Care Home: West Villas

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What the care home does well Service users receive clear information about the service to help them make a choice to live there. Service users are encouraged to make choices and decisions about their life style and supported in developing their social skills.In staff surveys five staff commented that supporting the people who use the service with activities, independence and a full and happy life was among the things the service does well. People living at the service enjoy active lives and are encouraged to try new experiences as well as to keep in touch with family and old friends. The home has made good links with local health services. This means that the people living at the home have their varied health needs addressed. The people who live at the home will have their own room and this will be adapted as far as possible to their individual needs. Staff work flexibly as a team to make sure that service users` lifestyles are supported. What has improved since the last inspection? The information available to people who use the service is now in an easy to read style. A regional training manager has been appointed and electronic learning tools are in place. This means that service users can expect staff training will match their needs and directly improve their lives. The garden has been improved so that the people living at the service look out onto a more attractive view. Information has been given to the people using the service to help them to raise their concerns. A regional quality assurance manager has been appointed. This means that the people who live at the service will have someone in the wider organisation they can expect to be concerned about their care. CARE HOME ADULTS 18-65 West Villas Wells Avenue Hartlepool TS29 6BJ Lead Inspector Carole McKay Key Unannounced Inspection 16th and 29th January 2008 10:30 West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service West Villas Address Wells Avenue Hartlepool TS29 6BJ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01429 890298 F/P londonroad@tiscali.co.uk Milbury Care Services Ltd Janice Davis Care Home 6 Category(ies) of Learning disability (6), Physical disability (3) registration, with number of places West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary need on admission to the Home are within the following categories: Learning Disability - Code LD, maximum number 6 Physical Disability - Code PD, maximum number 3 The maximum number of service users who can be accommodated is: 6 11th December 2006 2. Date of last inspection Brief Description of the Service: West Villas is a single storey purpose built home, owned by Milbury Care Services Limited, registered to provide care for up to 6 adults with a learning disability. Accommodation consists of 2 semi-detached bungalows providing six single bedrooms all with en-suite facilities and pleasant communal living and dining areas. Corridors and door openings are wide enough to accommodate wheelchair users. Specialist bathing facilities are available. There is an enclosed and private garden to the rear and side of the building. The property is situated close to the town centre of Hartlepool and is in walking distance of local shops and amenities. Information about the home is available. This includes a copy of the report form the previous inspection. The current fees charged are between £1078-£1777 per week, which does not include additional charges for personal items or holidays. West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit on 11 December 2006. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service. • The views of the people who work at the service. The Visit: Unannounced visits were made on the 16th and 29th January 2008. During the visit we: • • • • • • • Talked with people who use the service, staff and the manager. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. Left surveys for ten staff and six service users to complete. Seven of the staff surveys and three of the service users surveys were returned in time to be included in this report. We told the manager/provider what we found. What the service does well: Service users receive clear information about the service to help them make a choice to live there. Service users are encouraged to make choices and decisions about their life style and supported in developing their social skills. West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 6 In staff surveys five staff commented that supporting the people who use the service with activities, independence and a full and happy life was among the things the service does well. People living at the service enjoy active lives and are encouraged to try new experiences as well as to keep in touch with family and old friends. The home has made good links with local health services. This means that the people living at the home have their varied health needs addressed. The people who live at the home will have their own room and this will be adapted as far as possible to their individual needs. Staff work flexibly as a team to make sure that service users’ lifestyles are supported. What has improved since the last inspection? What they could do better: Make arrangements to ensure that information and property is handled confidentially and stored away from view of others. This will enhance the dignity of people who use the service and keep them safe. Repair the work surface in the kitchen and refurbish the office. This will ensure the safety of staff and the people who live at the service. West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 7 Reduce staff turnover. This will improve staff morale and ensure that the people living at the home receive uninterrupted care. Support staff to obtain formal qualifications so that the people who use the service continue to enjoy an improving level of care. 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. The summary of this inspection report can be made available in other formats on request. West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 8 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.V356872.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good systems in place for helping people make choices about living in this home, and people can be assured that their needs can be met. EVIDENCE: The home has a service user guide available in a pictorial format. Terms and conditions are now issued to each service user. Each person living at the home has a personal information file. In surveys service users confirmed that they had received information about the home to help them make a choice. Records of assessment of need on admission were available for each service user and included the home’s own assessment documents along with social service’s assessments where appropriate. Good background information has been gathered as part of the assessment. In staff surveys staff indicated that they either always or usually get up to date information about service users needs. West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the service will be able to make decisions and have their changing needs met. EVIDENCE: Each person has a service user plan. These include assessments and plans of care. Interests, wishes and goals are included. Care managers assessments are on file. Service user plans were being updated and redesigned. And included personal goals, identified strengths and risks. The plans clearly identify and detail how staff should support the people who live at the service to achieve their wishes. Daily diaries are kept in very good detail. These form the basis of a monthly review of care for each person. The reviews are recorded in the service user plans. Keyworkers for each service user, or the manager carry out the review. Professional visits are reviewed as well as any West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 11 other issues arising, such as changes in medication. The review identifies any action needed and the people who are involved. Risk assessments are also re visited as part of the review. The service supports decision making. Keyworker meetings take place with service users once per month. These are used to discuss service users’ decisions. Risk assessments are carried out for activities. For example very thorough risk assessments had been carried out for supporting a person with outings and vulnerability. In staff surveys four staff responded ‘always’, two responded ‘usually’ and one person responded ‘sometimes’ to the question – “ Do you feel you have the right support, experience and knowledge to meet the different needs of people who use the services? In surveys the service users confirmed that they could make decisions. West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The ethos of the service ensures that service users are enabled to live the lifestyle they would choose as far as possible. EVIDENCE: Risk assessments for independence are carried out. Management plans are produced to support service users’ independence safely. For example, for assisting with meal preparation. Monthly summaries of activity and well being are recorded in service users’ plans. Leisure time is planned around individual interests as well as some shared and some group activity. West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 13 Family links are encouraged and supported. A telephone conversation was arranged on behalf of and with a service user. Visits take place in the home and service users are supported to visit family or places they have previously lived. People are encouraged to reminisce about their history and where they have lived previously. The home does not have a list of rules but the main front doors are kept locked as a safety precaution as they open onto a busy junction for a health centre (located next door). Some of the service users lack road safety sense. The back doors into the garden are not locked through the day. Some service users have their own daily routines, such as going to the local shop each day for a pasty for supper, or going for a daily walk and a cigarette. Rules for one individual to control smoking within safe health limits have been agreed. This person demonstrated their understanding of the reasons for this and happily complied. In surveys service users confirmed that they can decide how they spend their time throughout the day. The manager said that all people have keys to rooms but do not use them. Meals and menus are planned with the people who use the service. The manager is working on a picture bank for service users to make choices from and to make up menus with. The manager is aware of healthy eating and said this is promoted, but choice is also accommodated. Weight gain and loss is monitored. Active lifestyles are encouraged. Walking, using buses for outings and regular disco and fitness club visits are organised. In staff surveys five staff commented that supporting the people who use the service with activities, independence and a full and happy life is among the things the service does well. West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive support in the way they require, and the diversity of their needs is fully recognised. EVIDENCE: Health care logs are included in service user plans. These show that regular routine health appointments are arranged for the people that live at the service. Special care is also arranged, for example one service user has seen a dietician recently. On going individual support is recorded showing the preferences and needs of each person. For example a bathing plan is in place for a person living at the home. General and specialised risk assessments are included in service user plans. These include assessments of service users needs for moving around and being supported with this. West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 15 Service users’ special health care needs are addressed. For example weight loss is being monitored for one person and another person is attending hospital for medical tests and investigations. Another person is being supported to attend regular reviews of a medical condition and associated medication with specialists. A specialist continence advisor visited the home very recently. This was discussed with manager. Advice has been given about promoting continence and the manger demonstrates insight into good practice and how sensitively this needs to be managed. This is still a developing area with staff and the manager is promoting a positive approach. Medication is managed on behalf of service users. This was observed in practice during the inspection. The process was handled well. Medicines and records are kept safely in the office, but this is the connecting thoroughfare between both bungalows, and forms the hub of “the home” so maintaining privacy and confidentiality is very difficult at times. Written policies and procedures are appropriate to the setting. The home has a process for assessing the competency of staff to administer medications. An assessment form is completed for each staff member. Medication training is part of the mandatory training provided. This covers the procedures which include reading prescription sheets, administering, recording and safekeeping of medication. The manager has identified that plans to do with the ageing process and death and dying need to be developed. In surveys some of the staff identified good care or a high standard of care as among the things the service does well. And the service users responded ‘always’ to the question about the staff treating them well. West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at the service are protected from harm and feel they are listened to. EVIDENCE: Service users’ monies are safely stored, and are fully accounted for where staff undertake the responsibility for handling money. Third parties manage some service users affairs. One service user is supported to manage their own affairs. The process of staff assisting a service user with this was observed in the office. During this process other staff and service users entered and passed through the room, as it is the only access route between the two bungalows that form the home. In the last 12 months service users have been issued with a “ let us know what you think “ leaflet, and information describing how they will be kept safe from harm. Local procedures for safeguarding vulnerable people are in place. Staff have received training in these and further training is being arranged. In the surveys all staff confirmed that they knew how to respond to concerns expressed by service users and/ or family or friends of service users. West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 17 Copies of complaints procedures are included in the service users guide. These have been recently updated and are in an easy read format. There are clear care plans with guidelines for people who need staff to protect them from harming themselves or others. In the surveys all staff confirmed that they knew how to respond to concerns expressed by service users and or family or friends of service users. No concerns have been received about the service by the Commission for Social Care Inspection. West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely comfortable environment that is adapted to their needs. The layout of the home makes it difficult for the staff to ensure service user confidentiality. But they are aware of this and do the best they can to manage this. EVIDENCE: The home comprises two bungalows which are joined, with a staff office and sleep in room in a central location. This means that the home has two kitchens, two laundries, and two sitting room/dining areas. The premises are modern and purpose built. The home is attractively decorated, but showing some signs of wear. For example the work surface in one of the kitchens is damaged. The staff said that this had been reported and a repair was being organised. The office carpet is marked and should be cleaned or replaced. The West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 19 doors leading from the office are scuffed. The gardens are to the rear of the home. The lawn slopes quite steeply towards the rear fence. This was raised at the last inspection. The manager said that plans were being prepared to have the garden landscaped. All the bedrooms are single rooms, attractively decorated and individually furnished. People living at the home have personalised their rooms with photographs, pictures, ornaments and other belongings. All of the bedrooms have en suite facilities. The staff said that these are spacious enough for the mobility needs of the current service users. Some small appliances have been added, such as handrails, raised toilet seats. One of the bathrooms has a specialist bath installed. This is located in the bungalow where service users have the highest mobility needs. The staff said that a shortage of storage is a problem. There is evidence of this. Packs of incontinence pads are stored in the bathroom. Black bags of unwanted linens and clothing are stored in here awaiting disposal. Some resources used for training of staff are located in one of the toilets. The bedrooms are personalised. Each room is painted a different colour and the people who live at the service are encouraged to display personal belongings, such as photographs, pictures, attractive wall hangings, mobiles and posters. The home also has a small activity room. This is located centrally to both bungalows. The staff said that some of the people who live at the service use this for hobbies and crafts. The office is located between the two bungalows and forms a physical link between the two. This means that staff and people who live at the service use the office as a thoroughfare and people are continually passing through this area. It is difficult for the staff to maintain confidentiality for service users as described in earlier sections of the report. The carpeting and décor in the office is showing signs of wear and tear. One of the staff highlighted garden improvements as something the service could do better. Written cleaning schedules are followed and the home is clean and hygienic throughout. West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home employs sufficient trained staff to meet service users needs. Consistency of care for people living at the service will be ensured by reducing staff turnover. EVIDENCE: The home employs one manager and 10 permanent staff. There is one senior staff and one senior staff vacancy. Senior staff are not designated on the rota. Two other names appear on the rota. The manager said that these are relief staff who are called upon from time to time to cover some hours when other staff are on leave. The current rota shows that it provides flexible cover of care staff on duty through the day. Staff cover is organised around the commitments of the service users, with one person sleeping in and one person on waking night duty. The home does not employ domestic staff, so all staff carry out these West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 21 duties. This includes cooking and cleaning. Service users are encouraged to be involved in this also, working alongside individual staff members. At the time of the inspection the home was one 30 hour post and one full time senior post down. Casual staff are employed to cover these vacancies. The manager said that recruitment is underway and new staff will be employed once all necessary checks have been carried out. Staff files show that new staff have to make a formal application and that references and other employment checks are taken up. The manager said that the organisation that runs the home has central procedures for recruitment. The staff surveys indicated that there is a high turnover of staff. All seven staff who returned a survey responded ‘ sometimes’ to the question about there being enough staff to meet the needs of service users. And in their additional comments, or comments under ‘ what the service could do better’ five of the staff cited poor wages as a factor in staff turnover or an area that needed to improve. There is a rolling programme of mandatory training in place with planned up dates for first aid, medication awareness, fire awareness, infection control, and moving and handling. Induction training includes abuse and neglect, and communication. Some specialist training has been arranged for later in January to support staff in working with individual service users. The manager said that induction training for staff has been revised and brought up to date. All staff who returned a survey confirmed that they had received induction training. This training was described in staff surveys as having covered things that they needed mostly or very well. In staff surveys all those who responded confirmed that they receive training which is relevant, helps them to understand the needs of the people who use the service and keeps them up to date with new ways of working. There is a staff development plan. This is covered in supervision with the manager and is part of the supervision form. In surveys staff responded that they had support meetings with their manager regularly or often. West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 22 The manager has identified that formal qualification training is required for more of the staff. And said that a staff training manager has been appointed by the organisation running the service since the last inspection. West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The safety, views and rights of service users are central to the running of the home. EVIDENCE: The manager, Janice, has experience in care, relevant qualifications and a job description. Janice has completed the registered managers’ award and is awaiting verification of the qualification. The operations manager, who carries out regular monthly visits to the home, supports Janice. An annual questionnaire is sent to staff. And a newsletter is West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 24 produced for staff and service users. The manager said that service users could contribute to this also. An internal inspection is carried out by the organisation every 6 months. Feedback is given to the manager. Quality surveys are given out and the results are returned to the head office. Milbury Care organise the general health and safety arrangements. Staff have guidance on Health and Safety in a central file called Health and Safety Essentials. This covers, hazards, risk and prevention. Hazardous substances are listed and risk assessed along with first aid treatment. Appropriate storage arrangements are identified and these are in use. There is a file of weekly and monthly safety checks carried out in the home. These include safety checks for the home’s minibus and wheelchairs. These were up to date. A record is kept of fire safety arrangements. This includes instruction, procedures, and training and preventative measures. Individual fire evacuation plans have been devised for service users. Weekly system checks are carried out and recorded. These are up to date. Fire drills are regularly carried out and staff receive fire instruction once every three months, the most recent being 11/01/08. A maintenance contract for fire extinguishers is in place. Two were replaced on the day of the visit. General risk assessments for safety have been carried out and steps are taken to minimise risk, for example for the use and storage of kitchen knives. Information about the ‘essential steps’ to good hygiene is posted in bathrooms. Staff follow a weekly cleaning schedule. Staff were busy with cleaning the bathrooms and bedrooms at the time of the visit. Monthly health and safety meetings take place at a central location and staff take turns to attend these. West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 25 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 3 2 3 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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 x 28 x 29 3 30 3 STAFFING Standard No Score 31 x 32 2 33 2 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 2 LIFESTYLES Standard No Score 11 x 12 3 13 4 14 x 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. 2. Standard YA24 YA32 Regulation 23(2)(b) Requirement Timescale for action 31/05/08 31/07/08 The kitchen work surface must be repaired. The office must be refurbished. 18(1)©(ii) At least 50 of the staff team to hold NVQ level 2 or above. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA10 Good Practice Recommendations The issue of confidentiality should be addressed. Either a separate access route should be created between the two bungalows, or support with finance, medication and personal information should be managed in the privacy of service users’ rooms. Storage facilities at the home should be improved. Staff roles should be clearly entered on the staff rota. Staff turnover should be addressed. The comments from staff to do with staff retention should be taken into account. 2. 3. 4. YA24 YA33 YA33 West Villas DS0000037224.V356872.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V356872.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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