Inspection on 06/02/09 for Victoria House

This is the latest available inspection report for this service, carried out on 6th February 2009.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Victoria House 06/06/07

Victoria House 23/11/06

Victoria House 21/08/06

Victoria House 27/01/06

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOME ADULTS 18-65 Victoria House 62/64 George Lane South Woodford London E18 1LW Lead Inspector Jackie Date Unannounced Inspection 6th to 12th February 2009 10:00 Victoria House DS0000066301.V374082.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 Victoria House DS0000066301.V374082.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. Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria House Address 62/64 George Lane South Woodford London E18 1LW 020 8530 3591 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) www.caremanagementgroup.com Care Management Group Ltd Manager post vacant Care Home 6 Category(ies) of Learning disability (0) registration, with number of places Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th April 2008 Brief Description of the Service: Victoria House is a six-bedded home for adults with learning disabilities and challenging behaviour. At the time of the visit four men were living in the home. It is in a residential area of South Woodford close to local shops and amenities and to local transport networks. People living in the home need varying degrees of support with everyday daily living tasks but all require a high level of supervision because of their challenging behaviour. Two of the four people can communicate verbally but the others have very limited communication. Some people access day services, others are supported in community based activities by the staff team. The building does not have any adaptations for people with physical disabilities and would not be accessible to wheelchair users. The scale of charges per week for each person range from £1,459 to £2,155 per week. This information was provided on the day of the inspection. Information about the service provided is contained in the service users guide. Victoria House DS0000066301.V374082.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 star. This means the people who use this service experience good quality outcomes. This inspection was unannounced and took place over two separate days. This was a key inspection and all of the key inspection standards were tested. Staff were asked about the care that people using the service receive, and were also observed carrying out their duties. People using the service were asked to give their views on the service and their experience of living in the home. All of the shared areas and four bedrooms were seen. Staff, care and other records were checked. Feedback questionnaires were sent to people who use the service, staff and other professionals. Feedback forms were received from, or on behalf of, three people who live at the home, four staff and one healthcare professional. In addition two relatives and a healthcare professional provided verbal feedback. Services are now required to complete an AQAA (Annual Quality Assurance Assessment) and the completed form was received in January 2009. Information provided in this document also formed part of the overall inspection We would like to thank the people living at Victoria House and staff for their input during the inspection. What the service does well: What has improved since the last inspection? Relatives said, “it’s a lot better now, a better atmosphere and everyone seems more settled. My son is doing a lot more”. “Things have improved, staff are settling in. There are more homely touches and my son is more settled and comfortable”. Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 6 The requirements from the previous inspection have been addressed. Care plans have all been reviewed and updated and contain the information needed for staff to be able to give people the support that they need. People living at Victoria House are attending more activities both at a day service and in the community. They all went on holiday last year. People are doing more in the home. There have not been any staff changes and people are being supported by a consistent staff team that know them well. Some improvements have been made to the house, the front garden has been landscaped and some areas have been redecorated and made more homely. 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. The summary of this inspection report can be made available in other formats on request. Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 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 Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 & 5. People using the service experience good quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. If a vacancy arose the required information will be gathered on a prospective user of the service and they and their relatives could spend time in the home to find out what would be like to live there and to enable the person to make a choice about living in the home. People and their representatives have a written contract/statement of terms and conditions and will therefore be clear about what they are entitled to. EVIDENCE: There have not been any new admissions to the home for about 8years and since the last inspection one person has moved to alternative accommodation. The remaining four people have lived together for some time. There have not been any admissions since Care Management Group (CMG) took over the home. The organisation has a central referral and assessment team. This team gathers initial information and assessments and then works with the manager to complete more detailed assessments. Prospective users of the service are given the opportunity to visit and to meet other people who live and work there before they make a decision about moving into the home Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 9 Each person has a contract/statement of terms and conditions. The contracts were available at the home. This means that there is clear information about the service that will be provided to each individual. Victoria House DS0000066301.V374082.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, 8, 9 & 10. People using the service experience good quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. People’s individual plans provide staff with the information that they need to meet individual needs. Risk assessments are appropriate and people are supported to take risks according to their needs. Strategies are in place to keep people as safe as possible. EVIDENCE: Each person has a confidential main file and also a working file. The working files seen contained a pen portrait of each person, a communication passport, individual action plan, care guidelines and risk assessments. These documents contained detailed information about each person, their needs and preferences and how to support them. The documents cover all of the necessary areas including spiritual and cultural needs. The documents show that the staff team have now got to know the people living there very well. For example one persons communication passport states, “I nod my head for yes, I look away Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 11 or walk away if I dont want something”. One member of staff is now being designated as a communication champion and they are trying to develop a total communication environment within the home. Staff have received some Makaton training and are now trying to use pictures and objects of reference to help people with communication and comprehension. Staff have also started to develop user-friendly person centred workbooks. One of these has been completed with one of the people living at Victoria House and he has signed this. This format will be developed for the other people using the service. The information seen was all up-to-date and had been reviewed regularly. Files contained details of internal reviews and also formal reviews to which relatives and other professionals were invited. Daily logs are kept for each person and entries are made in the morning, afternoon and at night. Entries are made under different headings and include health, social, activities and behaviour. Overall the entries seen were quite general. For example, “behaved well to day”, “interacted well today”. These do need to be more specific so that they give clear information about what each person has done and how they have been. This information can then be used for more accurate monthly key worker reports and for reviews. There were up-to-date risk assessments covering the necessary areas and these were relative to each individual, the activities that they do and their own specific behaviours. For example, being in the car, shopping, vulnerability and finance. Staff spoken to were aware of individual behaviours and the risks that this brings in a variety of situations. Guidelines are in place to assist them to work in a consistent manner with people A spoken said that people are now more involved in the running of the home. Residents meetings are held monthly and people are encouraged to give feedback about the service. Two people can and do express their views about what they want and what they like. They are able to discuss and decide what they are going to do and be involved in decisions about their lives. Staff make notes in the minutes as to how the people that do not have verbal communication have responded or reacted. Personal records are stored securely in the office and staff are aware of issues confidentiality. Victoria House DS0000066301.V374082.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): 11, 12, 13, 14, 15, 16 & 17. People using the service experience good quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. People are encouraged to be as independent as possible, to take part in activities and to be part of the local community. People are supported to keep in contact with their relatives and visitors are made welcome at the home. People are given meals that they have chosen, like, and that meet their needs and preferences. This includes their cultural preferences. EVIDENCE: Two people attend a day service run by the London Borough of Newham. One attends five days each week and the other for two. As part is this service they participate in a range of activities in the community. People also have the opportunity of using the day service attached to another care home operated Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 13 by CMG (Lilliputs) if they wish. All of the people living at Victoria House need support from the staff when they go out. People go out to local shops, to the cinema, the library, restaurants, swimming and the gym. Some of them are well known in local shops and restaurant. Two people attend a local church. One person likes to listen to Nigerian music and staff facilitate this. A relative said, “my son is doing more”. Last year one person went to Spain for a holiday and also went to Blackpool. Other people went to Clacton for a holiday. During the visits people were observed to spend time in the lounge, dining area or in their rooms. It was evident that they chose when and where to spend their time. People are encouraged to do things in the house and for themselves and staff record daily living skills and achievements. For example one person went to the food shop with staff and carried the basket. Another person made his bed, tidied up and emptied the bin. There was a picture of a third person cleaning the kitchen. All of the people using the service have contact with their families, some of their relatives visit the home regularly and some people visit their families at home. They also have a lot of contact with staff and people using the service at a nearby home run by the same organisation. One persons family live in the North of England and he has regular telephone and written contact. A member of staff supported this person to have a holiday in Blackpool with his parents. Feedback from these relatives was that this member staff had been very patient and was an asset to the service. Some people are able to say what they want to eat and are able to contribute to the menu planning. Staff use their knowledge of others likes and dislikes when planning the menu and have introduced ‘healthy eating’. One person likes African food and this is included on the menu. Another person likes to have a Chinese take-away on Fridays. Some of the people are not able to ask for a drink or something to eat but staff spoken to knew how to interpret their non-verbal communication. For example one person tends to pace around a lot when he is hungry or thirsty. People are given meals that meet their needs and likes and this includes their cultural preferences Victoria House DS0000066301.V374082.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 & 20. People using the service experience good quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. People who use this service receive personal care that meets their needs and preferences and staff support them to get the health care that they need. People are given their prescribed medication safely. EVIDENCE: People using the service require differing amounts of support with their personal care and some require a lot of support and are dependent on staff to meet their personal care needs. Two people are fairly independent and require reminders, prompts and minimal supervision. Staff know how each person needs and prefers to be supported and this information was detailed in personal care guidelines. These include ways in which people are encouraged to do things for themselves and also how they are offered privacy. For example staff monitor the more independent people but wait outside the bathroom. People are supported to receive the personal care they need in a way that is appropriate for them. Each person is registered with a local GP practice and receive specialist input Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 15 as and when required. Specialist help is received from the community learning disabilities team and this includes input from the psychiatrist and psychologist. On the first day of the inspection the consultant psychiatrist visited to carry out reviews. Staff support people to all of their medical appointments. Health Action plans have been introduced and there was evidence that staff follow up health concerns. The outcomes of all the visits are documented and show that peoples health care needs are monitored and addressed. Evidence was available that people have had checks from the optician, dentist and when appropriate chiropodist. Some of the people are not able to verbally indicate what they want, need or feel. However staff are aware of the behaviours that would indicate there was a problem. For example one person cries when in pain and another just sits in one place. Staff then try to establish what the problem is. Feedback from healthcare professionals was positive. The psychiatrist said that the staff team were responsive to changes and that there was good follow up. She also said that she gets good feedback about each individual. The GP said that staff were very diligent and caring in terms of healthcare. Feedback from a dentist was that staff provide good quality oral care. Therefore people are supported to receive the health care that they need. None of the people living in the home are able to self medicate and medication is administered by staff. This is usually the senior member of staff on duty. Staff cannot administer medication until they have received training and been assessed as competent. Copies of medication assessments were seen in some of the relevant staff files. Medication is securely stored in a locked cabinet in the office and most medication is in a monitored dosage system. There is also a lockable medicines case that is used when medicines are administered away from the point of medicines storage. Medicines can therefore be secured in the case of the carer having to deal with an emergency. A suitable cabinet is now available for the storage of controlled drugs should the need arise. Therefore medication is securely stored at all times. In line with good practice the medication file has information about the medication that people take, how it is taken and possible side effects. The file also contained a list of staff that are able to administer medication and a sample of their initials. Medication administration records are kept and are upto-date. All of the people taking medication have had medication reviews and there is a photograph of each person in the medication file. This is good practice. Examination of the MAR (Medication Administration Record) found that these had been appropriately completed. Guidelines/protocols are in place for the administration of PRN (when required) medication to assist staff as to when and how to administer this medication. A pharmacist from the medication suppliers visits regularly to check medication storage and records. On the first day of the inspection there was a handwritten entry on the medication administration record and the manager was advised that for accountability any handwritten entries made by staff must be endorsed with the date and the signed initials or signature of that person. This had been Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 16 done when we returned to complete the inspection. Therefore people are receiving their prescribed medication correctly and as safely as possible. Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 17 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 & 23. People using the service experience good quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. People living at Victoria House are safeguarded by the working practices and support of the staff team. EVIDENCE: There is a complaints procedure and a pictorial complaints procedure to help people understand how to complain. Two people can say if they are not happy about anything but due to the degree of their disability the other two people living in the home cannot. There is a complaints log and this contained details of complaints made and the action taken to address these. The records show that the complaints have been appropriately addressed. A relative said, “Tony (the manager) always asks if there are any issues or problems”. As part of the handover between shifts there is a section that is completed if a complaint has been made so that this can be brought to the managers attention. Staff have received Protection of Vulnerable Adults training and were aware of safeguarding issue and their responsibilities in this area. The section on staffing later in this report gives information that confirms that there is an appropriate recruitment procedure and this also helps to safeguard people living in the home. Relatives spoken to were happy with the care provided and feel that the home and the people living there are a lot more settled. They no longer had any concerns about the safety of their sons. None of the people using this service are able to manage their own finances. CMG now hold the appointeeship for 3 people and family of the other person Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 18 manage his finances. Two people are able to sign to withdraw the cash and they go to the bank with staff support. The manager and deputy are counter signatures for the third person. Cash and other paperwork are stored in a safe in a cabinet in the office. The senior on duty has the key to the cabinet. Cash is checked daily as part of the handover. Balances are checked as part of the monthly monitoring visits carried out by the organisation. It is recommended that when these checks are carried out the person doing this signs the record to say that they have been checked. This will help to provide an audit trail. The cash held for two people was checked as part of the inspection and was found to be correct in that cash held agreed with records. Receipts were seen for items purchased. There had not been a financial audit for some time and this was recommended to the manager and a senior manager present at the time of the inspection. There was a very quick response to this and the accounts were audited on the day the inspection was completed. Feedback from this was that the calculations were good and the records were well-kept in-line with the organisations requirements. Therefore safeguards are in place for people’s finances. Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 19 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, 27, 28, 29 & 30. People using the service experience adequate quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. People live in a clean home that is suitable for their needs. The house is much more homely now and scheduled refurbishments will mean that people live in a comfortable home that is decorated, fitted and equipped to a good standard. EVIDENCE: The house is in South Woodford and is near to the local shops, bus routes and a train station. The communal space consists of a lounge, dining room, and a conservatory that leads to the garden, kitchen, office and laundry. These areas are clean and satisfactorily maintained and decorated. Since the last inspection new lights and a new television have been purchased for the lounge and it is much more homely. The front garden has been landscaped and is much nicer. More refurbishment has been agreed. A relative said, “there are a lot more homely touches. Each person has a single bedroom that has been personalised to meet their individual preferences. Some bedrooms have been redecorated and one Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 20 person talked about decorating his room and the colours that he wants. Most bedrooms are upstairs. Bedrooms do not have en suite facilities. There is a toilet and shower upstairs and downstairs there is a bathroom with a toilet and shower. There is also a separate toilet on the ground floor. None of the people using this service require any specific adaptations at this time. There are enough baths, showers and toilets and these meet peoples’ needs. The bathing and toileting facilities are in need of refurbishment and this has been agreed. Quotes have been obtained and work will start in the near future. All the scheduled refurbishment is due to be completed within 6 months and this will mean that people will live in a comfortable home. In view of this no requirements have been made with regard to the environment. Staff have a daily schedule for cleaning and at the time of the visit the home appeared to be clean and hygienic. In December 2008 the service had a food safety inspection and received a very good 4 star rating. Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 21 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, 35 & 36. People using the service experience good quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. People are supported and protected by the recruitment practices of the service. Staff receive the necessary training and support to meet peoples current needs and to provide an appropriate service for them. Staff have the opportunity collectively and individually to discuss their own development and any problems and developments within the service. EVIDENCE: Since the last inspection there has not been any changes in the staff team and regular relief staff provided any cover that is needed. Therefore people are now supported by a consistent staff team that know them well. A relative said, “staff have settled in and things have really improved”. Three staff (including one senior) are on duty during the daytime and at night there is one waking night staff and one sleep in staff. From observations during the inspection, Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 22 examination of the rota and discussions with staff it was evident that there were sufficient staff on duty to meet people’s needs. Eight of the permanent staff have achieved NVQ level 2 or above. Staff spoken to said that they were up to date with mandatory and specialist training. In addition the organisation has introduced ‘e-learning’ which is linked to skills for care and NVQ. All staff will be doing a new induction within 12 weeks via e-learning. Staff training records are kept and staff receive the training that they need to provide a service for the people living there. The consultant psychiatrist was very positive about the service and recommended that staff receive more autism training to assist them in working with the complex needs of the people using the service. The organisation operates an appropriate recruitment procedure. Jobs are advertised, application forms completed and interviews held. A random sample of staff records were checked during the inspection and they contained the required information to demonstrate that staff had been appropriately recruited. This included application forms, references, proof of identification and CRB (Criminal Records Bureau) checks. Staff confirmed regular supervision and staff meetings. Overall staff spoken to said that they get support and that they feel more involved in the running of the home. Therefore staff have an opportunity individually and collectively to discuss issues, concerns and the development of the service. Victoria House DS0000066301.V374082.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): 37,38, 39 & 42. People using the service experience good quality outcomes in this area. We have made this judgement using all available evidence including a visit to this service. People living at Victoria House benefit from a service that is appropriately managed and that has improved over the past year. They live in a safe home. EVIDENCE: The manager has been in post for approximately one year. He has a NVQ qualification and has obtained the RMA (Registered Managers Award) and has also been a registered manager for services for people with learning disabilities. Feedback from staff and relatives was that the service has improved a lot, that ‘things are more settled’ and that ‘staff are doing their best’. Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 24 The manager has completed an application to be registered with the Commission. He is waiting for his CRB (Criminal Records Bureau) check to be completed and then all of the necessary documentation can be submitted. The quality of the service is monitored by the manager and by the organisation. A senior manager carries out monthly monitoring visits and also checks on the progress of the services. Copies of the reports on these visits are available at the home. The staff team carries all of the necessary health and safety checks out and records are kept of these checks. For example fire call points are tested weekly and appropriate servicing is carried out on the fire system and fire equipment. Fridge and freezer temperatures are tested daily and the service received a good 4 star food hygiene assessment from the Local Authority. A safe environment is provided. It is recommended that the size of the car used by the service be reviewed when the lease is due for renewal as a more spacious vehicle would be more comfortable for the taller people using this service and also would mean that when needed there could be more space between individuals and also between individuals and the driver. This would further lessen any potential risks if a person becomes agitated or displays challenging behaviour. Victoria House DS0000066301.V374082.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 X 2 3 3 3 4 3 5 3 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 2 28 2 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X X 3 X Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations It is recommended that daily logs are more specific so that they give clear information about what each person has done and how they have been. This information can then be used for more accurate monthly key worker reports and for reviews. It is recommended that when financial checks are carried out the person doing this signs the record to say that they have been checked. This will help to provide an audit trail. It is and recommended that staff receive more autism training to assist them in working with the complex needs of the people using the service. It is recommended that the size of the car used by the service be reviewed when the lease is due for renewal as a DS0000066301.V374082.R01.S.doc Version 5.2 Page 27 2. 3. 4. YA23 YA35 YA42 Victoria House more spacious vehicle would be more comfortable for the taller people using this service and also would mean that when needed there could be more space between individuals and also between individuals and the driver. This would further lessen any potential risks if a person becomes agitated or displays challenging behaviour. Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Victoria House DS0000066301.V374082.R01.S.doc Version 5.2 Page 29 - 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. 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