Inspection on 18/05/05 for West Villas

This inspection was carried out on 18th May 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

West Villas 11/12/06

West Villas 14/12/05

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 18th May 2005 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. West Villas B54_S37224 WestVillas V227629_stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service West Villas Address Wells Avenue Hartlepool TS29 6BJ 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) 01429 890298 Milbury Care Services Ltd Miss Claire Jackson Care Home 6 Category(ies) of Learning Disability (6), Physical disability (3) registration, with number of places West Villas B54_S37224 WestVillas V227629_stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The Manager (Miss Claire Jackson) should attain (by 2005) a qualification, at Level 4 NVQ in Management or equivalent. 25/03/2004 2 One named individual who is above the age category is allowed to reside in the home. 05/11/2004 Date of last inspection 3rd November 2004 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. Accomodation 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 B54_S37224 WestVillas V227629_stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 18th May 2005 over 5 hours. During the inspection time was spent talking to a service user, staff and the manager. A number of records and files and also the building and gardens were looked at. The home provided care in a recently built home and the manager and staff showed they were very able to care for service users. In discussion, one service user said he was “very happy” at the home and the staff “are very kind”. The service user also said that he often went out of the home on trips and to do things he liked, and would be accompanied by a staff member. There were many outdoor activities going on at the home and the manager and staff tried very hard to make sure that there was always something for the service users to do that they enjoyed. What the service does well: What has improved since the last inspection? Since the last inspection there has been more training provided to staff and NVQ study has progressed. West Villas B54_S37224 WestVillas V227629_stage 4.doc Version 1.30 Page 6 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 B54_S37224 WestVillas V227629_stage 4.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 West Villas B54_S37224 WestVillas V227629_stage 4.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) 1, 4 and 5 The home provides satisfactory information in appropriate formats, to enable service user choice about living at the home. EVIDENCE: Information was available for prospective service users to decide whether to stay at the home. The Statement of Purpose and Service user Guide were informative and available in a pictorial format. Both documents needed further review but were generally good. Previous inspection reports were also available. Evidence was available to show that service users are invited to stay at the home after a process of trial visits including staying for tea and overnight stays prior to moving into the home. Assessments are carried out during this time and over a full 24 hours. Reassessment is carried out after a period of five weeks to ensure the service users needs are met by the home. A contract or statement of terms and conditions was available in pictorial format. West Villas B54_S37224 WestVillas V227629_stage 4.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 and 9 Care plans are prepared and reviewed with each service user. Risk assessment is carried out to cover many aspects of daily life and activity. EVIDENCE: Individual service user care plans were examined and found to be informative and comprehensive. The plans were available in a pictorial format and held evidence of service user involvement. A descriptive dictionary of individual service user communication methods had been prepared and was noted as being invaluable to staff members in conducting effective communication. Risk assessments were completed for each service user covering many aspects of their daily lives and social activity. The assessments showed evidence of regular review and included aspects of transport, health and holidays. West Villas B54_S37224 WestVillas V227629_stage 4.doc Version 1.30 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 standard(s) 13, 14 and 17 The home provides satisfactory leisure and community interests. Meals and mealtimes are flexible and respect service users choice. EVIDENCE: Service users at the home use the local amenities, pubs and shops regularly and have the benefit of the homes own transport. Service users use the local college and sports club. There are a number of outside leisure interests pursued by service users including visits to places of interest, football matches, swimming and regular home visits to see family and friends. Menus are prepared with service user involvement and are flexible to meet the choice of food requested on a daily basis, within a balanced diet dependent upon dietary need. Alternatives to the menu are readily available. Mealtimes are flexible and service users are often encouraged to participate in the preparation of the table and meal. West Villas B54_S37224 WestVillas V227629_stage 4.doc Version 1.30 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 standard(s) 20 Records of medication administered at the home are appropriate but needs to include medication used on an irregular basis. EVIDENCE: Examination of medication records found them to be satisfactorily completed and clear. No service user was self-medicating but staff were able to demonstrate the process to be followed should a service user request to do so. It was noted that some medication held at the home for use on an irregular basis was not recorded. A record of all medication held at the home must be kept. It was noted that further to the regular review of the medication records, it would be beneficial if evidence of the manager carrying out monitoring and audit, be recorded. West Villas B54_S37224 WestVillas V227629_stage 4.doc Version 1.30 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 standard(s) 23 The home operates a thorough complaints procedure and can demonstrate good knowledge of Adult Protection issues and procedures. EVIDENCE: A complaints policy and procedure was made available that included timescales and stages of the complaints process. Staff said the policy and procedure was being redeveloped to be more service user appropriate. It was noted that the policy and procedure bore the heading Commission for Social Care Inspection. This should be removed. The manager and staff demonstrated a good working knowledge of Adult Protection issues and No Secrets, the strategy for the abuse awareness and were able to show the actions to be taken if an incident occurred. West Villas B54_S37224 WestVillas V227629_stage 4.doc Version 1.30 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 standard(s) 24, 25, 27 and 30 The home provides a safe, clean and pleasant environment, accommodating individual preferences and needs. EVIDENCE: The home is of recent construction, designed to meet the requirements of young adults and the National Minimum Standards, and provides a comfortable homely environment within a modern dwelling. It was noted that hot water pipe-work in the kitchen needs to be covered. Service users bedrooms are decorated and furnished to the individuals preference and reflect their chosen lifestyle and interests. One service users bedroom was equipped to provide sensory stimulation using lights and sound. The home is well equipped for bathing and toileting, each bedroom having an en-suite toilet with hand basin. The home was clean, tidy and free from odour although it was noted that the seating in both lounges needed cleaning and the kitchen worktops were damaged. West Villas B54_S37224 WestVillas V227629_stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Staff training is constantly updated and developing and there is a commitment to provide staff with the knowledge to meet service users assessed needs. EVIDENCE: Staff training files were looked at and found to contain evidence of regular updating and training. The deputy manager said the training files were being redeveloped and a training matrix showing detail of courses to be undertaken was prepared. The deputy manager said that by the end of July 2005, 50 of care staff at the home will have achieved NVQ2 in care alongside statutory courses of first aid, basic food hygiene and moving and handling. Staff said the training provided was very good and there were always many courses on offer. It was noted that the home did not have internet access, which would be beneficial to staff training, and there was no fax machine available. West Villas B54_S37224 WestVillas V227629_stage 4.doc Version 1.30 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 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) 37 and 42 The registered manager uses her skills and abilities to provide a good standard of care to service users and to ensure health and safety within the home. EVIDENCE: The manager has the NVQ4 in care and is studying to complete the Registered Managers Award and hopes to have achieved it before the end of 2005. The home appears to be well run and staff and a service user commented that the manager is approachable and competent. During the inspection it was demonstrated that the health, safety and welfare of service users, staff and visitors to the home, as far as reasonably practicable, was maintained West Villas B54_S37224 WestVillas V227629_stage 4.doc Version 1.30 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 2 x x 3 3 Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 3 x x 2 Standard No 11 12 13 14 15 16 17 x x 3 3 x x 3 Standard No 31 32 33 34 35 36 Score x x x x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 West Villas Score x x 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x x x B54_S37224 WestVillas V227629_stage 4.doc Version 1.30 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. 1. Standard 1 Regulation 4 Requirement The registered person must provide within the statement of purpose the items listed at Schedule 1 of the Care Homes Regulations 2001 The registered person must ensure that all medication held at the home is recorded. The registered person must ensure that exposed hot water pipes accessible to service users are covered. The registered person must provide a fax machine. Timescale for action 31st July 2005 2. 3. 20 24 13 23 31st July 2005 31st June 2005 31st July 2005 4. 35 16 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 20 23 30 Good Practice Recommendations The manager shopuld provide evidence of monitoring and auditing of the medication system. The words Commission for Social Care Inspection should be removed from the headings of policices and procedures in use at the home. The manager should make arrangements to clean or replace the lounge suites and to carry out repair or B54_S37224 WestVillas V227629_stage 4.doc Version 1.30 Page 18 West Villas 4. 37 replacement of the kitchen workbench surfaces. The manager should achieve by 2005, NVQ4 in management or equivalent. West Villas B54_S37224 WestVillas V227629_stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection 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. 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