Inspection on 15/06/05 for Villosa II

This inspection was carried out on 15th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 II 21/07/08

Villosa II 13/07/07

Villosa II 14/07/06

Villosa II 14/11/05

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 AL2 3HL Lead Inspector Julia Bradshaw Unannounced 15.06.05 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 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 Stationary 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 I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 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 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 LD LD Learning Disability - 6 registration, with number of places LD(E) LD(E) Learning Disability - 6 Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: There are none. Date of last inspection 8 February 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 I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection of the inspection year and took place over one day. The majority of time was spent talking to the manager, members of staff on duty and the service users who were at home. Some time was also spent looking at service user Plans, risk assessments, complaints, staff training, and staff files. Discussions were held with the manager Mr Puvanandradasa Shanmugadasa regarding the new inspection format and report. Service users and staff were very welcoming This was generally a positive inspection, and the majority of standards inspected were met. However there was a serious concern that was identified when inspecting the staff recruitment records regarding the appointment of a new member of staff without the appropriate CRB or POVA documentation being received back into the home. What the service does well: What has improved since the last inspection? The manager has worked hard to improve and develop the “in-house” systems of recording and monitoring of the service since the last inspection took place. Some areas of the home have been improved and developed since the last inspection took place, including service users bedrooms. The water temperatures are now being controlled more effectively. The manager has worked hard to improve the levels of supervision offered to each member of Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 Page 6 staff and is in the process of carrying out staff annual appraisals. The home now maintains accurate medication records in relation to PRN medication. The home has benefited from having new flooring fitted in the kitchen, the garden has been cleared and the area to the front of the home has been improved to accommodate the parking and manoeuvring of the minibus in a more effective and safe manner. 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 I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 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 standard(s) These standards were not inspected on this occasion. EVIDENCE: These standards were not inspected on this occasion. Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 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 standard(s) 6,7,8,9 &10 Individual needs and choices within the home are being promoted to encourage and empower user self-determination. Service user plans fully reflect the service users needs. Service users have the opportunity to contribute to some decisions taken within the home. Service users risk assessments are in place and reflect risks in relation to personal health and safety. EVIDENCE: All service users have an individual care plan and an allocated key worker to support them within the home. Individual daily notes and guidelines for the service users where observed within the home. All service users are supported within the Care Programme Approach or Whole Life Review framework to ensure changing needs are continuously assessed and reviewed. The ethos within the home promotes that the care plans of each individual are owned by Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 Page 10 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 partake in some daily living tasks. All information within the home is handled with care and respect. All personal notes and files detailing information on the service user are locked away ensuring confidentiality of service users. The home has risk assessment procedures in place and all risk assessments were up to date and accurate regarding generic risk assessments. There were also some individual risk assessments in place, in particular, with regard to one service user who at risk of absconding form the home and who requires clear and detailed guidelines regarding their own safety and the safety of others. The home has good systems of communication with both the service users and their carers and information is made available. There is a general policy on confidentiality. Service users’ individual records are accurate and they are stored securely in a locked filing cabinet. All staff signs each document to confirm they have read the necessary policies and procedures. Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 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 standard(s) 11,12,13,15 &17 Personal development opportunities are encouraged for all service users ensuring interactions with the outside community are encouraged. Individual rights and opportunities are recognised and supported, where possible. Restrictions on service users independence and rights are recognised and respected. Personal and sexual relationships are supported in a mature and professional manner. Service users are provided with a varied and wholesome diet. EVIDENCE: All service users attend a variety of day-care facilities including, Bricket wood daycentre and Thirlmere day-centre. All service users also have a day off to Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 Page 12 attend to their weekly tasks which include doing their laundry, clothes shopping and cleaning their rooms. The home provides a range of social and leisure activities for all the service users and these include meals out, day trips to the coast, bowling, cinema and trips to places of local interest. The home is in the process of also co-ordinating holidays and have several trips will be planned for later on in the year including taking one service user to Spain. Service uses are unrestricted in their movement around the home, with the exception of the kitchen area where staff support is required. The home is providing a varied and wholesome menu and diet. There was evidence to support that service users are fully involved in choosing their own meals and take turns to assist in the weekly shopping trips. The home has regular advice and support from the local community dietician. Alternatives are recorded, when required, although this is rare as the home has detailed knowledge of all the service users likes and dislikes and therefore provides the appropriate meals accordingly. Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 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 standard(s) 18,19,20 &21. The current medication practices and maintenance for medication are detailed and comprehensive. The ageing, illness and death of a service user is handled with respect. Information should be recorded to verity and ensure that staff are aware of these wishes. Service users emotional and physical needio hjbs are being met adequately. EVIDENCE: The majority of the current service users require some assistance with personal care. Support is provided in a respectful and dignified manner and within the privacy of service users own rooms. There is a good gender mix of staff with a balance of male staff to the majority of male service users. Service users can choose when they get up and go to bed, and they choose and pay for their own clothes and haircuts. For those who are assessed, mental health needs are met by visiting community psychiatric nurses and social workers. Service users visit their psychiatrists on an out patient basis. All the service users are registered with the same GP practice, but with different GPs. They visit a local dentist, optician and chiropodist when required. Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 Page 14 The home currently uses a monitored dosage system for dispensing medication. The home’s medication was suitably stored and the disposals book was up to date. All PRN medication is positively recorded and a running record maintained. All new staff receives a full induction, which includes three observation sessions with a senior member of staff before they are able to administer medication and assessed as competent. A pharmacist from Boots visited the home in May 2005 to review the home’s current medication procedures. There have been no serious accidents or incidents within the home since the last inspection took place. The manager should ensure that all service users last wishes are recorded on their individual service user plans. Some documentation assessed on the day of the inspection did not contain this information. Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 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 standard(s) 22 & 23 The complaints procedure within the home 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 but not being adhered toby the manager and therefore placing service users at risk. EVIDENCE: The home has a comprehensive complaints procedure in place, which details that the manager responds to all complaints. A record is maintained within the home of complaints made detailing actions and outcomes as necessary. The home has received no complaints since the last inspection. All service users have been informed about the complaints procedure. This is also on display within the home. The complaints procedure includes the correct contact details of the CSCI. Robust procedures are in place to ensure that service users are protected from abuse and harm. However, two staff files checked did not contain adequate information, prior to them commencing work at the home. This included NO CRB OR POVA clearance for one member of staff. The manager must ensure this situation does not re-occur and that he familiarises himself with the correct recruitment procedures so to proctect service users. Staff receive adequate Protection of Vulnerable Adults (POVA) training, which was last held on the 16/3/05. Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 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 standard(s) 24,25,26,27,28,29 & 30. The home and its surroundings offer a pleasant, comfortable environment to its service users. The home is generally clean and well maintained. All bedrooms are personalised offering a homely, lived in feel. The bathroom and laundry areas require attention. The health and safety of service users is currently being compromised in some areas of fire safety. EVIDENCE: The home provides sufficient lighting, heating and ventilation. A maintenance and renewal and redecoration plan is in place. Each service user has a single bedroom. Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 Page 17 The communal areas of the home are decorated and furnished to an adequate standard and there is a range of home entertainment equipment for service user to access. The home also benefits from having a large enclosed garden. Service users are encouraged to bring personal items such as furniture and pictures into their room when they move in. Service users spoken to were happy with their rooms and commented on how staff assist them in choosing and purchasing new items for their rooms and are wholly involved in deciding on their own colour schemes and soft furnishings. The home is exceptionally clean and attention to detail is given. The cleaning of the home is carried out by the care staff and with service users assisting where possible. The manager monitors this closely to ensure that standards of cleanliness remain high. Hygiene and infection controls are adequate. The kitchen/ laundry areas are domestic in style and appear to manage their current workload effectively. However the manager must ensure that the flooring in the laundry room is relaid as currently there is inadequate flooring provided and the machines are sitting on only a concrete floor, which is not impervious. This may increase the risk of infection as the floor can not be cleaned properly. The home has one domestic style bathroom with a bath/shower and toilet. However the flooring in this bathroom is badly stained and worn and requires replacing in order to maintain safe levels of infection control. Water temperatures were checked and were being delivered within safe limits. There are some areas of the home that still require re-decoration and these include the front and rear hallways The fire door from the hallway to the kitchen is poorly fitted and requires immediate attention in order to ensure the health ad welfare of the service users and staff is maintained. Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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 users but are not being adhered to and therefore compromising the health and safety of the service users. 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, Adult protection (16/3/05) fire safety training, (26/1/05) first aid (17/2/05) and challenging Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 Page 19 behaviour training (14/6/05). Accurate training records are maintained within the home and certificates were seen to support this evidence. Recruitment practices were inspected and found to be inadequate. The two files checked did not contain all the required information. In particular one file did not provide any evidence that the person had been CRB or POVA checked and there were no references on file. The manager must ensure that all staff recruited have had the appropriate checks and references in order to protect the service users. Supervision and appraisal occur within the home. The home employs seven full time staff who work both morning and evening shifts and there is also one Waking night careworker per night provided. There is a minimum of 2/3 staff on duty per shift and additional staff are used when required. The home is in the process of recruiting into the one full time post that is currently vacant. Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for 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 Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 Page 21 supported and valued. A commitment is made to equal opportunities within the home, with staff expressing positive views with regards to this. The service 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 and the organisation is carrying out regular Regulation 26 visits (last visit 9/6/05). The manager has daily contact with each service user and therefore the service users have the opportunity to raise issues or concerns informally. The service users spoken to felt that their views were listened to and considered. However, records of service user meetings are not maintained. 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 ensuring that service users rights and best interests are safe guarded by the homes polices and procedures. Records regarding staff recruitment were inspected and there was inadequate evidence to confirm that the recruitment and selection procedures were being adhered to. Individual and generic risk assessments were in place within home, with all external required safety checks occurring. All fire records were up to date and all health and safety records were in place and being maintained appropriately. However the fire door leading from the hallway into the kitchen was badly fitted and would not shut on the day of the inspection, hence compromising the health and welfare of the service users and staff. Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 1 3 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 3 1 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Villosa II Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score x x 3 x 1 1 x I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 Page 23 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 27 30 Regulation 23(2)(d) 16 (2) (c) Requirement The manager must replace the current flooring in the toilet/bathroom to the rear of the property and provide suitable flooring in the laundry room The manager must ensure that the fire door leading from the kitchen into the hallway is correctly fitted. The carpet leading through the downstairs hallway requires replacing. The manager must ensure that all recruitment procedures are strictly adhered to in order to protect the service users. Timescale for action 31/07/05 2. 24 23 (4) (c ) (iii) 16 (2) (c) 19 (1)(b) Schedule 2 17 (2) Schedule 4 31/07/05 3. 4. 28 34 31/07/05 From 15/06/05 and henceforth 5. 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. 2. Villosa II Refer to Standard 21 34 Good Practice Recommendations Records should be maintained regarding service users in the event of aging illness and death. Job Descriptions and person specifications should be I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 Page 24 3. 30 40 maintained on staff files. Service user meetings are recorded and the records available for inspection. Villosa II I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 Page 25 Commission for Social Care Inspection Mercury House 1 Braodwater 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 I52_s55526 Villosa 11 v232562 160605 stage 2.doc Version 1.30 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!