Inspection on 13/07/07 for Villosa II

This inspection was carried out on 13th July 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Villosa II 21/07/08

Villosa II 14/07/06

Villosa II 14/11/05

Villosa II 15/06/05

Villosa II 08/02/05

Villosa II 17/08/04

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 II 40 Tippendell Lane Chiswell Green St Albans Hertfordshire AL2 3HL Lead Inspector Julia Bradshaw Key Unannounced Inspection 13th July 2007 9.30 Villosa II DS0000055526.V347904.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 II DS0000055526.V347904.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 II DS0000055526.V347904.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Villosa II Address 40 Tippendell Lane Chiswell Green St Albans Hertfordshire AL2 3HL 01727 874169 01727 874169 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 Puvanandradasa Shanmugadasa Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places Villosa II DS0000055526.V347904.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th July 2006 Brief Description of the Service: Villosa 11 is a detached chalet bungalow, which has been extended and converted into a Care Home for six people with a learning disability. The premises comprises of six single bedrooms, a combined lounge/dining room, separate kitchen and laundry room. The home also has a large conservatory on the side of the house, which was built in 2001. The home is situated in a residential area of St Albans with a shopping parade, public house, sports centre and grassed activity centre nearby. The home is a short bus journey from the main City centre. The Service User’s Guide and Statement of Purpose provide information about the service to prospective residents. Copies of the latest report from the Commission for Social Care Inspection (CSCI) are available in the home. The fee range is £900 - £1,150.00. Villosa II DS0000055526.V347904.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day. Documentation examined included three service users’ care plans, medication records, and health and safety records. A tour of the premises was made, taking in all the bedrooms, communal areas and the external grounds of the home. Unfortunately the inspector was unable to access staff recruitment, supervision records, training records and quality assurance information as the registered manager was away on a training course on the day of the inspection. However these records were thoroughly inspected during the July 2006 inspection and were found to be both accurate and complete. The inspection indicated that the home was adequately run, with a calm and relaxed atmosphere. What the service does well: There are various systems in place, which reflect the good working relationships within the staff team. Working practices were observed as both caring and appropriate to the needs of the service users. The manager and staff continue to work hard to improve and develop the environment and have endeavoured to create a homely and comfortable atmosphere. The assessment system in place is both detailed and comprehensive in its approach to identifying all the needs of new and existing service users. The staff team appear to be committed in their approach to service users. The service users appear to have some degree of involvement in their care planning. Three plans were inspected and were detailed and comprehensive. However these care plans were not reviewed regularly or signed by either the service user or their representative in order to confirm they have been fully consulted in the planning process. The environment continues to be developed and improved to provide a homely domestic setting in which the service users can live safely and lead lifestyles that suit them. In particular, the bedrooms are well presented and have suitable furnishings and décor that both promote the residents’ dignity and provide an acceptable level of comfort and individuality. Two staff on duty were spoken to during the inspection and appeared to have a clear understanding of their individual roles and responsibilities. Villosa II DS0000055526.V347904.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 II DS0000055526.V347904.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 II DS0000055526.V347904.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): 1 – 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The appropriate information is available in order for prospective residents to make a choice about where to live and concerning how the home operates; including a description about the systems in place to meet their care needs and aspirations. Visits and ‘test drives’ to the home are supported. A copy of the individual contact/terms and conditions is provided to each resident. EVIDENCE: The Statement of Purpose and Service Users Guide detail the aims of the service and the way it is proposed to operate. These documents enable prospective service users and their representatives to make an informed choice about whether to use the respite care service. However not all the documentation that requires service user involvement/contribution is produced in a format that is easily understood by the service users. New service users are normally accepted following a referral process and are subject to thorough assessments of individual needs. These form the basis of the care plan drawn up detailing how the needs will be met. There is currently one vacancy. Villosa II DS0000055526.V347904.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): 6 – 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users have a detailed care plan covering all needs and aspirations. However, risk assessments are currently incomplete and therefore service users health and safety is currently compromised. Residents are involved in some aspects of making decisions in relation to the running of the home. All personal information is securely stored and staff are provided with training in confidentiality. EVIDENCE: Three service users plans were inspected on this occasion and were generally found to be detailed in containing all the required information. Information varied about individual needs and personal preferences, coupled with clear instructions to staff on how to proceed, including useful behaviour management guidelines as well as tips on personal care, preferred daily routines and social/cultural issues. However care plans were not reviewed at Villosa II DS0000055526.V347904.R01.S.doc Version 5.2 Page 10 regular intervals and did not have up to date risk assessments where there has been an identified risk i.e. risk of choking. Either the service user or their representative is not signing care plans. Service user’s files are kept securely in the office. The company has a policy on confidentiality that staff are aware of and follow. Information is shared with partner agencies and others on a need to know basis. This topic is also covered during the induction of new staff. Service use contracts are not produced in a ‘user friendly’ format and are not signed by either the service user or their representative. Villosa II DS0000055526.V347904.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): 11 –17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The opportunity for personal development alongside peers of a similar age and ability is provided. Residents’ rights and responsibilities are recognised. Planned activities ensure the residents are part of their local community. The residents maintain close relations with friends and relatives to whom some are able to make visits. A nutritious and varied menu chosen by the residents is provided at suitable and flexible times and in a comfortable setting. EVIDENCE: Day activity programmes are in place (evidence was available in the individual care plans), which provides the opportunity for personal development. Activities are selected to meet the residents’ interests and where appropriate to enable them to achieve realistic personal development goals. The individual Villosa II DS0000055526.V347904.R01.S.doc Version 5.2 Page 12 care plans demonstrated how the residents are supported to enjoy appropriate community resources. Some of the residents are able to maintain close ties with their relatives and friends and make visits/stays on a regular basis. Routines within the home are designed to promote service user independence. However the current service user group have limited independence skills due to their advancing years and for some people, a life that has involved extensive years of institutional care. The inspector therefore has assessed the quality of life of these service users against the need to further develop these daily living/independent skills. The outcome for these service users is therefore considered good. Service users are unrestricted in their movement around the home. Menus are offered on a flexible basis, with service users making choices over the meals. Meals taken were observed and were unrushed and relaxed. Adequate food stocks were noted in the kitchen cupboards and freezer. Particular food preferences and dietary needs are noted in the care plans. Villosa II DS0000055526.V347904.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): 18 – 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal support is provided in the way individual residents prefer. The residents’ physical and emotional needs are met. Medication records are inadequate and therefore the health and safety of residents is currently compromised. EVIDENCE: All care provided is individual and tailored to each person needs with service users choices and preferences being promoted. Assessments are completed ensuring that the approach adopted 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. However on the day of the inspection there Villosa II DS0000055526.V347904.R01.S.doc Version 5.2 Page 14 was a gap found on the MAR sheet for that morning’s medication and no running record was being maintained regarding the dispensing of paracetemol to individual service users. Medication training was unable to be evidenced on the day of the inspection as the manager was not on duty and staff spoken to were unable to confirm when they last received this training. Villosa II DS0000055526.V347904.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): 22 –23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is sufficient and adequate in order for the service users to feel that their individual views are listened to. Robust policies and procedures are in place to ensure service users are protected and safe. EVIDENCE: The Company’s own in-house complaints procedure is used and contains all the elements to meet the standard. There have been no complaints since the last inspection took place. The service users living at Villosa 11 have limited communication skills therefore it is imperative that all staff have a comprehensive knowledge of each service user and their understanding. This should be supported through other forms of communication in order to ensure that they are able to express any concerns or issues they may have about the service they are receiving. Villosa II DS0000055526.V347904.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): 24 –30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home and its surroundings offer a pleasant and comfortable environment to its service users to enjoy. All bedrooms are personalised and meet the individual’s needs. EVIDENCE: Service users are encouraged to bring personal items such as furniture and pictures into their room when they move in. The home was clean and odour free on the day of the inspection. The cleaning of the home is carried out by the care staff and with service users assisting where possible. The manager monitors this to ensure that standards of cleanliness are maintained. Villosa II DS0000055526.V347904.R01.S.doc Version 5.2 Page 17 Hygiene and infection control standards are adequate and gloves and aprons are available. The kitchen and laundry rooms are domestic in style and appear to manage their current workload effectively. Sufficient lighting, heating and ventilation is provided. Each service user has a single bedroom. The communal areas of the home are decorated and furnished to an acceptable le standard and there is a selection of home entertainment equipment for service user to access. The water temperatures on the day of the inspection were recorded within safe limits. The home also benefits from having an enclosed garden area and a large conservatory as a secondary communal area. Although on the day of the inspection door wedges were seen around the home. This suggests that therefore there is a likelihood that they will be used inappropriately and compromise service users, staff and visitors health and safety. Villosa II DS0000055526.V347904.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): 32, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are appropriately trained and supervised and that there was an appropriate skill mix to meet the current needs of the service users. Appropriate policies and procedures are followed in regard to staff recruitment to ensure service users are kept safe. EVIDENCE: The inspector was unable to access the required information due to the manager being away from the home. However these standards were thoroughly inspected during the inspection carried out in July 2006 and were found to be satisfactory with no cause for concern. Villosa II DS0000055526.V347904.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Policies and Procedures within the home must be adhered to in order to ensure service users are safeguarded. Individual risk assessment requires completion. Quality assurance systems must be improved in order to ensure service users are fully involved and consulted and areas of development improved. EVIDENCE: The ethos and management approach creates an open. The manager has daily contact service users, therefore assisting in any issues of concern being dealt with immediately. All records inspected were secure and were up to date and held in accordance with the Data Protection act 1998 ensuring that service users rights and best interests are safe guarded by the homes polices and procedures. Records Villosa II DS0000055526.V347904.R01.S.doc Version 5.2 Page 20 regarding staff recruitment were not inspected on this occasion but confirmed as adequate during the last inspection in 2006. Individual and generic risk assessments were in place, with all external required safety checks occurring. However there were not individual risk assessments for service users who are at risk of choking. The general standard of fire checks/recording had improved and fire records on the day of the inspection were up to date and recorded accurate. There was inadequate information during the inspection to confirm that regular quality assurance assessments are carried out within the home, in particular information regarding the opportunity for service users to have a ‘voice’ and to contribute to the running of the home. The manager should further implement a more formal quality assurance system in all areas of the service in order to ensure there is regular monitoring and reviewing to improve areas of development, with a particular focus on service user involvement and ensuring that all documentation relating to service users is produced in “user friendly format”. The inspector sampled three service user plans and found inadequate information to confirm that these plans were reviewed and updated regularly. There were gaps within these plans, which indicated that these plans required more attention to detail. The care plan should provide the information in “ working style” document that can easily understood, with particular focus on the service users understanding of this plan. The manager must ensure that care plans are monitored more regularly and that either the service user or their representative signs each service user plan. Villosa II DS0000055526.V347904.R01.S.doc Version 5.2 Page 21 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 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 3 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 2 3 x 2 x Villosa II DS0000055526.V347904.R01.S.doc Version 5.2 Page 22 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 (2) Requirement Timescale for action 31/08/07 2 YA9 YA42 13 (4) (c) 3. YA20 13 (2) 4. YA39 24 Service user care plans must be reviewed regularly and the service user or their representative must sign them to confirm that service users have been involved in the care planning process. Individual service users who are 31/08/07 at risk of choking must have an up to date risk assessment in place, which is reviewed regularly in order to maintain resident’s health and welfare. The systems for the monitoring, 31/08/07 recording and administration of medication must be robust. There were gaps found on the 12th July for one service user and there was no running record maintained for the administration of paracetemol. The quality assurance system 30/09/07 requires further expansion and completion. The current systems do not ensure that procedures are monitored and reviewed i.e. medication and care plan checks. Systems must be in place to ensure service users have a “voice” within the home. DS0000055526.V347904.R01.S.doc Version 5.2 Villosa II Page 23 5. YA42 23 (4) To ensure the integrity of the fire 31/08/07 system and peoples welfare fire doors must only be held open by systems approved by the fire safety officer – door wedges must not be used. 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 II DS0000055526.V347904.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. Extracts may not be used or reproduced without the express permission of CSCI Villosa II DS0000055526.V347904.R01.S.doc Version 5.2 Page 25 - 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. 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