with accidents. As previously stated in this report there was a delay in notifying the commission of an incident under Regulation 37 this was rectified immediately following discussion with the assistant manager. Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 26 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 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 2 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 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 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.V352300.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 (2) (c) Requirement The written care plans must include more detail to demonstrate the actions being carried out by staff to support residents. The registered manager must notify the commission without delay of the occurrence of any event in the care home, which adversely affects the well being of a resident. (Immediate) Minor works and redecorating must be carried out as identified in this report. Timescale for action 30/04/08 2. YA23 37 12/12/07 3. YA24 23 (2) (b) 30/04/08 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. 2. Refer to Standard YA5 YA32 Good Practice Recommendations Minor revision should be carried out to the contract to include more detail about what constitutes a breach of contract, and why you may be asked to leave the service. Staff training files could be better organised to make it clear if staff have completed all necessary training. DS0000032750.V352300.R01.S.doc Version 5.2 Page 28 Villette Lodge Villette Lodge DS0000032750.V352300.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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