Care Home: Burlington Villa

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What the care home does well Information about the service is made available in a variety of formats such as pictures and graphics, to aid peoples understanding. People are consulted on an ongoing basis about all aspects of their lives at Burlington Villa and these views are listened to and acted on. People are supported to access the local community and to maintain relationships with family and friends as well as develop new friendships.Equality and diversity is recognised and celebrated throughout the service. Staff provide appropriate support to enable people to make choices and take (assessed) risks and staff levels are calculated to afford people as many opportunities to live their chosen lifestyle as possible. The service benefits from an experienced manager who ensures the Health and Safety of people is managed effectively and alongside the directors, ensures that the service is run in the best interests of the people who live there. What has improved since the last inspection? One requirement was made at the last inspection and one recommendation. These have both been addressed and work has been on going to ensure that the documentation that was introduced has developed to reflect the good practice of the service. The manager has now registered with the Care Quality Commission. What the care home could do better: The manager and staff continue to develop and improve the service that is provided for people living at Burlington Villa. This is a process which identifies that there is always scope to do things better and provide people with the best service possible. Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Burlington Villa 15 Burlington Road Sherwood Nottingham NG5 2GR The quality rating for this care home is: three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Angela Starr Date: 2 0 0 8 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Reader Information Document Purpose Author Inspection report CSCI Page 2 of 36 Care Homes for Adults (18-65 years) Audience Further copies from Copyright General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 36 Information about the care home Name of care home: Address: Burlington Villa 15 Burlington Road Sherwood Nottingham NG5 2GR 01159826644 01159602737 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): MGB Care Services Limited Name of registered manager (if applicable) Mrs Bridgette Jayne Denman Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 9 0 care home 9 learning disability Additional conditions: The registered persons may provide the following category of service only Care home code PC To service users of the following gender Both Whose primary care needs on admission to the home are within the following category Learning disability code LD The maximum number of service users who can be accommodated is 9 Date of last inspection Care Homes for Adults (18-65 years) Page 4 of 36 A bit about the care home Burlington Villa is a care home for up to 9 younger adults with Learning Disabilities, which was re-registered as a company in January 2007. The refurbished accommodation is sited over 3 floors with a shaft lift to assist independent access. All bedrooms are for single occupancy, they are well decorated, comfortably furnished and have en-suite facilities. There are two lounges, a large dining room and an activities room. There are additional toilets and a bathroom on each floor. Care Homes for Adults (18-65 years) Page 5 of 36 The rear garden is pleasantly landscaped, private and fully enclosed. The home is situated a few hundred yards from the centre of Sherwood, which has a range of facilities and good public transport links. Fees range from £1310.00 to £2309.49 per week dependent on assessed needs. Extra charges are made for toiletries. The manager makes information about the service, such as the service users guide, complaints procedure and statement of purpose available to people who may consider living at the service, before they are offered accommodation. Care Homes for Adults (18-65 years) Page 6 of 36 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home Care Homes for Adults (18-65 years) Page 7 of 36 How we did our inspection: This is what the inspector did when they were at the care home The focus of Inspections undertaken by the Care Quality Commission is upon outcomes for people who use the services and their views on the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Care Homes for Adults (18-65 years) Page 8 of 36 We ask managers to fill in a questionnaire called an Annual Quality Assurance Assessment, which tells us about how well their service provides for the needs of the people who use it and how they intend to improve their service. We received this back from the manager within the required timescale and the form was completed in a satisfactory manner, providing us with information to assist in planning our visit and deciding what areas to look at. Care Homes for Adults (18-65 years) Page 9 of 36 The main method of Inspection we use is called case tracking which involves us selecting a number of people who use the service and looking at the quality of the care they receive by speaking with them, observation, reading their records and asking staff about their needs. We spoke with three members of staff, three people who use the service and two relatives to form an opinion about the quality of the service being provided. We read documents as part of this visit and medication was inspected to form an opinion about the health and safety of people who use the service. Care Homes for Adults (18-65 years) Page 10 of 36 What the care home does well Information about the service is made available in a variety of formats such as pictures and graphics, to aid peoples understanding. People are consulted on an ongoing basis about all aspects of their lives at Burlington Villa and these views are listened to and acted on. People are supported to access the local community and to maintain relationships with family and friends as well as develop new friendships. Care Homes for Adults (18-65 years) Page 11 of 36 Equality and diversity is recognised and celebrated throughout the service. Staff provide appropriate support to enable people to make choices and take (assessed) risks and staff levels are calculated to afford people as many opportunities to live their chosen lifestyle as possible. The service benefits from an experienced manager who ensures the Health and Safety of people is managed effectively and alongside the directors, ensures that the service is run in the best interests of the people who live there. Care Homes for Adults (18-65 years) Page 12 of 36 What has got better from the last inspection One requirement was made at the last inspection and one recommendation. These have both been addressed and work has been on going to ensure that the documentation that was introduced has developed to reflect the good practice of the service. The manager has now registered with the Care Quality Commission. Care Homes for Adults (18-65 years) Page 13 of 36 What the care home could do better If you want to read the full report of our inspection please ask the person in charge of the care home Care Homes for Adults (18-65 years) Page 14 of 36 If you want to speak to the inspector please contact Angela Starr City Gate, Gallowgate, Newcastle upon Tyne. NE1 4PA TEL. 03000 616161 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line - 0870 240 7535 Care Homes for Adults (18-65 years) Page 15 of 36 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 16 of 36 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People who want to live at the service have their needs fully assessed over an extended period to ensure that these needs can be met. People are given up to date and accurate information about the service that is provided. Evidence: The written information provided to us by the manager tells us that anyone considering moving to the service has an extended community care assessment completed by a social worker. The person is then assessed by staff from the service to ensure that their needs and wishes can be met. Following the assessment, people are invited to visit the service and spend time getting to know the staff and the other people who live there. Family members are closely included in this process where appropriate. People are provided with opportunities to have meals and stay at Burlington Villa as part of a getting to know you process. Dependent on the needs and wishes of a person, staff may be allocated to go and participate in various activities with the person or to spend time at their Day Centre getting to know them and further assessing their individual needs, likes and dislikes. Care Homes for Adults (18-65 years) Page 17 of 36 Evidence: As part of our case tracking process we looked at the care files for three people who live at the service including the last person to move there. All three files contained thorough assessments of need as well as detailed person centred support plans which provided personal history, goals and aspirations. The files also contained copies of the service user guide and statement of purpose as well as contracts of residency. The manager and staff members that we spoke with were very knowledgeable about each person’s individual preferences. People we spoke with who live at the service told us I love living here. There is a friendly atmosphere and we all get on well. A relative we spoke with told us that they were given a lot of information about the service and felt it had More than lived up to it. This is the best place for my relative. They have never been happier. Care Homes for Adults (18-65 years) Page 18 of 36 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People are involved in regular reviews of their needs and participate in the development of their support plans. People are supported to make decisions and take risks as part of a chosen independent lifestyle. Evidence: The manager provided us with written information which tells us that each person living at the service has a comprehensive individual support plan with assessments based on the activities of daily living. We looked at care plans for three people chosen for case tracking and found them to be appropriately detailed providing staff with all the information they need to provide a high level of person centred support. All contained clear evidence of people being involved in the development and people we spoke with were aware of their support plans and what was in them. One person told us I told the staff what I like to do and I get to do it. I know my care plan says I like going out and I like my holidays. Care Homes for Adults (18-65 years) Page 19 of 36 Evidence: People told us that they make choices about how they are supported and they decide what they want. All three files contained individual risk assessments as well as generic ones. People told us they do want to do things that may have an element of risk but that is their choice. Examples given were taking holidays abroad and going out alone to the shops. Each care plan had been developed in a format suitable for the individual person. Some contained a lot of pictorial information whilst others had more written down. One plan we saw had been produced by a person living at the service as a daily diary and detailed the person’s routines in their chosen manner. A member of staff has developed a summary sheet for all the plans that provides enough information about each person to enable continuity of support in an emergency, such as hospital admission. Peoples personal goals are clearly recorded and as goals are achieved, new ones are identified. These vary in degree from person to person and include such things as going out alone and travelling abroad. People told us I love to go out for a walk on my own. I like to go into town with staff, horse riding and swimming. A relative told us I think its wonderful that my relative gets support to attend our place of worship and follow our culture. All the support plans we saw had evidence of regular reviews taking place with the person and where appropriate, their relatives. Staff we spoke with were all aware of each persons individual likes and dislikes as well the necessary support required for them to achieve their goals and enjoy the activities of daily living. Care Homes for Adults (18-65 years) Page 20 of 36 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People living at Burlington Villa experience a fulfilling lifestyle. The staff team are committed to promoting peoples rights and maintaining peoples dignity. Individual goals are identified and achieved and people are enabled to make choices and exercise preference. Evidence: The written information provided by the manager tells us Each person has recently completed a Road Map chart of their life. This is a person centred tool and outlines the activities that they have enjoyed participating in. The files we looked at, including the records of activities, showed us that people are pursuing activities of their choice on a daily basis. The activities are extremely varied and many people are supported on a one to one basis to ensure that their individual requirements and wishes are met. Care Homes for Adults (18-65 years) Page 21 of 36 Evidence: These activities include playing games, doing puzzles, watching DVDs, videos, music and therapeutic pamper sessions. There is also a multi-sensory room for recreation and relaxation in addition to separate lounges on the first floor and ground floor. Regular visits include walks to the local shops and supermarket, library, cinema and the pub as well as outings in the car to a variety of local attractions. A person told us about a regular event they attend where they meet friends and enjoy dancing and socialising. Another person showed us photographs and told us about the Christmas party they had attended at a local football ground, where they had worn formal evening wear and had been transported in a limousine. We were told I like to go horse riding and swimming We spoke with people living at the service and were told by some of them that they enjoy regular visits to family and friends. One person said I go to my family every week People told us that they also receive visits from family members who join in some of the activities. We spoke with two relatives as part of this inspection and they confirmed that they feel very involved in the lives of their relatives living at the service. Peoples rights and responsibilities are fully supported and evidence of this was seen in the care plans as well as observed at the time of the inspection. On the day of the inspection we saw people choosing to go out with staff to participate in routine activities such as filling the car with petrol and shopping for groceries. We also saw people going out to visit a local tourist attraction and one person planning a meal at the local pub for later in the day. We observed people to be happy and occupied throughout our visit. The dining room appears to be the favoured area where people spend time interacting with each other and with the staff. On one of the walls, we saw a map of the world and one person told us We have looked at the different countries where some of the staff come from and we put a pin in that country and a string to another pin where we write the words for hello and thank you. I like to learn about other people and I can say words in other languages. We saw that cultural requirements are identified and respected. Appropriate activities are followed, including visits to the Temple and food is provided to support this. The dining room is spacious and provides a comfortable area for people to enjoy their meals. The menu is varied and is produced in conjunction with the people living at the service. People told us I usually have what I want to eat. I like sweet and sour, chilli, curry and stir frys. Care Homes for Adults (18-65 years) Page 22 of 36 Evidence: People told us that the food is Great and there is plenty of it. Care Homes for Adults (18-65 years) Page 23 of 36 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People are receiving personal support in the way they prefer and require, and their health care needs are met. Evidence: The manager told us in the written information she provided, Staff ensure that personal and health care needs are maintained with privacy and dignity. Individual support plans detail any support people need to maintain their personal hygiene and health. Peoples health needs are monitored and appropriate action and intervention taken as required and everyone living at Burlington Villa has an individual Health Action Plan. People are encouraged to be as independent as possible. Support plans that we saw were all developed in a person centred way and the person they related to had been involved. Each plan was agreed and signed by the person or their representative and people we spoke with were very confident that their wishes had been recorded and were being met where possible. Evidence of health intervention was clear and there were records of all involvement from other professionals. e.g. Doctors, specialist teams such as the speech and language therapy service, district nurse intervention, opticians, physiotherapists etc., Care Homes for Adults (18-65 years) Page 24 of 36 Evidence: Peoples emotional needs are also addressed and where possible they are met. We saw the minutes of the regular residents meetings that take place and some issues are addressed at this time. The manager told us that day to day issues are always dealt with on an individual basis and she has introduced a strategy for enabling people to deal with their feelings about other people who live at the service. This involves people meeting to talk about their feelings and the things that make them happy or unhappy. One person said we have our ups and downs but mostly we are friends. People told us that if they want to see the Doctor, they ask the staff and an appointment is made. Staff do accompany people for appointments as necessary according to peoples wishes and needs. One person said I need the staff there to explain things to me and help me remember. The manager told us that when a person was admitted to hospital to undergo surgery, a member of staff stayed with them throughout their waking hours to alleviate any unnecessary anxiety. This has happened on more than one occasion and is believed by the person’s doctor to have aided a speedy recovery. A relative told us they always go over and above what we would expect to make peoples lives better. As part of our case tracking process we looked at the medication administration records for the people chosen. All the records were accurately completed and signed. We also looked at the risk assessments for people to manage their own medications and found that there is currently no-one at the service who is assessed as being able to do this. The storage, ordering and disposal of medication was checked and found to be in order. The manager has introduced a system whereby staff check the record sheets when they hand over and therefore, any irregularities would be identified before the person responsible had finished their shift. There are currently no controlled drugs being prescribed for people but there is a suitable storage facility and record book if this changes. Training records showed us that all staff have undergone medication training and refresher training is planned for some. Staff we spoke with were knowledgeable about the medication policies and practices and the importance of clear and accurate record keeping. Care Homes for Adults (18-65 years) Page 25 of 36 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . People living at the service are protected from potential abuse and harm and their views are actively sought, listened to and acted on. Policies and procedures are understood and are followed correctly by the staff team. Evidence: The manager told us The Home has a complaints procedure that is up to date and documents the stages of the process. The complaints procedure is presented in a clear and simple format using signs and symbols along with photos. This is to enable people to know who to make a complaint to if they have one. The complaints procedure is clearly displayed in the entrance to the home and is also contained within the policies and procedures of the home. To ensure people are safeguarded from abuse, prior to commencing employment at the home, staff have a Criminal Record Bureau and Protection of Vulnerable Adults check. All staff employed at the service have completed Safeguarding Adults training. A copy of the Nottingham and Nottinghamshire Safeguarding Adults Policy, Procedure and Guidance for Alerters and Referrers is kept in the Managers office and all staff are encouraged to refer to this. (Safeguarding Adults is a process of identifying and reporting suspected or potential abuse of vulnerable people and provides a framework of consistency to protect those individuals at risk.) We saw that a copy of the complaints procedure was displayed in the entrance hall of Care Homes for Adults (18-65 years) Page 26 of 36 Evidence: the service and a further copy which had been produced in an easy read format was also displayed for the benefit of people living at the service. We looked at records of complaints and saw that one had been recorded since the last key inspection. Records showed us that this had been investigated and the outcome shared with the complainant, who was satisfied with the process. We spoke to the person who had made the complaint and they confirmed that it had been acted upon immediately and everything was resolved. People living at the service told us that they do know how to complain and that they would know who to speak to. They also told us that there is nothing to complain about. People living at the service have the opportunity to meet with the directors of MGB care services every two months. People told us that this is another opportunity for them to voice any complaints or concerns. One person said We meet with the bosses and they talk to us about everything. I would soon tell them if something was wrong. We have a get together and drinks and talk about things. Staff told us If I ever have any problems or concerns about anything the office is always open. The manager is very good. The directors are very good and they make time to listen to us. Staff we spoke with were familiar with the complaints procedures and demonstrated a clear understanding of the policies as well as confirming they have undertaken training in safeguarding adults and would not hesitate to report anything of concern. Staff demonstrated an understanding of the whistle blowing policy and confirmed that they would not hesitate to follow this if they had any concerns. Whistle Blowing is a means for staff to feel supported to report anything of concern that they may witness. Care Homes for Adults (18-65 years) Page 27 of 36 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The home provides a physical environment that is appropriate to the needs of the people living there and is well maintained. Evidence: The written information provided to us prior to our inspection visit tells us The home is well decorated, very clean, safe, comfortable, homely and all staff and residents take pride in the home. The home benefits from having a variety of communal space and a garden, The home benefits from having two lounges, a dining room and a sensory/relaxation room for the residents to enjoy. Residents’ rooms are en suite, having a toilet and wash basin. Residents are encouraged and supported to personalise their bedrooms and also to keep them clean. All bedroom doors have locks and a few residents have their own keys. Residents bedrooms also benefit from having a nursecall system in place which is maintained. We undertook a partial tour of the service where we looked at all communal areas, the kitchen, laundry and some peoples bedrooms. The home was clean and tidy and free of any odours. People living at the service were using all the areas including the gardens. People only have access to the laundry room with staff support where they are enabled to do their Care Homes for Adults (18-65 years) Page 28 of 36 Evidence: own laundry if they wish. We observed the service to be homely and furnished in a way that suits the people who live there, with modern, comfortable furniture. Peoples bedrooms that we looked at were all decorated differently in a manner chosen by the person and all had many personal possessions. All the bedrooms have en-suite facilities and there are two bathrooms for people to use. No one currently has need of any specialist equipment but we were assured by the manager that this would be provided if required. One person told us I have a nice bedroom, its how I want it. Ive just decorated it and chose the colours myself. Another person told us This is the nicest room Ive ever had. Ive got everything I want and my pictures are on the wall. A relative told us Its always clean and very welcoming. There is always somewhere quiet to spend time with my relative. Care Homes for Adults (18-65 years) Page 29 of 36 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . Recruitment practices, training and support for staff are well managed providing good outcomes for people living at Burlington Villa. The home is run in the best interests of the people living there. Evidence: The written information provided by the manager tells us The company has a recruitment and selection process to ensure equal opportunities and protection of residents. The recruitment of all staff (including volunteers, work placements) are confirmed in post only following receipt of two written references and completion of a satisfactory police and POVA check prior to commencement of employment. Staff have a thorough induction at Burlington Villa and all staff are issued with an Induction Book. Day one of the induction is spent at MGB Care Services Head Office where staff sign their contract of employment and complete a mandatory fire safety awareness session on the computer. New members of staff are allocated a mentor for their first few shifts and are required to complete their induction book with guidance from the Manager. Burlington Villa has an excellent and diverse staff team. We observed people being supported by staff who were competent and had received training to enable them to do their jobs. On the day of the inspection we observed a high ratio of staff on duty. Six care staff are employed on each shift to support the Care Homes for Adults (18-65 years) Page 30 of 36 Evidence: current occupancy of nine people. In addition to this, the manager was on duty, a domestic and a cook. One to one support is provided where required. Training records that we looked at showed us that the service benefits from staff who have obtained or are working towards a National Vocational Qualification Level 2 or above in Health and Social Care. Staff are also given opportunities to complete various training courses linked to the needs of the Service Users. Training records showed us that training courses provided have included Food Hygiene, Health & Safety, Infection Control, Autism Awareness, Emergency First Aid, Safeguarding Adults, PROACT SCIP training (This is a specialist training which equips staff with the necessary skills to work with people with a range of different behaviours.), History of Care, Epilepsy Awareness, Person Centred Planning and Therapeutic Hand and Arm Massage training and care of medicines. We spoke with staff who told us that they hold regular staff meetings and we saw that the minutes are recorded, documented and plans of action are implemented. We saw evidence that staff supervisions take place on a 3 monthly basis and this was confirmed by staff who told us that they find supervision to be very useful. Staff also told us that they have the opportunity to access the latest information regarding learning disabilities in the Training Resource Room at MGB Care Services Head Office. Training and resources such as journals (from the British Institute of Learning Disabilities), magazines, videos, DVDs are available. We also saw a collection of learning resources that can be accessed by any staff member in the managers office at the service. Staff files we saw contained all the necessary information including two references, Criminal Record Bureau checks, proof of identity etc. A key worker system is in place at the service and people were able to tell us who their key workers are and what their expectations are of their key worker. Each shift is lead by a shift leader and at each handover, a number of areas are double checked to reduce the incidence of any omissions or errors. The staff we spoke with all felt that the team are very good. We have a good team and a good manager who is very easy to talk to and is always available. People living at the service told us The staff are all nice. They are very good and good fun. Care Homes for Adults (18-65 years) Page 31 of 36 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The management and administration of the home is based on openness and respect. There is an effective quality assurance system to ensure the service runs in the best interests of the people living there. Evidence: The Annual Quality Assurance Assessment returned to us by the manager gave us comprehensive and useful information about the service. It told us All staff adhere to the policies and procedures of the Home and undertake regular training. The Home has clear documentation of all safety checks to ensure compliance with current legislation as well as the health and safety of residents and staff. The staff team have an excellent working relationship and ensure the needs of the residents are met. Feedback is actively sought from residents at the Home through Service User Questionnaires. This is in addition to monthly visits through Regulation 26 and monthly financial audits to ensure effective safeguarding and management of residents money. Staff we spoke with all said that they enjoy working at the service and feel supported Care Homes for Adults (18-65 years) Page 32 of 36 Evidence: and listened to by the manager. They told us This is a well run home and run in the best interests of the people who live here People who live at the home told us that they think the home is well run and the manager is very approachable. They told us that they have plenty of opportunities to talk to the manager and the directors and they feel confident to make their views known. The quality assurance system used to gather information from people living at the home and their relatives /representatives, is effective and demonstrates that peoples views are always considered. We saw that the evidence is collated and any actions that are identified are planned with a timescale by which they must be achieved. Staff we spoke with told us I have regular supervisions, staff meetings and appraisals. Support and guidance relating to the needs of all clients is given via the manager and training. We complete internal surveys for quality purposes. A relative we spoke with told us Communication is facilitated well by phone calls They have been very supportive when my relative was experiencing difficult health issues in the past. We looked at the arrangements for supporting people with their finances and saw that the system is safe and all transactions are carefully documented. The fire log shows that all necessary fire safety testing and fire drills have been carried out. Servicing of equipment including gas and electricity is up to date and there are measures in place for the prevention of Legionella. The accident book was seen but no accidents have been recorded. The manager assured us that no accidents have occurred. The manager told us that Health and Safety of staff and people living at the service is of primary importance and records seen by us, support this statement. Care Homes for Adults (18-65 years) Page 33 of 36 Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 34 of 36 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Adults (18-65 years) Page 35 of 36 Helpline: Telephone: 03000 616161 or Textphone : or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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