Inspection on 13/10/05 for Villosa I

This inspection was carried out on 13th October 2005.

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 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

Villosa I 03/08/07

Villosa I 26/10/06

Villosa I 20/12/05

Villosa I 23/03/05

Villosa I 08/10/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Villosa I 390 Hatfield Road St Albans Hertfordshire AL4 0DU Lead Inspector Julia Bradshaw Unannounced Inspection 10:00 13 October 2005 th Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 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 Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 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. Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Villosa I Address 390 Hatfield Road St Albans Hertfordshire AL4 0DU 01442 858504 01442 861152 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) Psycare Hostels Limited William John Fitzpatrick Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd March 2005 Brief Description of the Service: Villosa 1 is a detached family house, extensively developed and converted as a residential care home for nine adults with a learning disability. The premises consist of nine single bedrooms (two which are on the ground floor). The home has a reception area leading into the main lounge, a separate dining room and a conservatory. The home also benefits from an additional sunroom, which is built on to the side of the house. The kitchen and a bathroom are situated on the ground floor. The laundry facility is in a separate prefabricated building at the rear of the home, which is also used as storage. There are good links with local transport into the main city centre. St Albans has two railway stations, on the main line out of Kings Cross and a local service to Watford Junction. The premises have been adapted on the ground floor of the home to create some additional office space to the side of the house. Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection of the inspection year and took place over one day. The majority of time was spent talking to service users, and staff. Some time was also spent in the office looking at Service user Plans, risk assessments, complaints and staff training. Discussions were held with the manager regarding the new inspection report format. Service users and staff were very welcoming This was generally a very positive inspection, and the majority of the standards were met and only one requirement was made in relation to a fire risk assessment. What the service does well: Villosa 1 is a very well managed home. The manager and staff have created a welcoming, comfortable and enhancing environment for the 8 people who currently live there. Service user files contained all the relevant information and risk assessments had been updated since the last inspection took place. Health and safety is being well managed and all COSHH assessments are updated and reviewed annually. All the required policies and procedures were in place including a copy of the statement of purpose and service user guide. The home was clean and well cared for on the day of the inspection. Staffing levels in the home are adequate and regular staff cover vacant posts to ensure consistency of approach is maintained. A range of activities and entertainment organised by the staff team are provided. Staff members spoken to were very positive about the home and appeared committed to their work. There is plenty of opportunity for staff to progress within their role and training and development is very much encouraged. There are currently 10 care staff in post, one newly appointed carer on probation and one full time vacancy. One waking night care per night is provided. The manager and staff have worked hard to improve the environment since the last inspection took place with the dining room being redecorated, the conservatory has been repainted externally and two new bed have been purchased and two service users bedrooms re-decorated. The home has an ongoing issue with subsidence, which has caused large cracks to appear on some of the internal walls. This is currently being investigated but could be another year before it is resolved. The manager has recently purchased a new DVD/TV for the service users enjoyment. Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 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. Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 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 Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 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): 1,2,3,4. Prospective service users individual aspirations and needs are assessed and reviewed, enabling the service user and staff to continuously review the individuals care package provided. Information provided to the service user about the home and its terms is suitable to meet their needs and therefore enables the service user to make an informed choice about where to live. EVIDENCE: A comprehensive Statement of Purpose is held within the home and all current and prospective service users are provided with a copy. The Statement contains information for the service user to make an informed choice about where to live. The content is suitable to meet individual needs. The manager and staff have worked hard to produce some information in a format that is understood by all service users living at the home. However all these documents could further benefit from being adapted into a more “user friendly format”. Full assessments of each service users needs and aspiration are made before the service user moves into the home. The assessments carried out within the home are continuously occurring, supporting and monitoring individual progress and needs identified. Experienced and competent people complete the assessments. The home also receives and seeks external specialist support to meet the individual service users needs. Whole Life Reviews/CPA’S occur to support the service users in achieving and reviewing individual needs, goals and aspirations. Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 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 the following standard(s): 6,7,8,9 & 10. Individual needs and choices are being promoted to encourage and empower user self-determination. EVIDENCE: All service users have an individual care plan and an allocated key worker to support them. Individual daily guidelines/diary notes for service users were observed within the home. All service users are supported within the CPA programme and regular reviews occur to ensure changing needs are continuously assessed and reviewed. The ethos within the home promotes that the care plans of each individual are owned by the individual, those service users spoken to during the inspection were aware of their individual care plans Within the home each service user is encouraged to partake in daily living tasks, for example being supported with meal preparation, washing up, laying the table, shopping. However this appears on occasions to be quite difficult to implement due to the majority of service users coming from large institutions or living in homes where they were discouraged from taking part in the daily living tasks. There has been an improvement in the past two years due to the new manager and staff being pro-active in implementing self helps Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 Page 10 programmes. Also there are some service users who are becoming frailer and less mobile which prevent them from taking part in certain tasks. All information within the home is handled with care and respect. All personal notes and files detailing information on the service user are locked away. Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,13,16 & 17. Personal development opportunities are encouraged for all service users ensuring interactions within the local community and that individual rights and responsibilities are recognised and supported. EVIDENCE: Service users attend either the Bricket wood centre or local college. Discussions with the service users determined that they have a variety of day activities to be involved in. Access to transport occurs with the use of the home’s onsite transport and public transport, with staff support. Staff support and encourage all service users to maintain and develop social, emotional, communication and independent living skills. Some service users are able to access local transport independently. The involvement of the service users in a variety of tasks was observed throughout the inspection. All eight service users have one day off per week in order to attend to their personal tasks including washing, cleaning their rooms and personal clothes shopping, this is usually combined with a trip out for lunch. The home has provided several trips out since the last inspection which include day trips to Woburn, Southend, Whipsnade zoo and Dunstable Downs. Regular trips to Stanborough Park and a recent trip to St Albans Arena. There is one service user who has recently Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 Page 12 joined a local rugby club and one person who has started a paper round once a week. All service users are encouraged and supported to maintain links to the local community. The home is central to the city centre and is within a residential area of the city. During the inspection staff and service users were observed to interact equally with one another. Routines within the home endeavour to promote service user independence. Service uses are unrestricted in movement around the home. Menus within the home are offered on a flexible basis, with service users making choices over the meals daily. The current menu is on a four-week rolling rota and has recently been reviewed with the involvement of the service users. Service users are involved in some meal preparation with appropriate support provided. Meals observed were unrushed and relaxed. Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 19 All personal and health care support is well maintained within the home ensuring individual needs, choices and preferences are met at all times. EVIDENCE: All care provided is individual and tailored to each person needs with service users choices and preferences being promoted. Assessments and reviews are continuously completed ensuring that the approach adopted by the home is person centred and holistic to each service users needs. Service users are supported with all aspects of their physical and emotional health and receive adequate and appropriate input from specialists such as community nurses, consultants, GP, dentists, opticians and dieticians. Information and advice is provided to all services users regarding general health issues. A robust policy and procedure is in place to support the safe administration, storage and receipt of medicines. All staff receive training prior to being deemed competent to administer medication. However medication was not inspected on this occasion. Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 Page 14 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 The complaints procedure within the home is sufficient and adequate in order for the service users to feel that their individual views are listened too. Robust policies, procedures and training are in place to ensure service users are protected and safe. EVIDENCE: A comprehensive complaints procedure is in place, which details that all complaints are responded to within 28 days. A record is maintained of complaints made detailing actions and outcomes as necessary. The staff should be congratulated in providing this information in a format for all service users who find the written word difficult to interpret. All service users have been informed about the complaints procedure, this is also on display. The complaints procedure includes the correct contact details of the CSCI. Robust procedures are in place to ensure that service users are protected from abuse and harm. Staff receive adequate Protection of Vulnerable Adults (POVA) training, which was last held on the October 2005. Staff employed within the home are all subject to enhanced Criminal Records Bureau (CRB). Two Staff personnel files were inspected and both contained all the required information including two staff references, CRB and POVA checks. However each file should contain a current job description. Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 Page 15 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): 24,25,27,28 & 30 The home and its surroundings offer a pleasant, comfortable and safe environment to its service users. The home is clean and well maintained although some bedrooms still require attention. The proprietors continue to improve the living environment for it’s service users. EVIDENCE: Service users are encouraged to bring personal items such as furniture and pictures into their room when they move in. Service users spoken to were happy with their rooms and commented on how staff assist them in choosing and purchasing new items for their rooms and are involved in deciding on their own colour schemes and soft furnishings. The home is generally clean and attention to detail is given. The cleaning is carried out by the care staff and with service users assisting where possible. The manager monitors this closely to ensure that standards of cleanliness remain adequate. Hygiene and infection controls are good. The kitchen/ laundry area are domestic in style and appear to manage their current workload effectively. There is one domestic style bathroom with a bath/shower and toilet and one Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 Page 16 assisted bathroom on the ground floor. Water temperatures were checked and were being delivered within safe limits. Sufficient lighting, heating and ventilation is provided. A maintenance and renewal and redecoration plan is in place. The main outstanding issue relating to the environment is the problem with subsidence, which is continuing to prove problematic and creating a problem with the internal decoration programme of the home. The home has also inherited a problem from the previous owners with regard to the inadequate plumbing system, which has caused several leaks over the past year and created internal damage to both ceilings and walls. The communal areas of the home are decorated and furnished to a good standard and there is a range of home entertainment equipment for service user to access. The home also benefits from having an enclosed garden area for service users to enjoy in the warmer months. There is parking for several cars at both the front and rear areas of the property. All fire records were checked and were accurately recorded with the last fire drill being carried out on the 27/8/05.Weekly fire checks were last carried out on the 9/10/05.The last fire system check was carried out on the 3/5/05. However the manager must carry out a fire risk assessment for the home, as there was no evidence on the day of the inspection that one had been carried out. Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 Page 17 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): 31,33,35,36 . The home is suitably staffed with well-trained and experienced individuals ensuring that at all times service users changing needs can be met. The staff team are enthusiastic and appear to take great pride in the service. Recruitment procedures are robust and effective in the protection of service users. The manager is providing an effective programme of training. EVIDENCE: The Staff spoken with during the inspection appeared to be clear of their individual roles and responsibilities. The members of staff on duty was seen to support the main aims and values of the home. The home has clearly defined job descriptions and person specifications in place. All staff have received a series of mandatory training course in order for them to meet the needs of the service users. Recent training includes, Adult protection (5/10/05) Learning disability awareness, food hygiene, challenging behaviour (26/9/05) and fire training.( 31/1/05) Accurate training records are maintained within the home. The home currently has three staff on NVQ level 2 training and the manager had NVQ level 4. Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 Page 18 Recruitment practices were inspected and proven to be accurate and the two files checked contained all the required information. However the manager should ensure that all staff files contain a current job description. Supervision and appraisal occur within the home. The home employs a total of ten Care pathway facilitators, one person is currently on their probationary period and the home currently has one full time vacancy. Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 Page 19 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): These standards were not inspected on this occasion. EVIDENCE: These standards were not inspected on this occasion. Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 Page 20 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 3 3 3 3 x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 3 x 3 LIFESTYLES Standard No Score 11 3 12 x 13 3 14 x 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score 3 x 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Villosa I Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x DS0000055525.V254786.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? NO 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 24.1 Regulation 23 (4) Requirement The manager must complete a fire risk assessment. Timescale for action 14/10/05 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 34 Good Practice Recommendations The manager should maintain a current job description for each member of staff on their personal files. Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Villosa I DS0000055525.V254786.R01.S.doc Version 5.0 Page 23 - 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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