Inspection on 11/12/06 for West Villas

This inspection was carried out on 11th December 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 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

West Villas 14/12/05

West Villas 18/05/05

West Villas 03/11/04

West Villas 14/06/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Blenheim House

Prince Bishop Court

Park View (15)

Craigmore House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 West Villas Wells Avenue Hartlepool TS29 6BJ Lead Inspector Lesley-Anne Moore Unannounced Inspection 11 December 2006 10:00 th West Villas DS0000037224.V313473.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 West Villas DS0000037224.V313473.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. West Villas DS0000037224.V313473.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service West Villas Address Wells Avenue Hartlepool TS29 6BJ 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) 01429 890298 F/P londonroad@tiscali.co.uk Milbury Care Services Limited Janice Davis Care Home 6 Category(ies) of Learning disability (6), Physical disability (3) registration, with number of places West Villas DS0000037224.V313473.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th December 2005 Brief Description of the Service: West Villas is a single storey purpose built home, owned by Milbury Care Services Limited, registered to provide care for up to 6 adults with a learning disability. Accommodation consists of 2 semi-detached bungalows providing six single bedrooms all with en-suite facilities and pleasant communal living and dining areas. Corridors and door openings are wide enough to accommodate wheelchair users. Specialist bathing facilities are available. There is an enclosed and private garden to the rear and side of the building. The property is situated close to the town centre of Hartlepool and is in walking distance of local shops and amenities. There is a committed staff team comprising of care staff. The current fees charged are between £1078-£1777 per week, which does not include additional charges for personal items or holidays. West Villas DS0000037224.V313473.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 11 December and lasted for approximately 6 hours. The Acting Manager supplied some information on the pre-inspection questionnaire. 5 service user questionnaires were completed with help from the staff and returned. The inspection focussed on key standard outcomes for service users and to check whether the requirements and recommendations made at the previous inspection had been implemented; in particular to confirm the appointment of a Registered Manager following a period where a vacancy existed and a temporary staff member was in place; that improvements had been made to the external area in terms of access to the rear garden and that the fence situated outside a service users bedroom and partially obstructing the window had been resited; to meet with the service users and their relatives and talk to them about their experiences of living in the home; to meet with the staff; and to look at the home’s records. The inspector was given a tour of the premises. There were 5 service users at the time, the remaining service user had recently been admitted to hospital. On entering the home there was a relaxed and homely atmosphere. Service users appeared happy, were carrying out their normal daily activities and interacting well with the staff. One service user was out with a member of staff doing some personal shopping, another had just got up and was choosing what to do with his day. Due to the nature of the service users’ disability, communication could prove difficult but staff were using well-developed communication skills to effectively engage with the service users. It was noted that recommendations made at the previous 2 inspections relating to the resiting of a fence outside a service users window and also the levelling off of the rear garden for easier and safe access for service users have not been implemented What the service does well: Service users are encouraged to make choices about their life style and supported in developing their social skills. Service users are also encouraged to take part in group activities on a weekly basis. Staff take the time to explore the interests of individual service users and encourage them to achieve their maximum potential. One service user had an interest in making collages and evidence of this was seen in his room with various pieces mounted on the wall. West Villas DS0000037224.V313473.R01.S.doc Version 5.2 Page 6 Individual records have been developed with the service user both in text and pictorial format and are supplemented with personal photographs where possible. 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. West Villas DS0000037224.V313473.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 West Villas DS0000037224.V313473.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): 2,3, and 5. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Admission only takes place if the home is confident that the staff have the skills, ability and qualifications to meet the assessed needs of the prospective service user. EVIDENCE: Records of assessment of need on admission were available for each service user and included the home’s own assessment documents along with social service’s assessments where appropriate. Each service user is provided with a copy of the Service User’s Guide, which gives details of the services offered in a simple text and picture format. The Guide was seen to include a service agreement for each service user but this did not include details of the total fee payable or the arrangement for the payment of such. The Manager explained that individual contracts were held at Head Office at the current time since service users would obtain little benefit from the documents being kept in the home. Good practice would be for the home to consider a statement of intent if it considers that it is not in the service users interest to have copies of the contract at West Villas including details of how to access the information. West Villas DS0000037224.V313473.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, 7, 8 and 9. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Service users are involved in decisions about their lives and play an active role in planning the care and support they need. EVIDENCE: Care plans are developed following person centred planning principles whereby each service user has a care plan that has been agreed with him and is presented in a format that service users can access and understand the information it contains. The care plan titled ‘What I do now and how I like to spend my time’ considers all areas of the service user’s life including personal and social care needs, health needs, behaviour management and risk assessments. A section dedicated to personal goals ‘Planning and dreaming about the future’ considers the future aspirations of service users. Service users commented on the pre-inspection survey ‘I do what I want to do’ and ‘If staff ask me to do something it is always my decision’. West Villas DS0000037224.V313473.R01.S.doc Version 5.2 Page 10 Staff have the skills and ability to support and encourage service users to be involved in all aspects of life at the home. Each care plan includes a risk assessment that is reviewed on a 6 monthly basis and enables service users to make choices about their lifestyle within a supportive framework. West Villas DS0000037224.V313473.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, 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgment has been made using available evidence including a visit to this service. The home understands the importance of enabling the service users to achieve their goals, follow personal interests and leisure activities, and be integrated into community life. EVIDENCE: The Manager discussed the various activities that service users are engaged in to include educational, social and employment. One service user is supported in an employment initiative locally in another home within the group carrying out basic domestic chores, a number of service users attend a local college to develop their independent life skills, there is a full activity programme within the home to include art and craft activities, and there is an active social programme run in the home. A programme of weekly activities is written in consultation with each service user and displayed within the service user’s West Villas DS0000037224.V313473.R01.S.doc Version 5.2 Page 12 room. The staff encourage a good relationship with the local community and neighbours. Several of the service users spoke enthusiastically of their weekly visits to local organised events for people with similar disabilities and regular outings to Sacriston where one of the service users was brought up and friends still lived. Individual records are held securely. Each file contains a statement agreed with the service user as to where they wish their personal records are to be kept. The aims and objectives of the home reinforce the importance of treating service users with respect and dignity in all aspects of their life. Service users are involved in menu planning and contribute with supervision to the preparation of all meals. There is a varied menu on offer and each week the service holds a ‘take-away’ night to encourage service users to sample different foods. The staff support those service users who have difficulty with eating and give assistance where appropriate. West Villas DS0000037224.V313473.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, 19 and 20. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Staff understand the key principles of giving personal support and are responsive to the varied and individual needs of each service user. EVIDENCE: Service users are supported where possible to be independent and responsible for their own personal hygiene and personal care. The staff have developed excellent pictorial care plans written in consultation with the service user that describe the personal care that is required and individual preferences. Personal photographs are inserted to support the care plans showing service users engaged in personal care activities. The health care needs of service users are met locally. The home has a medication policy in place in which medicines are generally received, administered and disposed of safely. However, examination of the stock control procedures identified a number of service users in which stock levels of medicines were considered excessive, in one instance 4 months West Villas DS0000037224.V313473.R01.S.doc Version 5.2 Page 14 supply of a regular drug. Good practice would be to review the home’s medication policy to ensure that over stocking is prevented. There are currently no service users who self-medicate. West Villas DS0000037224.V313473.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 and 23. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users are able to express their concerns and have access to an effective complaints procedure within the home. EVIDENCE: There is a clear and accessible complaints procedure available to enable anyone associated with the service to make a complaint or make suggestions for improvement. Any complaint received by the home is fully investigated and an accurate record documented of the nature of the complaint and action taken. The 5 service users completing the pre-inspection survey all identified their key worker as being the person who they would talk to if they were unhappy with any aspect of the service. The Manager confirmed that there had been no complaints since her appointment in September and to the best of her knowledge no complaints since the last inspection visit. Regular residents meetings are held in which service users are encouraged to talk about any areas they are unhappy with. The policies and procedures regarding protection of service users are of a high standard and are reviewed and updated on a regular basis. Staff receive training on the protection of vulnerable adults. The service is clear when incidents require external input and which agency to refer to. The staff recruitment policy is adequate showing evidence of the appropriate checks being made prior to staff being appointed. West Villas DS0000037224.V313473.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, 25 and 30. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users live in a safe and homely environment. EVIDENCE: The home appears to be a well-maintained environment with the provision of pleasant communal areas both inside and outside for dining and relaxation. Although the communal areas are relatively small there is a sense of homeliness and community where service users can enjoy maximum independence in a non-institutional environment. Service users’ bedrooms are individualised giving the opportunity for choice to be exercised in the colour of décor. There is also the opportunity for a limited number of personal possessions and furnishings to be brought in. It was noted that the rear garden to West Villas 1 still presents a challenge to service users with limited mobility to safely access the lawned area since the area continues to slope. This is also the part of the building that accommodates the service users who may have a physical disability. However, West Villas DS0000037224.V313473.R01.S.doc Version 5.2 Page 17 the Manager explained that the garden area to West Villas 2 is always available for access. It was agreed that the fence partially obstructing the view from one service user’s room and commented on at the 2 previous inspection visits would be unsuitable to remove since the bin area would then be exposed and in view. However, the Inspector and Manager discussed a number of ways in which the appearance of the fence could be improved. All 5 service users commented on the pre-inspection survey that the home is always fresh and clean and ‘staff work very hard to keep the home clean’ West Villas DS0000037224.V313473.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): 32, 34, 35 and 36. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Sufficient staff are employed to support the care needs of the individual service users. An on-going training programme to support the changing needs of service users supports the recruitment policy. EVIDENCE: Discussion with the Manager, examination of the duty roster and observation during the inspection visit demonstrates appropriate number of staff and skill mix on duty at all times to meet the needs of the service users. One service user commented on the pre-inspection survey ‘all staff always listen to me and try to sort any problems I may have’. The service ensures that all staff receive relevant training that is targeted and focused on improving outcomes for service users. Documentation within the home gives evidence of the training that staff members are currently receiving, e.g. health and safety, first aid, food hygiene, manual handling, Protection of West Villas DS0000037224.V313473.R01.S.doc Version 5.2 Page 19 Vulnerable Adults. The Manager confirmed that a number of staff were due to commence the National Vocational Qualification Levels 2 & 3 in Care. Recently appointed staff files were examined which gave evidence of a proper recruitment process to ensure the delivery of a quality service and for the protection of service users. The recent appointment of a new Manager has provided stability to the staff team. There is an on-going supervision and appraisal system. The staff are very positive about the high standards of care they provide both individually and as members of a team. West Villas DS0000037224.V313473.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, 41 and 42. Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The newly appointed Manager provides direction and leadership to a service that is already committed to ensuring quality of life for its service users. EVIDENCE: The Manager, who has come from another home within the group, has the required experience, is competent to run the home and is respected by her staff team. Although new to the service she is adopting a leadership style of that of a democratic manager who listens to, respects and supports her staff whilst encouraging an open, friendly culture between staff, service users and their relatives and visiting support staff. To support her professional development she hopes to undertake the Registered Manager’s qualification in the next year. West Villas DS0000037224.V313473.R01.S.doc Version 5.2 Page 21 Service users views about the running of the home are sought on a regular basis at residents meetings; the staff spoke of the importance of involving and keeping the service users up to date with planned changes and new developments in the home. Quality surveys are undertaken informally and a senior member of the company’s management team also audits the service. The home has sound policies and procedures in place, which the Manager described as being reviewed and updated on a regular basis. Detailed health and safety policies safeguard the interest of service users, staff and visitors to the home, and are available for inspection to include evidence of regular servicing of fire equipment and gas and electrical appliances. There is evidence to confirm that accident records are duly completed and reviewed to detect a trend emerging in relation to any individual service user upon which remedial action is taken. The Inspector sought further information on two such incidents involving service users and staff and the Manager was able to confirm that the appropriate risk assessments had been carried out and that the required action had been taken. West Villas DS0000037224.V313473.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 X 2 3 3 3 4 X 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 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 4 13 4 14 X 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X 3 3 X West Villas DS0000037224.V313473.R01.S.doc Version 5.2 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA5 Good Practice Recommendations A copy of each service users statement of terms and conditions setting out in detail the fee, what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the service user should be held in the home. The home should consider a statement of intent if it considers that there is little value in holding the actual contract on site in view of the nature of the service users disabilities and their level of involvement in the agreement of the contract. A review of the medication policy in relation to stock control should be undertaken to ensure that over stocking is prevented. In consultation with the service user an attempt should be made to improve the appearance of a fence sited outside a service user’s window. 2. YA19 3. YA24 West Villas DS0000037224.V313473.R01.S.doc Version 5.2 Page 24 4. YA24 5. YA37 The Manager should undertake a risk assessment to provide evidence that the garden area at the rear of West Villas 1 is safe for use by service users with physical disabilities. The Manager should commence the Registered Manager’s qualification in the next year. West Villas DS0000037224.V313473.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 West Villas DS0000037224.V313473.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. 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