CARE HOME ADULTS 18-65
Villosa II 40 Tippendell Lane Chiswell Green St Albans Hertfordshire AL2 3HL Lead Inspector
Julia Bradshaw Unannounced Inspection 14th November 2005 10:00 Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Villosa II Address 40 Tippendell Lane Chiswell Green St Albans Hertfordshire AL2 3HL 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 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.V267089.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 16th June 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. Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? What they could do better:
The manager must improve the current system of recording medication in particular with regard to controlled medication. The manager must also ensure that there are no door wedges used within the home as this presents a health and safety risk to both service users and staff. The manager must create a Quality Assurance system that incorporates the monitoring of food hygiene and general standards of health and safety. Out of date food was found in the fridge on the day of the inspection. Menus must be reviewed annually and the manager should consult the community dietician for advice and support regarding healthy eating plans. The manager must ensure staff meetings are held more regularly and although regulation 26 visits are being carried out
Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 6 there was no evidence to support these visits have been completed since June 2005 and the reports were missing. An up to date fire risk assessment must be completed. A visitor’s book must be provided. 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.V267089.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: These standards were not inspected on this occasion. Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10. Individual needs and choices within the home are being promoted to encourage and empower user self-determination. EVIDENCE: All service users are part of either the Person Centred Planning or CPA process and this currently provides an over-view and plan of the needs of all individual service users. The manager and staff continue to work hard to improve and develop the assessment process within the home. All service users have an allocated key worker to support them in the home. Individual daily guidelines/diary notes for service users where observed. The ethos promotes that the care plans of each individual are owned by the individual, those service users spoken to during the inspection were aware of their individual care plans. Within the home each service user is encouraged to take part in daily living tasks, for example being supported with meal preparation, washing up, laying the table, shopping. However this appears on occasions to be quite difficult to implement due to the majority of service users coming from large institutions where patterns of behaviour have been learnt and depended upon. Also the
Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 10 service user group at the home are becoming frailer and therefore unable to carry out specific tasks. Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: These standards were not inspected on this occasion. Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. All personal and health care support is well maintained within the home, ensuring individual needs, choices and preferences are met at all times. Medication procedures must be improved as the current system is inadequate and could present a risk to service users. EVIDENCE: All care provided is individual and tailored to each person needs with service users choices and preferences being promoted. Assessments and reviews are continuously completed ensuring that the approach adopted by the home is person centred and holistic to each service users needs. Service users needs and 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. The home has a policy and procedure in place to support the safe administration, storage and receipt of medicines. However on the day of the inspection the current system of recording controlled medication was misleading and unclear hence, creating a risk to service users. The home is currently using a book that does not comply with the current legislation regarding the safe handling of controlled medication. This has created a
Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 13 system that is both confusing and inaccurate. The witness column appears empty and the pages are not individually numbered. Therefore the home is required to replace the current book with a “bound” and “numbered” book in line with the current procedures. All staff receives training prior to being deemed competent to administer medication. The manager must ensure that Lactulose is stored at below 20 degrees centigrade at all times. Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: These standards were not inspected on this occasion. Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28 & 30. The home and its surroundings offer a pleasant, comfortable and safe environment to its service users. The home is clean and generally well maintained. The proprietors continue to improve the living environment for its service users. There are some areas of the home that require attention. EVIDENCE: The premises are generally in good order both internally and externally and meet all the required standards. However there are two general areas of the home that require attention. The flooring in the laundry must be fitted as it is currently bare concrete and the door lock on the conservatory remains inoperable and constitutes a safety risk to both service users and staff. All the bedrooms are adequate in size and continue to be re-furbished when required. Some service users have new beds since the last inspection took place and others have new furniture on order. All service users spoken to were very happy with their accommodation and all personal items of furniture were accommodated without any problems. There is adequate living space, which
Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 16 includes a lounge/diner and large conservatory. The house has a large back garden, which is well maintained. The office is located on the first floor of the home and provides adequate work and storage space. The staff team must ensure that food that has been opened and stored in the fridge must carry “a date of opening” on each individual item. Fire records are being maintained within the home. However the manager must ensure that a current fire risk assessment is in place. The manager MUST ensure that the practice of using door wedges ceases immediately. Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 17 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36. The home is suitably staffed with experienced individuals ensuring that at all times service users changing needs can be met. The staff team are enthusiastic and appear to take pride in the service. Recruitment procedures are robust and effective in the protection of service user. The manager is providing an effective programme of training. EVIDENCE: The staff spoken with during the inspection appeared to be clear of their individual roles and responsibilities. The members of staff on duty was seen to support the main aims and values of the home. The home has clearly defined job descriptions, although not all staff files contained this information. All staff have received a series of mandatory training course in order for them to meet the needs of the service users. Recent training includes, Moving and handling, (7/9/05) fire safety training, (26/1/05) first aid (5-8th September 05) and challenging behaviour training (14/7/05). Accurate training records are maintained within the home and certificates were seen to support this evidence.
Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 18 The manager has worked hard to improve the recruitment procedures within the home and the home now has a full compliment of staff. Supervision and appraisal occur within the home. The home employs eight full time staff who work both morning and evening shifts and there is also one Waking night care worker per night provided. There is a minimum of 2/3 staff on duty per shift and additional staff are used when required. Although staff meetings appear to be in operation there were several weeks minutes missing and therefore insufficient evidence to confirm these meetings are being held regularly. Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 41 & 42. The management within the home is effective ensuring that changing needs of service users are met and that the home is running meeting its aims and objectives. Some Quality assurance systems are in place although service user meetings are not currently documents. Health and safety standards within the home are currently being compromised. EVIDENCE: Service users appear to be happy with the home and observed to be relaxed in their environment. The relationship between the service users and the staff is well balanced with interactions observed being appropriate and supportive. The ethos and management approach of the home creates an open, positive and inclusive atmosphere, staff and the service user spoken to felt that they are supported and valued. A commitment is made to equal opportunities within the home, with staff expressing positive views with regards to this. The service
Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 20 users appeared to benefit from this well structured home. The staff and manager within the home are adequately and suitably trained in order to meet the changing needs of the service users. Some Quality assurance systems are in place. However there are inaccuracies regarding the regulation 26 visits as on the day of the inspection the last documentation seen was June 2005.This situation must be rectified immediately as this was identified during the last inspection as an outstanding requirement. The manager still needs to improve and develop some quality assurance systems within the home with a particular focus on health and safety and medication. (Monitoring of foods within the fridge and freezers and Controlled Drug medication records) The service users spoken to felt that their views were listened to and considered. However, records of service user meetings are not consistently maintained and the manager must ensure these minutes are taken and available for service users and staff. All records required by legislation are secure within the home and were up to date and held in accordance with the Data Protection act 1998. The manager must complete a fire risk assessment. The door lock on the conservatory needs to repaired and a visitor’s book needs to be re-introduced into the home. All door wedges must be removed from the home. All these aforementioned issues currently constitute a health and safety risk to service users and staff. Regulation 26 visits must be carried out monthly and an accurate record of these visits maintained within the home. Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X 2 X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Villosa II Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X X 3 X 2 2 X DS0000055526.V267089.R01.S.doc Version 5.0 Page 22 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 Medication procedures within the home must be improved with particular focus on the management of controlled drugs. The manager must ensure the door lock to the conservatory is repaired and the flooring in the laundry room is fitted with a non-pervious substance. There must be a current fire risk assessment held within the home. Regulation 26 visits must be carried out on a monthly and an accurate record of these visits maintained and to be held within the home. The manager must ensure that an effective quality assurance system is implemented into the home to ensure that all areas of health and safety are maintained effectively. Timescale for action 31/03/06 2 YA24 23 (2) (b) 31/03/06 3 4 YA40 YA41 23 (4) (a) 26 31/03/06 31/03/06 5 YA39 24 (1) (a) & (b) 31/03/06 Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 23 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 YA36 Good Practice Recommendations The manager should hold regular staff meetings and ensure that minutes are taken and retained. Villosa II DS0000055526.V267089.R01.S.doc Version 5.0 Page 24 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
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