Inspection on 26/10/06 for Villosa I

This inspection was carried out on 26th October 2006.

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

Villosa I 03/08/07

Villosa I 20/12/05

Villosa I 13/10/05

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 Hazel Wynn Unannounced Inspection 26 and 30 October 2006 10:00 th th Villosa I DS0000055525.V309682.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 Villosa I DS0000055525.V309682.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. Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 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.V309682.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 2005 Brief Description of the Service: Villosa I is a detached family house, extensively developed and converted for use as a residential care home for nine adults with a learning disability. The premises consist of nine single bedrooms (two of which are on the ground floor). The home has a reception area leading to the main lounge, a separate dining room and a conservatory. The home also benefits from an additional sunroom that has been built at the side of the house. The kitchen and bathroom are situated on the ground floor. The laundry facility is in a separate prefabricated building at the rear of the home and this facility is also used for storage. There is an office at the side of the house on the ground floor. There are good links to the city centre via local public transport. St Albans also has two railway stations, one main line service to Kings Cross and the other a local service to Watford. The fee range to the date of this inspection is £905.23 – 1331.25 (the fee is variable according to assessed need of each individual proposal to provide service). Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the afternoon/evening of 26th October and 30th October 2006. Service users gave positive feedback about all aspects of life in the home both on an individual level and jointly. The records of the home were well maintained. Health and safety was well managed. Staff training and supervision was in place. There were adequate staff on duty and medication was being well managed. The service users had full programme of activities and community participation and gave positive feedback regarding this area of their lives. A healthy and varied diet is planned with the input of the service users. Policies and procedures were in place to provide safeguards and had been reviewed. The home was clean, fresh and tidy and there is a full maintenance programme in place. The proprietor’s agent visits and carries out audits and a copy of the monthly report is kept in the home; these reports are meaningful and service user views put forward are tracked in these reports. The home was well run and the registered manager’s ethos, leadership and management approach was, from the evidence gained, found to be excellent; staff provided excellent feedback about their experience of supervision and support from the manager. Staff on duty stated that the team works very well together in meeting the needs of the service users. Based on this inspection visit and information received since the last inspection, the overall quality of this service is good. What the service does well: The service provides good information to prospective service users and carries out thorough pre placement assessments; followed by pre-placements visits and overnight stays for proposed service uses who meet the criteria for admission. Service users are very involved with the formulation of their care plans and regular reviews. Risk assessments are in place to promote and support independence. There are Health and Safety risk assessments in place. Records are well maintained. The service provides neat and comfortable accommodation. Safeguards are in place for service users through robust recruitment and staff training. The home has employed an occupational therapist who was involved in looking at activities of daily living (one-one) work and generally reviewing the service and activities offered. The service users enjoy a wide range of holidays and outings and frequent the community resources/leisure pursuits on a very regular basis. There was strong evidence available that the service users strongly influence how the home is managed and developed. A healthy meal choice is in place. A cohesive team supports the service users in a consistent manner. Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 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.V309682.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 The homes statement of purpose and service users guide are both kept reviewed. Service users are provided with a copy of the service users guide prior to moving in. A comprehensive initial assessment of proposed service users’ needs and aspirations is completed prior to offering a placement with the home. Prospective service users visit and ‘test-drive’ the home prior to moving in. Service users are provided with terms and conditions of the service to be provided. The quality in this outcome group is excellent; this judgement has been made using all available evidence including a visit to the service. EVIDENCE: As part of the records check the homes statement of purpose and service users guide were seen and both were kept reviewed. The service users had received a copy of the service users’ guide and a copy was maintained on the individual file. As evidenced on six service users files seen during this inspection visit, a full assessment of need, including the individual’s aspirations, is completed prior to admission and where a referral had not met the criteria this was recorded. The Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 9 pre-placement assessment includes the service users individual needs and aspirations. Prospective service users make visits and ‘try out’ the service prior to decision making, as part of the assessment process. One service user currently proposing to move into the home has a plan for his visits and test-drive in place. A copy of the terms and conditions are provided to each service user and this was further explored on the 30th October as noted below: On the visit of 30th October, the registered manager explained that they had tried out the user-friendly format but found that sitting with service users on a one to one and talking them through the terms ands condition, was more effective and useful to the service user; this is the practice in use. The inspector recommended that this process is recorded and used as a part of formal recording of this fact on each service user’s file. Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 Service users are very involved in their care planning and so are aware of their individual assessed and changing needs and goals, as recorded in their personal care plans. Service users make their own decisions about their lives and are appropriately supported to do so. Service users are consulted about all aspects of life in the home and their views are obtained and are acted upon. Service users are supported to take risks as part of an independent lifestyle. The quality in this outcome group is excellent; this judgement has been made using all available evidence including a visit to the service. EVIDENCE: One of the service users spoken with on the visit of the 26th October knew her care plan well and said she is very involved with her meetings. The risk assessments on each service user’s file are written positively. Those historical risks with no current presentation are given a low risk score. Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 11 The inspector met and spoke with six of the service users who said they plan trips and holidays and the things that they like to do in the week. Evidence was seen in six care plans that independence is very much promoted, with risk assessment in place to support service users and guide staff to support service users with their independence.The proprietor visits take place each month and his reports show that he checks service user’s minutes and any issues arising for action; during his visits he obtains service users views and these will form part of decision making. Service users who spoke to the inspector during this visit talked about holidays and outings they have chosen and enjoyed and how they have made changes to their own personal rooms and have been involved in changes around the home. Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 - 17 The service users are supported to make personal progress and maintain good mental health status. The service users enjoy age, peer and culturally appropriate activities. The service users have become very much part of their community; using local facilities and resources. A variety of leisure activities are enjoyed. Relationships with family and friends are supported where relevant and appropriate. Service user rights and responsibilities are recognised and respected. A healthy diet is enjoyed in an acceptable setting (several small tables in dining room – not typically domestic in style) and at flexible times. The quality in this outcome group is excellent; this judgement has been made using all available evidence including a visit to the service. Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 13 EVIDENCE: Discussions with six of the service users and inspection of their records provided evidence that they are given ample opportunity for personal development; for example one particular service user’s main goal is to move on to live in his own flat and his care plan is designed to further his independence to achieving his goal. In examining records and discussions with the service users, evidence was gained that the service users enjoy plenty of culturally, peer and age appropriate activities, including: trips to cinema, clubs, restaurants, pubs, parks, bowling and leisure centres. Service users talked about the good time they’d had on recent holidays and trips and they said they choose where they want to go for holidays and trips. In their use of local shops, restaurants and pubs the service users are very much part of their community. On the second day of this inspection visit 30/10/06, the inspector met with the occupational therapist who works at the home one day a week, she was involved in looking at activities of daily living (one-one) work and generally reviewing the service and activities offered. Care plans and progress notes evidence that personal, family and appropriate sexual relationships are fully part of the service users (where relationships exist and staff have a good understanding of the importance of relationships that develop and offer guidance as appropriate). Several service users are in regular contact and meet up with their family members. The service uses rights and responsibilities are recognised in their daily lives and service user meetings help service users to express their views and listen to the views of others. Staff support the service users to recognise their rights and responsibilities and this is included in care planning. A group of service users said that everyone puts the menu together so that each gets to have their favourite choice and that they can choose something else if they don’t want the meals of the day. The dining areas are not particularly typically domestic with several tables in a room there was a relaxed atmosphere as service users were enjoying an unhurried meal. Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 - 20 Personal support is provided in a manner preferred by individual service users. Service users physical and emotional health needs are met. Medication is appropriately managed and the home has a policy and procedure in place, which is adhered to. The quality in this outcome group is excellent; this judgement has been made using all available evidence including a visit to the service. EVIDENCE: The six care plans seen during this visit provided evidence that there is clear guidance to providing support in a manner preferred by the individual service user with regard to personal support needs. The service users spoken with confirmed that the staff support them well with health and emotional care needs. The care plan progress notes show that medical appointments are made as necessary and that the outcomes of appointments are recorded. The emotional needs of service users are well documented in their care plans with guidance for staff to provide the individual support needed. Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 15 The occupational therapist who works at the home (see previous section where her work is explained) is also involved with the well being of the service users. Medication was being managed according to the needs of the service users. There were no gaps on the medication administration records and the medication was well stored in a small locked room. Two staff members on duty were well versed in the different medication administration arrangements for each service user when they stay away from the home. Although none of the service users administer their own medication at present, suitable arrangements would be put in place if the circumstances were to change. 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. Currently a new training event is being organised by the company in conjunction with Hertfordshire Adult Care Services. The inspector asked how the room is kept cool in hot weather and the staff said fans were used; the inspector advised that a more effective way of keeping the area cool in hot weather would be a small portable air conditioning unit and this is recommended. Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Service users feel that their complaints are listened to and acted upon. Robust policies, procedures and training are in place to ensure service users are protected and safe. The quality in this outcome group is good; this judgement has been made using all available evidence including a visit to the service. EVIDENCE: A robust policy and procedure is in place at the home and staff have all received training in abuse awareness as evidenced in their training record. There had been no complaints in the period between inspections. If a service user raises any issue, this is responded to and resolved without the need for it to escalate to a complaint stage; evidence of this was gained from the proprietors visit records. Care plans contain all necessary information to minimise the risk of self harm or neglect, with clear guidance to staff to provide the level of support each individual needs and risk assessments are kept reviewed and up to date. Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 – 28 and 30 The service offers a comfortable and safe environment to its service users. Bedrooms are personalised and comfortable. Service users look after their own room, as part of promoting independence, with some support were needed. There are ample bathrooms and toilets at the home that provide privacy and meet needs of all of the service users. The communal space is very adequate and comfortable and compliments the service users good-sized rooms. The home is clean and well maintained with an ongoing maintenance programme in place. The quality in this outcome group is good; this judgement has been made using all available evidence including a visit to the service. Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 18 EVIDENCE: Three service users showed the inspectors their rooms; the rooms were attractive with personal possessions on display. One service user took great pleasure in recalling the origin of many of her possessions. Another service user enjoyed talking me through the plans she has in mind to add to her room, pointing out exactly what she was going to have and where. The service users were obviously very happy with their rooms and said that they choose and new items for their rooms. The staff explained how the service users are involved in deciding on their own colour schemes and soft furnishings. The home was clean, tidy and fresh on the two days that this unannounced inspection took place. The cleaning is carried out by the care staff and with service users assisting where possible. The manager (and the proprietors agent, when he regularly visits) monitor this closely to ensure that standards of cleanliness remain adequate. 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. Hygiene and infection controls are good. The kitchen/ laundry area domestic in style and appear to meet needs effectively. There is a domestic style bathroom upstairs with a bath/shower and toilet and an assisted bathroom on the ground floor, there are also additional toilets. Water temperatures were checked and were being delivered within safe limits and records are made of the regular temperature checks carried out by the home. 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 previous year and created internal damage to both ceilings and walls, which then had to be redecorated. Service users benefit from having an enclosed garden area to enjoy and relax in; when the British weather permits. There is generous parking facilities for several cars at both the front and rear of the property. All fire records were checked and were accurately recorded with the last fire drill being carried out on the 22/10/06.Weekly fire safety system checks were last carried out on the 23/11/06.The last fire system check was carried out on the 3/5/05. A fire risk assessment for the home had been carried out but the Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 19 inspector had not been able to access it at the last inspection and so a requirement was made; the requirement is met. Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 20 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 - 36 Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported and protected by the home’s recruitment policy and practices. Service users joint and individual needs are met by appropriately trained staff. Service users benefit from a well supported and supervised staff team. The quality in this outcome group is good; this judgement has been made using all available evidence including a visit to the service. EVIDENCE: A copy of the staff member’s job description is available on their individual file; this was recommended at the last inspection. The proprietors visit reports record evidence that any staff issues are explored and action taken accordingly. Feedback is given to staff regarding any inspectorate visit reports; evidence gained from records on site. Staff are provided with a handbook at the commencement of employment and this is updated with any change to relevant policies and procedures. The disciplinary procedure is Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 21 included in the handbook as is abuse awareness procedures. There is a thorough induction process. Four staff records were checked on the 30th October and these contained evidence that the home recruits staff in a robust manner. The necessary references had been obtained together with Criminal Records Bureau checks and Protection of Vulnerable Adult register checks. The registered manager stated that any gaps in the completed application form are explored and notes added to this effect. Staff training records show that all mandatory training and additional training is provided. Evidence gained from the training record and in discussion with staff showed that the following training had been covered recently: Fire safety, moving and handling, abuse awareness, food hygiene, first response/first aid. One member of staff on duty informed the inspector that she is interested in doing a dementia course to support service users who are beginning to age and she had found the registered manager most supportive and he is looking into providing this and also a computer training course that she would like to do; the registered manager had wasted no time in getting in touch with a provider and a representative had been in contact with the member of staff. Progress is being made with NVQ and one member of staff informed the inspector that she has completed level II NVQ and hopes to start level three the month after this inspection (this had been delayed by the local college and she had hoped to start earlier). Staff on duty stated that the team works well together and all are supportive to one another. Communication in the team is good and this provides a consistent working approach to meeting service users needs – the records seen during this inspection evidence that good communication is in force. Formal supervision is regularly provided to staff and this was evidenced from the records. A member of staff stated that the supervision is very supportive both from a work angle and in relation to any personal needs. The above evidence shows that the service users joint and individual needs are met by appropriately trained staff. Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users can be confident that 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 and staff is promoted and protected. The quality in this outcome group is excellent; this judgement has been made using all available evidence including a visit to the service. Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 23 EVIDENCE: The records seen during this inspection visit and recorded earlier throughout this report provides evidence that this is a very well run home. Evidence that the ethos leadership and management approach benefits the service users has been gained from well kept records, feedback from staff who highly praised the registered manager and feedback from the service users is earlier recorded in this report. Service users views are gained and recorded and responses can be seen in service users minutes and in the proprietor visit reports, several of which were read during the first day of the inspection visit on 26.10.06. Service users views are responded to and wherever possible are included in decision making and progress – e.g. refurbishments/maintenance programmes, holiday and outing planning.. Policies and procedures are in place to protect the rights and best interests of the service users and the review dates were current at the date of this inspection. The inspector checked a random sample of two services users’ finances on the second day of the inspection and these were transparently managed and the balances reconciled with the account. All transactions are receipted. An audit of each service current balance and record of spending is carried out weekly by the registered manager; the proprietor’s visiting agent also carries out audits. The service users personal records, health and safety systems in place, and staff training records all provided evidence that the service users. The risk assessments in regard to supporting individuals toward further independence are very clear and provide staff with a solid framework for supporting progress with regular review. More has been mentioned in regard to health and safety matters earlier in this report (in particular see the section covering Environment. The registered manager explained that despite providing user friendly formats of terms and conditions to service users, these were not terribly effective and so uses a one to one approach with the service users to go through and explore the terms and conditions with them. This excellent approach to supporting service users should be recorded in a formal manner as the userfriendly approach evidence; the inspector recommended that the registered manager, formalise work by creating a statement to complete and keep on file with the agreement after the one to one session has been completed. Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 24 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 3 2 3 3 3 4 3 5 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING3 Standard No Score 31 3 32 3 33 4 34 4 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 4 13 4 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 4 4 X X 4 X Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 YA5 Good Practice Recommendations The inspector recommended that the process of using the one to one be described in a simple statement and attached to the service user guide. Attach a record of the one to one session to the signed terms and conditions (one part for the organisation and one part for the service user) so as to formalise the recording of this fact on each service user’s file. Regarding using fans to keep the medication storage area cool, a more effective way of keeping the area cool in hot weather would be a small portable air conditioning unit and this is recommended. 2. YA20 Villosa I DS0000055525.V309682.R01.S.doc Version 5.2 Page 26 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.V309682.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!