Inspection on 03/08/07 for Villosa I

This inspection was carried out on 3rd August 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 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 26/10/06

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 Yoke-Lan Jackson Unannounced Inspection 3rd August 2007 10:00 Villosa I DS0000055525.V347912.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.V347912.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.V347912.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Villosa I Address 390 Hatfield Road St Albans Hertfordshire AL4 0DU 01727 860805 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.V347912.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2006 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 home charges £905.23 - £1331.25 per week (the fee is variable according to assessed need of each individual proposal to provide service). Further information about services can be obtained from the home’s Statement of Purpose and the Service User Guide. A copy of the CSCI inspection report should be available in the home. Villosa I DS0000055525.V347912.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out on 3 August 2007. The registered manager was present. The home currently has 8 residents. The inspection included a tour of the premises. Time was spent observing how the staff interacted with the residents. The inspector met all the residents and spoke to some of them. Staff were interviewed and documents were examined. To gain the view of people who use the service and those who visit socially and professionally the Commission sent survey forms to residents, relatives and health & social care workers. Their comments have been included in this report. Information received by the Commission since the last inspection has also been reviewed. This includes the Annual Quality Assurance Assessment (AQAA) which providers of registered services are required to complete. The AQAA focuses on how well outcomes are being met for people using the service. What the service does well: The home is well managed. Staff have the knowledge and experience to care for the residents, who appeared happy and content. All the residents participate in the daily routine and decision-making. The following responses were obtained in the recent CSCI written survey: “Since I came to live at Villosa about a year ago, I have been very settled and happy here. The staff are supportive and helpful”. “I am happy in many ways in my home. The staff support me and listen to what I say when necessary. My life style is good and I am comfortable”. ‘I like living at this home. Happy to. My life is good” A relative commented, “He is receiving good care. He looks healthier. He is a bit more mobile and his physical appearance is always good.” A social worker said “The staff appear to have a positive and supportive relationship with the residents. This also includes supporting them through periods when their mental health state has deteriorated”. Villosa I DS0000055525.V347912.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. The summary of this inspection report can be made available in other formats on request. Villosa I DS0000055525.V347912.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.V347912.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 & 3. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective clients have the information they need to make an informed choice. A pre-admission assessment is carried out before the prospective client is admitted to the home. They have the opportunity to visit the home and a trial period is arranged to ‘test drive’ the home. EVIDENCE: In a recent CSCI survey, 80 percent of the respondents (residents) said that they had enough information to make an informed choice. The admission files examined contained detailed pre-admission information concerning the residents. All the residents had been assessed prior to their admission. There have been no new admissions since the last inspection. However, there is one vacant bedroom following the transfer of a resident to another sister home. The home manager had carried out a pre-admission assessment on a prospective client but had declined admitting him because his needs could not be met at this service. Villosa I DS0000055525.V347912.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8, 9. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are given the opportunity to make everyday choices and they are encouraged to achieve independent lifestyles, and their preferences and requests are respected. Each resident has a written care plan which details the care required and how to meet any individual needs. EVIDENCE: The service users appeared well cared for. Their assessed and changing needs were reflected in the care plans examined. The care plans were detailed and person-centred. Risk assessments were carried out when necessary. The home works closely with the Community Psychiatric Team and the plan of care is jointly developed to ensure all care needs are being met in the home. Residents’ care needs are reviewed regularly and documented in their care plans. Relatives and the relevant clinical team and social worker are involved in the annual review of a resident’s care needs. Villosa I DS0000055525.V347912.R01.S.doc Version 5.2 Page 10 The home operates a key-working system. This is a one to one session to ensure that each service user is consulted on all aspects of life in the home. Residents are encouraged to make their own decisions and the key worker assists and supports them in the process. Villosa I DS0000055525.V347912.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11, 12, 13, 14, 15, 16 & 17. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ rights are respected and they have opportunities for personal development. Residents are encouraged to maintain links with their families. Residents are encouraged to have a healthy diet. EVIDENCE: Most residents attend their relevant day care centre daily. They are encouraged to get involved in activities that are stimulating and educational. One resident attends the local college regularly. There are individual shopping trips to the local town centre and a weekly visit to the Gateway Club (Jim McDonald). Villosa I DS0000055525.V347912.R01.S.doc Version 5.2 Page 12 Group activities include trips to cinemas, clubs, restaurants, pubs, parks, bowling and leisure centres. Day trips and weekend holiday breaks have been arranged for the residents. Recently the residents visited Stanborough Park for walks and meals in the café. Seven residents had a short break at Butlins in Bognor Regis. On 02/08/07, the residents and staff enjoyed a day trip to Southend. Additional service is provided by a part time occupational therapist who works at the home one day a week. She assists with the general review of the activities in the home and support in planning activities that suit individual needs and preferences. The current therapy sessions focused on menu planning, choice, budgeting, good hygiene and cookery. On the day of the inspection, the art therapist was assisting residents in the home. In addition, residents may attend the art and craft activity in the local community centre, organised by the home itself. In response to the CSCI survey, 4 out of 5 residents who responded said that they usually make decisions about what they do each day and all of them said that they can do what they want at any point in the day. Relatives are encouraged to visit the residents and are encouraged to get involved in the resident’s routine and social activities. The meals provided are nutritious and balanced. A dietician has been involved in assessing the nutritional needs of each resident. Staff take turns to cook the meals. They encourage the residents in healthy eating. Residents are encouraged to get involved in meal preparation. Villosa I DS0000055525.V347912.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 & 20. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are treated with respect and they receive personal care and support in the way they prefer and require. The administration of medication is in accordance with legislation. A robust policy and procedure is in place to support the safe administration, storage and receipt of medicines, which keeps residents safe. EVIDENCE: The residents appeared cheerful and content. In a recent CSCI survey, one relative commented, “He is receiving good care. He looks healthier. He is a bit more mobile and his physical appearance is always good.” The home has the support of health care professionals such as the General Practitioner and the Community Psychiatric Team. Health and behavioural concerns are referred to them for immediate assessment. There is a good rapport between the home and the clinical team to the benefit of all residents. Residents are encouraged to look after their own personal needs as much as possible. Guidance and support are offered and staff assist them where Villosa I DS0000055525.V347912.R01.S.doc Version 5.2 Page 14 necessary. Residents who are at risk of self-harm are provided with one-to-one care. Residents are encouraged to attend all health appointments that have been arranged for them. On the day of the inspection, one resident was helped to attend a doctor’s appointment. A referral has been made for a resident to attend a specialist appointment in preparation for a surgical operation. The member of staff interviewed said that all staff have training and regularly attended refresher courses on the safe administration of medication. The Monitored Dosage System is used for drug administration. The drug cupboard was checked and all medicines were appropriately labelled with the opening date written on the container. The Medication Administration Charts examined were correctly filled in and kept up to date. There are no controlled drugs in use at the present time. Since the last inspection there have been no medication errors. Villosa I DS0000055525.V347912.R01.S.doc Version 5.2 Page 15 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): Standards 22 & 23. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a robust complaints policy and procedure in place. Residents are listen to and their wishes are respected. EVIDENCE: A robust policy and procedure is in place and the staff have all received training in abuse awareness. The staff follow the joint agency guidelines for Safeguarding Adults (Adult Protection) issued by Hertfordshire Social Services. They are aware of the in-house Whistle Blowing Policy. There have 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 the complaint stage. A regular residents’ meeting is held and the residents are well informed about aspects of their home and arrangements that affect them. In a recent CSCI survey all the respondents (residents) said that they know who to complain to and how to make a complaint. Four out of five residents who responded said that staff always treat them well. Three out of five said staff usually listen and two said the staff always listen. Villosa I DS0000055525.V347912.R01.S.doc Version 5.2 Page 16 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): Standards 24, 25, 26, 27, 28 & 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a homely and comfortable environment. There is a rolling maintenance programme. EVIDENCE: The home is clean and tidy. The cleaning is carried out by the care staff with residents assisting where possible. On the day of the inspection, a member of staff was seen hoovering the floor in the dining area. There is a rolling maintenance programme. Since the last inspection, a new shower and bathroom suite have been installed. There are additional settees in the lounge. The kitchen and all the bedrooms have been redecorated. The carpet in the lounge, hallway and stairs has been replaced. The communal areas of the home are furnished to a good standard and there is a range of home entertainment equipment for residents to access. The bedrooms seen were clean and well equipped with personal items on display. Villosa I DS0000055525.V347912.R01.S.doc Version 5.2 Page 17 The garden and the surrounding grounds are reasonably maintained. However, there is some repair work to be done in the outhouse. The manager said that the new maintenance man will be commencing work in a week’s time and assured the inspector that repair work to the outhouse will be carried out. Villosa I DS0000055525.V347912.R01.S.doc Version 5.2 Page 18 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): Standards 31, 32, 33, 34 & 35. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are well supported by an effective staff team. Residents are protected from possible harm by the home’s robust recruitment policy and practices. EVIDENCE: Staff have defined roles and responsibilities. They are appropriately trained to ensure that they can meet the service users’ individual and joint needs. Proper staff records are kept and these are available for inspection. On the day of the inspection, there were three members of staff present. Team working was evident. Staff appeared confident and interacted well with the residents, who appeared at their ease with the staff. The management encourages staff to undertake professional development in addition to mandatory training. Progress is being made with NVQ and one member of staff informed the inspector that she is currently studying for her NVQ3, funded by the provider. The home follows the training guidelines from Skills for Care. Villosa I DS0000055525.V347912.R01.S.doc Version 5.2 Page 19 Staff turn over is minimal. A recent provider’s survey indicated that staff enjoyed working in the home. There is an ongoing recruitment programme. In addition to the robust recruitment process, the management ensures that every applicant undergoes a psychometric test to ensure that their personality, temperament and manner match the clients’ group. On the day of the inspection, a prospective applicant was told that his application had been rejected because of the negative outcome of his psychometric test results. Villosa I DS0000055525.V347912.R01.S.doc Version 5.2 Page 20 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): Standards 37, 38, 39, 40, 41, 42 & 43. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The standards of administration and management of the home are well maintained. The health, safety and welfare of residents are both promoted and protected. EVIDENCE: The home is very well managed. Both residents and staff benefit from the management approach and clear leadership shown. Staff have specific roles and responsibilities. There is a comprehensive set of policies and procedures that staff adhere to. Residents’ health, safety and their welfare are therefore safeguarded and protected. Residents appeared happy and content living in the home. Villosa I DS0000055525.V347912.R01.S.doc Version 5.2 Page 21 An effective quality assurance and monitoring system is in place. The provider makes regular visits. There are regular reviews of the service and there is an annual improvement plan in place. The last provider’s review of Villosa 1 was on 3rd July 2007. All servicing records are updated. The building was assessed and certified safe by an insurance company on 06/06/07. The Liability Insurance certificate and the CSCI Registration certificate are on display in the office. The yearly CSCI Annual Quality Assurance Self-Assessment (AQAA) form was completed and sent to CSCI on time for this inspection. Villosa I DS0000055525.V347912.R01.S.doc Version 5.2 Page 22 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 X 5 x 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 STAFFING Standard No Score 31 3 32 3 33 3 34 4 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 4 12 3 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 3 3 3 3 3 Villosa I DS0000055525.V347912.R01.S.doc Version 5.2 Page 23 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. 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. Refer to Standard Good Practice Recommendations Villosa I DS0000055525.V347912.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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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