Inspection on 06/01/06 for Wortley Villa

This inspection was carried out on 6th January 2006.

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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wortley Villa 24/02/09

Wortley Villa 27/02/07

Wortley Villa 25/08/05

Wortley Villa 01/11/04

Wortley Villa 14/07/04

Wortley Villa 02/12/03

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Wortley Villa Bath Road Nailsworth Glos GL6 0HH Lead Inspector Mr Paul Chapman Unannounced Inspection 6th January 2006 10:35 Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 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 Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 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. Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Wortley Villa Address Bath Road Nailsworth Glos GL6 0HH 01453 833140 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) admin@ggh.org.uk Gloucestershire Group Homes Mr Jeffrey Michael Bird Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th August 2005 Brief Description of the Service: Wortley Villa is a detached three-storey house with accommodation for five adults with Aspergers Syndrome. The organisation offers a very specialised, individual service for people with Aspergers syndrome, and staff receive training to support service users appropriately. The home is conveniently situated in Nailsworth, which enables service users to access local community facilities. Service users also have access to transport that is provided by the home and this enables them to access facilities in several other local towns. The home is staffed 24 hours a day, seven days a week. Family and friends are welcome to visit the home at any time and service users can meet them in private if they wish to. The service users attend various activities, which include Day services provided by Gloucester Group Homes, College courses and work experience. The Inspector has visited the day service that is provided by the organisation, it has been developed specifically for people who have Aspergers and offers service users very individual programmes to meet their needs. Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was completed over a period of 1 hour and 30 minutes on a day in January 2006. At the time of the inspection one staff member was present at the home, whilst another staff member was out with a service user. The inspector spoke with one service user, and met another briefly as they were going about their morning routine. The aims of this inspection were to assess the home’s progress towards meeting the 3 requirements of the previous inspection. The inspector spoke at length to the staff on duty and examined some of the service users’ records. It is recommended for a more comprehensive overview of the service provided at the home this report should be read in conjunction with the previous report dated 25th August 2005. What the service does well: What has improved since the last inspection? Since the previous inspection staff have worked hard with the last person to move into the home and this has resulted in their behaviour becoming more stable. Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 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. Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 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 Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 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): EVIDENCE: None of these standards were inspected at the previous inspection. Standard 1 was inspected at the previous inspection and found to meet the required standard. Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 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): EVIDENCE: At the previous inspection all of these standards were inspected and only one shortfall was identified against standard 7. The inspection report made a requirement to address this shortfall. The manager was to ensure that any limitations to a service user’s freedom were supported by the reasons, agreement of all parties involved and documented. The inspector found one document signed by the service user agreeing a restriction as to when they receive their personal money. This clearly showed that the service user agreed to this. The inspector was unable to find documentation to support another specific restriction to the service user. The inspector understands the reasons for the restriction, and the home are acting appropriately in that it is in the best interests of the service user. In conversation with the service user they understand and agree to the restriction. The shortfall lies with the documentation leading to the home making the decision to restrict the service user’s freedom of choice. The home should identify what actions led to the restriction being implemented, and the different approaches adopted by them before this current restriction. After the Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 Page 10 inspection the inspector visited the manager to discuss this and it was agreed that this would be completed. The home keep comprehensive records that monitor peoples’ moods and the inspector examined the records for the last person admitted to the home. These records showed that since their admission their mood has become more stable and the staff on duty were able to explain how the strategies they use have achieved this. Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 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): EVIDENCE: At the previous inspection all of the standards considered by the CSCI to require inspection annually were assessed and the home were found to meet the required standard. Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: At the previous inspection the 3 standards considered by the CSCI to require inspection annually were assessed one shortfall was identified. The requirement to address this shortfall was for the manager to ensure that no gaps were left in the recording of service users’ medication administration. Examination of the records on this occasion showed further shortfalls: 1. Staff had not signed to confirm a service user had received their medication on 12/12/05. The staff member responsible for this was on duty and the inspector spoke about ensuring they always sign to confirm the medication has been administered. The staff member stated that they could confirm that they had administered the medication to the person on that morning. 2. Examination of one person’s medication specifically showed that between 01/01/06 and 04/01/06 they had only received 2 of the 3 doses of their medication as prescribed, and that on 03/01/06 they had only received 1 of the 3 prescribed doses. The staff member on duty stated that this was due to the person’s sleep pattern deteriorating and them missing the Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 Page 13 morning dose, as they were still asleep. They were unable to give a reason as to why the person had missed 2 doses on 1 day. 3. Where the person had not received their medication staff had left a blank space with no explanation of why the person had not received their medication. When a person does not receive, or refuses their medication the medication sheet should be completed appropriately to identify this. It is recommended that the medication sheet should have a key that identifies different letters that staff could use to explain different actions. After the inspection the inspector met with the registered manager to discuss these findings. They stated that the service user had an appointment for a medication review with their psychiatrist in February as the service user felt they no longer needed 3 doses per day and it should be decreased to 2 doses. And this is why they were refusing 1 dose. The manager was unaware that on 03/01/06 the person had only received 1 dose. In relation to the medication sheet not being signed by staff and left blank the manager agreed that this was unacceptable and it would be reviewed. The manager also stated that they would send the inspector confirmation of the date for the medication review. Requirements for these findings are as follows: The manager must continue to monitor medication records to ensure that they are signed by staff. The manager must ensure that staff record on the medication sheet reasons why medication has not been administered. Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Staff completing training in adult protection further safeguards Service users’ from abuse. EVIDENCE: Since the previous inspection the organisation have implemented training for staff in adult protection. Staff spoken with during this inspection have not completed this training to date but will be completing it in the future. Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 30. The communal environment meets the needs of the current service users in providing them sufficient space and different areas in which to relax and be alone if they wish. EVIDENCE: The communal areas of the home are decorated to a good standard and the home employs cleaners to ensure that the high standard cleanliness are maintained. No issues were identified with the bathroom and toilet. None of the service users bedrooms were seen during this inspection. Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 Page 16 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): EVIDENCE: None of these standards were inspected on this occasion, at the previous inspection all of the standards were inspected and one shortfall was identified. The staff member spoken with as part of this inspection explained that they had completed their induction training, fire safety and will be attending the adult protection training in the future. The shortfall identified at the previous inspection related to the training provided to staff. Evidence from staff spoken with during this inspection shows that training needs identified in the previous report are beginning to be delivered. The organisation’s progress towards meeting all of these training needs will be examined more closely at the next inspection. Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 Page 17 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): EVIDENCE: None of these standards were inspected on this occasion. At the previous inspection standards 37, 38, 39, 42. When the inspector met with the registered manager after this inspection they explained that a regulation 26 visit had been completed on the previous day. Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 Page 18 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 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 2 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X X X X X X Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 Page 19 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 YA7 Regulation 12(2) Requirement The manager must ensure that any limitations to a service user’s freedom are supported with the reasons and the agreement of all parties is documented. The manager must ensure that medication administration sheets are always signed to confirm that the medication has been administered. Where the medication has not been administered the reason should be documented. Timescale for action 03/03/06 2. YA20 13(2) 03/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Wortley Villa DS0000016657.V276983.R01.S.doc Version 5.1 Page 21 - 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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