Inspection on 14/07/06 for Villosa II

This inspection was carried out on 14th July 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 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 13/07/07

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 Hazel Wynn Key Unannounced Inspection 14th July 2006 10:00 Villosa II DS0000055526.V304364.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.V304364.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.V304364.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 01442 858504 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.V304364.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 2005 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 fee range is £900 - £1,150.00; the fees are currently under review. Villosa II DS0000055526.V304364.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report contains the outcomes of the unannounced inspection carried out by one regulation inspector representing CSCI on 4th July 2006. using available evidence gathered, since the last key inspection and during this visit. The visit included observation, discussion with residents, care staff and the manager and perusal of records maintained in the home. All of the key standards were assessed during this inspection and the overall outcome was positive. Requirements made at the last inspection had been met or partially met; two of the requirements had been partially met. The fire risk assessment had been commenced but not completed and a further requirement was made at this visit. A good attempt had been made to provide a quality assurance report; this required expansion and completion. A recommendation made at the last inspection had been met by the provision of regular staff meetings, which had been minuted. All residents spoken with expressed being happy living at the home, and said they liked the staff. Evidence was provided that activities suited individual needs, wishes and abilities. The registered manager was present during the inspection and he demonstrated a good ethos and purpose. Medication, care plans and health and safety records were sampled during the inspection and were accurately recorded. A record was not maintained of the temperature of the medication storage area and a requirement was made in this respect. Based on this inspection visit and information received since the last inspection visit, the overall quality of this service is good. What the service does well: The home provides a service that appears to be run in the best interests of the residents and provides a warm, friendly and homely atmosphere. Individual programmes of care are monitored and reviews are kept up to date. A good lifestyle is provided for residents. The care staff demonstrated a sound understanding of individual needs and were observed to be very supportive of the residents both individually and collectively. The home provides a healthy varied diet. Health and safety protocols are in place. Recruitment is robust and a rolling programme of staff training is provided. Villosa II DS0000055526.V304364.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 II DS0000055526.V304364.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.V304364.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 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. The quality in this outcome group is good; this judgement has been made using all available evidence including a visit to this service. EVIDENCE: The manager produced the package that is provided to prospective residents to help them to know about the home and what it offers. A transition plan for a prospective resident was perused during the inspection and this provided for the opportunity to make visits and an overnight stay to “test drive” the home and also to further the assessment process. The transition plan helps the prospective resident to learn more about the home and helps the staff at the home to learn more about the prospective resident’s needs, likes, dislikes and about what they would want. Contracts are with the Local Authority and a simplified version is provided to the resident when a decision has been made to accept the placement. Villosa II DS0000055526.V304364.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6-10 The residents know that they have a detailed person centred care plan covering all needs and aspirations. Detailed risk assessments are also maintained. Residents are supported to take risks within a risk management framework. Residents are supported to make decisions about their lives and are involved with making decisions in relation to the running of the home. All personal information is securely stored and staff are provided with training in confidentiality. The quality in this outcome group is good; this judgement has been made using all available evidence including a visit to this service. EVIDENCE: Two care plans were explored; these were well organised and gave clear guidance to care staff to enable safe and consistent care. There is a multi disciplinary approach to drawing up the care plans and reviews of the same and this is evidenced on file. The individual residents and their representative are involved in the care plan and review process (Whole Life reviews take place). The individual residents’ files provided evidence that the care plans, which include appropriate risk assessments, had been recently reviewed. Villosa II DS0000055526.V304364.R01.S.doc Version 5.2 Page 10 The residents are involved in the running of the home and choose how they will decorate and furnish their own room, collectively choose the décor for communal areas of the home, take part in gardening, cooking and domestic chores. This evidence obtained from the individual files and from discussions with the residents. Risk Assessments are in place to support the residents to achieve their fullest potential. In order to ensure that the residents are encouraged to be involved in the decision-making processes concerning the running of their home, the registered manager explained that Residents meetings take place on a one to one basis (which has been found to work best with the group). Outcomes of the one to one meetings are recorded in the individual’s file but are difficult to track and it is recommended that an easy to track record is used for this purpose. The information about the residents was observed to be appropriately and securely stored and staff demonstrated a good awareness of the keeping of confidences and confidentiality training is provided in line with the homes policy and procedure. Villosa II DS0000055526.V304364.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 - 17 The opportunity for personal development alongside peers of a similar age and ability is provided. 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. Residents’ rights and responsibilities are recognised. A nutritious and varied menu chosen by the residents is provided at suitable and flexible times and in a comfortable setting. The quality in this outcome group is good; this judgement has been made using all available evidence including a visit to this service. 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 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. One of the residents explained that she visits her husband on a regular basis. The registered manager was able to demonstrate how rights are respected and Villosa II DS0000055526.V304364.R01.S.doc Version 5.2 Page 12 responsibilities recognised. The contract/agreement is explanative and explains the service that will be provided and the rights and responsibilities of the individual resident. The residents had chosen a nutritious and varied menu. The dining area was observed to be bright and comfortably furnished. Villosa II DS0000055526.V304364.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 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 the way individual residents prefer. The residents’ physical and emotional needs are met. The residents are supported with medication in an appropriate and safe manner in accordance with policy and procedure. Other than the need to record the temperature in the medication storage area to ensure controlled temperatures, the quality in this outcome group is good; this judgement has been made using all available evidence including a visit to this service. EVIDENCE: Two care plans were explored; these were well organised and provided clear guidance to care staff to enable safe and consistent care and in the manner preferred by the individual resident. The care plans show how physical and emotional needs are to be met and progress notes support the evidence of needs met. The home is small and the registered manager was able to demonstrate an in-depth awareness of the residents’ emotional needs and how to meet these on an individual basis; clear guidance was also entered into the care plans. The residents have general and specific health care needs and the records show how these are met on an individual basis. All of the residents attend a well-women’s or well-men’s clinic at their local GP service. A member of staff was observed to be providing one to one company for a considerable period to one of the residents. The residents are supported to manage their Villosa II DS0000055526.V304364.R01.S.doc Version 5.2 Page 14 medication needs as is appropriate and policies and procedures are in place to provide safeguards. Controlled medication is managed within the guidelines and an appropriate system is used for recording these. There were no gaps on the Medication Administration Records and Medication was appropriately recorded on these. A check of the system provided evidence of good management and this is audited by the home on a regular basis. The medication storage temperature was not recorded and a requirement was made in this respect Villosa II DS0000055526.V304364.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22-23 Residents’ views are listened to and acted on and service uses are protected from abuse, neglect and self-harm. The quality in this outcome group is good; this judgement has been made using all available evidence including a visit to this service. EVIDENCE: The complaints folder showed that no complaints have been received by the home. Care staff were able to demonstrate their awareness of procedures and guidelines in place to protect the residents from abuse, neglect or self-harm. Training in abuse awareness and the whistle blowing procedures are provided during induction and at regular updates as observed on the staff files training records and as confirmed by staff. Risk assessments were in place to minimise risk of harm. A resident who had been at risk from another resident in the home has been protected and action taken with protocols put in place. Villosa II DS0000055526.V304364.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The home is very comfortable and homely. The accommodation meets the needs of the current residents. Resident’s own rooms have been decorated and personalised to their own preference and promote independence. Safety measures are in place to maintain a safe environment. The home was fresh, clean and hygienic. The quality in this outcome group is good; this judgement has been made using all available evidence including a visit to this service. EVIDENCE: The inspector observed the home to be well decorated and maintained; the home was fresh, clean, hygienic, comfortably and attractively furnished throughout. The registered manager had commenced work on a review of the fire risk assessment and the inspector advised that he might wish to compare the tool in use to the tool provided on the Hertfordshire Fire Authority website. The fire safety records were being maintained. The fire risk assessment had not been fully completed and has been further discussed in the management section of this report. The weekly testing of water temperatures was also seen and water was being maintained at a temperature of close to 43°C. A new impermeable floor had been laid in the laundry room. A new lock had been fitted to the conservatory door. Door guards had been fitted to some doors and Villosa II DS0000055526.V304364.R01.S.doc Version 5.2 Page 17 plans were in place to fit these to other fire doors; door wedges were not in use at the time of this inspection and the registered manager stated that these were disposed following the last inspection. The fire records provided evidence that regular checks and drills are in place and that servicing of the fire safety equipment is carried out on a contractual basis. Villosa II DS0000055526.V304364.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 and 36 The staff demonstrated that they were aware of the their roles and responsibilities. The staffing levels are adequate and staff have appropriate skills to meet the current residents needs. The home has robust recruitment policies and procedures to ensure the necessary protection and safety for the residents. The staff are appropriately trained and supervised to meet joint and individual needs of the residents. The quality in this outcome group is good; this judgement has been made using all available evidence including a visit to this service. EVIDENCE: All staff have a copy of the job description on file and staff spoken with appeared clear about their roles and responsibilities. The staff spoken with stated that they were well supported. Mandatory training had been provided and updated and certificates were seen to support this. Diabetes training had also been provided and the registered manager stated that he was in the process of obtaining training in Makaton. Evidence of regular supervision was seen; a discussion took place about the possibility of providing monthly formal supervision sessions. The staff files seen were for the most recently recruited staff and these contained the necessary checks and references. Some staff were recruited prior to the National Minimum Standards and did not contain two references; the registered manager was advised it would be best practice Villosa II DS0000055526.V304364.R01.S.doc Version 5.2 Page 19 to write a report about their employment performance and place this on file to remedy the shortfall as many of the staff had come from working in long stay hospitals that had closed and they did not have contacts for references but have worked successfully in the home for several years. Villosa II DS0000055526.V304364.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, and 42 The home appears to be well run. The management of the home demonstrates a good ethos and leadership. The residents are confident that they are listened to and that their views are incorporated into the progress made by the home. The fire risk assessment requires completion. The Quality Assurance system requires expansion and completion. The quality in this outcome group is adequate; this judgement has been made using all available evidence including a visit to this service. EVIDENCE: A numbered and columned book has been put in place for the purpose of recording one controlled medication in use, meeting the requirement made at the last inspection. The requirements in relation to the environment had been met – see the relevant section. The registered manager was in the process of completing a fire risk assessment. The regulation 26 visit reports were being maintained for perusal in the home. The registered manager had been completing a quality assurance document at the time of this inspection and advice was given on other areas to add to this. Regular staff meetings were Villosa II DS0000055526.V304364.R01.S.doc Version 5.2 Page 21 being held and the minutes of the last staff meeting were dated June 2006. The registered manager demonstrated that he was keen to meet the National Minimum Standards and residents and staff stated that they are well supported by him. From the records examined, observation and discussion with residents and staff, the health, safety and welfare of residents and staff appears to be promoted. The completion of the fire risk assessment and the Quality Assurance report will better satisfy the meeting of standards 39 and 42. Villosa II DS0000055526.V304364.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 3 5 3 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 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 3 Villosa II DS0000055526.V304364.R01.S.doc Version 5.2 Page 23 Yes 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 YA20 Regulation 13 (2) Requirement A record must be kept of the temperature of the medication area to ensure that medication is stored at a temperature in compliance with guidelines. The current fire risk assessment held within the home requires completion. (It is advisable to compare the fire risk assessment with the Local Fire Authority Fire Risk Assessment tool available on their website). The quality assurance system requires expansion and completion to ensure that all areas of health, safety and welfare are maintained effectively. (It is acknowledged that a good attempt has been made). Timescale for action 15/07/06 2. YA42 23 (4) (a) 31/08/06 5. YA39 24 (1) (a) & (b) 30/09/06 Villosa II DS0000055526.V304364.R01.S.doc Version 5.2 Page 24 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 YA8 Good Practice Recommendations The residents meetings held on a one to one basis should be minuted in a manner easy to track. The current practice of adding residents views to their progress/daily notes is not easy to track either for inspection purposes or for your own quality audits. For staff members employed pre National Minimum Standards and who were unable to obtain their references following closure of the long stay institutions, provide a statement on file that includes an appraisal of their performance during the years that they have been employed in the home. 2 YA34 Villosa II DS0000055526.V304364.R01.S.doc Version 5.2 Page 25 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 II DS0000055526.V304364.R01.S.doc Version 5.2 Page 26 - 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!