Inspection on 14/12/05 for West Villas

This inspection was carried out on 14th December 2005.

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 11/12/06

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 Stephen Willcock Unannounced Inspection 14th December 2005 11:00 West Villas DS0000037224.V259281.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 West Villas DS0000037224.V259281.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. West Villas DS0000037224.V259281.R01.S.doc Version 5.0 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 01429 890298 Milbury Care Services Limited Miss Claire Jackson Care Home 6 Category(ies) of Learning disability (6), Physical disability (3) registration, with number of places West Villas DS0000037224.V259281.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Manager (Miss Claire Jackson) should attain (by 2005) a qualification, at Level 4 NVQ in Management or equivalent. One named individual who is above the age category is allowed to reside in the home. 18th May 2005 Date of last inspection Brief Description of the Service: West Villas is a single storey purpose built home registered to provide care for up to 6 adults with a learning disability. Accommodation is provided in six single bedrooms all with en-suite facility. 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. West Villas DS0000037224.V259281.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 14th December 2005 and lasted around 3 hours. Time was spent talking to staff and the manager. We looked around the building and at a number of records and documents. Since the last inspection the manager has been carrying out secondment duties at another home in the group and is currently carrying out the role of line manager. At the time of the inspection an acting manager was in charge of the home and the acting line manager gave assistance. The home was very pleasant and the service users who were at the home on the day appeared happy, well cared for and interacted well with staff. Due to the nature of service users disability, communication can often be difficult, however a number of ways to engaged service users effectively have been developed at the home. Some improvements could be made to access the rear garden area as there are slopes and kerb-stones that may cause difficulties to service users with mobility or visual impairments. What the service does well: What has improved since the last inspection? What they could do better: Some improvements could be made to the garden environment by improving access and levelling of the sloping ground. A fence that could be removed obstructed the view from one service users bedroom, and a lounge suite was in need of replacement. West Villas DS0000037224.V259281.R01.S.doc Version 5.0 Page 6 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.V259281.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 West Villas DS0000037224.V259281.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): 2 and 3 Appropriate assessment of individual service users needs is undertaken and the home can demonstrate how it can meet the service users needs. EVIDENCE: Assessment documents for individual service users were seen to be in place. The documents contained original assessments from social workers and also the homes own assessments conducted prior to admission. The home produces and individual Service Users Guide for each service user, available in a picture format and giving good detail of the services provided. Service users files were seen to be well-documented and contained individual needs within a care plan. Regular review of the plan ensured that changes in need were acted upon. West Villas DS0000037224.V259281.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): 7, 8 and 10 Service users are enabled to make decisions about their lifestyle and in the running of the home, and confidential information is securely held. EVIDENCE: The manager gave details of regular meetings with service users either as a group or more often on an individual basis, where decisions about lifestyle and choices were made. It was common for family to be invited to participate in the decision making. Evidence was available to show that staff involved service users in making decisions about the running of the home. Recently, a service user suggested the installation of a shower. Confidential notes and files are secure, and service users are given the option of where they wish the files to be kept. A record of these wishes and agreement is in place for each service user. West Villas DS0000037224.V259281.R01.S.doc Version 5.0 Page 10 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): 12, 15 and 16 Service users are provided with a range of opportunities for personal development and are encouraged to maintain contact with families and friends. EVIDENCE: In discussion, the manager was able to demonstrate the varied activities, educational, employment and social, on offer to service users. These included college placements and outings to local amenities. Arrangements for future trips out were being discussed with the service users, families and care managers. Contact with family and friends, was maintained and regular. Staff often encourage visits by family and arrange transport when needed. One service user visits their family with the support of staff who stay with the service user overnight. Staff were seen to carry out their roles with respect and maintaining the dignity and rights of the service user. West Villas DS0000037224.V259281.R01.S.doc Version 5.0 Page 11 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 and 19 Service users preferred way of receiving care is respected and health and emotional needs are met. EVIDENCE: Details of the personal support that each service user needs are recorded in the care plans and staff have full knowledge of service users preferred way of giving their care. Contact with local healthcare providers is maintained and health checks are arranged and carried out regularly. West Villas DS0000037224.V259281.R01.S.doc Version 5.0 Page 12 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 The home operates a thorough complaints procedure. EVIDENCE: A corporate complaints policy and procedure was made available that included timescales and stages of the complaints process. The manager said that service users were asked about any issues they were unhappy with during regular residents meetings that took place on a monthly basis. West Villas DS0000037224.V259281.R01.S.doc Version 5.0 Page 13 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): 28 and 29 The home offers satisfactory shared space and the specialist equipment required. EVIDENCE: The layout of the home, being two joined bungalows, provides two lounge areas and a shared activity room containing a computer and learning material. New carpets had been recently fitted but one of the lounge suites showed signs of wear and needed repair or replacement. It was noted that the view from one of the service users bedrooms was severely restricted by a fence. The garden areas are quite open but access could be quite difficult for service users with mobility impairments due to the slopes and curbs in place. The manager said that this had been highlighted as a problem for some of the service users. The home provides the specialist bathing and toileting equipment required and has implemented a pictorial system of routines for one service user who had recently been readmitted to the home. West Villas DS0000037224.V259281.R01.S.doc Version 5.0 Page 14 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 and 34 Staff at the home are competent and trained to provide effective care to service users, and recruitment is carried out competently. EVIDENCE: Staff training is ongoing and further studies’ leading to NVQ2 in care are being undertaken. Two staff already held the qualifications. The manager confirmed that all staff had completed the Learning Disability Awareness Foundation (LDAF) course in addition to courses in food hygiene and first aid. Staff files were seen to follow the homes recruitment and selection policies and contained the appropriate references and Criminal Bureau checks. West Villas DS0000037224.V259281.R01.S.doc Version 5.0 Page 15 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 and 43 Service users are consulted about the running of the home, and regular review and audit of the service takes place. EVIDENCE: The manager demonstrated the need to keep service users informed about changes in the home and the value of service users views and opinions. The manager said that due to the nature of service users disabilities, it was essential that they were always made aware of changes at the home including visits by contactors to do repairs. The home had an annual development plan and information about changes in the organisation was available through the company’s “Kite” newsletter. A senior manager conducts an audit of the service, and seeks service users views and opinions about the running of the home, on a monthly basis. West Villas DS0000037224.V259281.R01.S.doc Version 5.0 Page 16 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 3 3 X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X 2 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 West Villas Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score X X 3 X X X 3 DS0000037224.V259281.R01.S.doc Version 5.0 Page 17 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. 2. 3. Refer to Standard YA23 YA28 YA28 Good Practice Recommendations The words Commission for Social Care Inspection should be removed from the headings of policies and procedures in use at the home. (Previously recommended) The manager should make arrangements to clean or replace the lounge suite. The manager should make arrangements to re-site the fence obstructing a service users view and make the garden area more accessible. West Villas DS0000037224.V259281.R01.S.doc Version 5.0 Page 18 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.V259281.R01.S.doc Version 5.0 Page 19 - 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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