Inspection on 13/06/06 for 119 Victoria Street

This inspection was carried out on 13th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

119 Victoria Street 17/06/09

119 Victoria Street 19/06/08

119 Victoria Street 22/06/07

119 Victoria Street 25/02/06

119 Victoria Street 20/09/05

119 Victoria Street 23/03/05

119 Victoria Street 23/03/05

119 Victoria Street 23/03/05

119 Victoria Street 23/03/05

119 Victoria Street 13/04/04

119 Victoria Street 13/04/04

119 Victoria Street 13/04/04

119 Victoria Street 13/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 119 Victoria Street 119 Victoria Street Cinderford Glos GL14 2HU Lead Inspector Mr Simon Massey Key Unannounced Inspection 13th&19th June 2006 10:00 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 119 Victoria Street Address 119 Victoria Street Cinderford Glos GL14 2HU 01594 516582 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) Mr Thomas Alfred Mills Mrs Beverley Mills Mr Graham Fredrick Jeremiah Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th February 2006 Brief Description of the Service: 119 Victoria Street is a terraced house on the outskirts of Cinderford. Care and accommodation are provided for three people with learning disabilities. Support and staffing levels are minimal and the home aims to help service users to develop their independent living skills. Two part-time staff work in the home. Service Users each have their own room. In addition there is a lounge, bathroom and kitchen. A smaller room upstairs is used as an office. There is a garden with a patio at the back of the house and a small front garden. The home has close links with another nearby home, which is operated by the same providers and run by the same manager. Service users move on from there to 119 Victoria Street when they are assessed as able to manage more independently, rather than being directly referred to the home. The home’s Statement of Purpose and Service User Guide provide information as to the services that the home provides. The current fee range for the home was not available at the time of the inspection 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This unannounced inspection was started on June 13th 2006 and continued on 19th June. The inspector met with the Registered Manager, care staff and all of the service users. Records relating to medication, staff recruitment and training, health and safety and care planning were examined. The environment was also inspected. In the three months since the last inspection a new manager has been appointed who is yet to be registered and this inspection focused upon the progress made towards the requirements of the last inspection as well as looking at the majority of the core standards. Whilst there is still work to do, progress has been made in the relatively short time since the last inspection. Action has been taken to address the requirements made as result of the previous inspection. The inspector is grateful to the three service users for their co-operation and help in the inspection process. What the service does well: What has improved since the last inspection? Work has begun on providing more “person centred” plans for the service users. Staffing rotas have been reorganised to ensure more flexible support both in the evenings and occasionally at weekends. More structure is being applied to the learning of independence skills such as cooking and shopping. All safety checks and fire testing have been completed regularly and recorded. 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Provision of an updated written admissions policy will help ensure that service users are admitted in line with regulations and that their needs can be met by the home. EVIDENCE: The new manager, who has only recently been appointed, was unsure about the admissions process for the home and whether there was an up to date written policy. A requirement has therefore been made that the home provides a written admissions policy in line with the current regulations. A copy of this must be forwarded to the Commission. The home has supplied the Commission with the updated Statement of Purpose and Service Users Guide, that was a requirement following the previous inspection. 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 &9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The provision of person centred plans for all the service users should improve the quality of care and support provided. Service users are encouraged and supported to make decisions about their daily lives and activities. The provision of risk assessments relating to the degree of independence and support required will further protect service users and help develop skills. EVIDENCE: Work has begun on producing person centred care plans after the manager and deputy completed some training in this area. There are plans for the key workers and service users to develop person centred plans for all the service users. Service users will be fully involved in the developing of their care plans. There is work to do in this area but good progress has been made since the previous inspection. As these plans have not yet been developed for all service users the requirement made at the last inspection in relation to care planning has therefore been repeated. 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 10 The service users are provided with staff support but also spend time independently in the home and gave examples of how they make decisions about daily activities and domestic tasks and chores. Service users have had increased input around menu planning shopping, and cooking skills, and all said they were pleased with this. A requirement was made at the previous inspection that detailed risk assessments were developed around the degree of independence that service users are afforded. This is particularly relevant given the amount of time that the home is unstaffed. These are yet to be produced and this requirement has therefore been repeated. 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A more structured and planned approach to day care activities is providing the service users with more organised day care arrangements. Service users are supported to access and be part of the local community. Service users receive the required support to maintain their family relationships. Increased input around independence skills should improve the confidence of the service users to live independently. EVIDENCE: Service users gave example of a variety of activities and trips out they had completed over the previous month and all felt that they now received sufficient support in this area. 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 12 The service users felt that they worked well together within the home and, although there were occasional differences of opinion, that they co-operated on domestic tasks and were happy how there routines were organised. People said they were busy Monday to Friday working at a local gym, which provides supported employment. This work had ceased at the time of the last inspection but has now restarted. This employment provides structure to the week and offers the chance to develop skills and take on responsibility. However, with all three service users having the same daily routine in terms of their daytime activity, the requirement has been repeated in relation to individual assessments of needs and aspirations. The revised care plans should identify individual goals and aims in relation to daytime activities and employment. People have some contact with the neighbours and felt this was generally positive. An example was given of when an issue had arisen and how this was resolved with support from the Provider. The service users continue to get support to maintain the pet budgie and said they had plans to get another. All felt that the level of activities had increased and that they got sufficient choice about what they chose they to do with their time. Service users confirmed they are supported to maintain their family contacts where appropriate. The inspector left some comment cards to be distributed to friends and families. At the time of the inspection the kitchen was well stocked with fresh and packaged produce. The menus showed increased involvement from the service users in shopping and cooking. The menu was reasonably varied and people said that they were encouraged to eat healthily. 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19&20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to the service. Service users receive the required level of support for their personal care in a way that promotes their privacy and dignity. Service users access the healthcare professionals they require but greater clarity is needed over the support required for arranging appointments. EVIDENCE: There was some evidence that medical checks and appointments are supported but the service users said that occasionally there was some confusion as to when appointments were scheduled. It was not clear how much responsibility for arranging appointments the service users have and how much is dependent on the key-workers. It is recommended that this is clarified and that if possible service users are encouraged to take more responsibility in this area themselves. One service user has been risk assessed as being able to self medicate. They are happy with this arrangement and all records were in place and correct recording completed. All medication was correctly stored. 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22&23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users are able to approach care staff and the Providers to raise concerns, and feel confident that they will be listened to. Training in Adult Protection for the management and staff team will provide further protection for the service users. EVIDENCE: The requirement that the manager completes Adult Protection training has been made at a previous inspection and the process for accessing this was explained to the manager. This training should be cascaded down through the staff team. The inspector was informed that this training had been arranged and both the manager and deputy would be attending the course. Staff spoken to were able to demonstrate an awareness of the issues but greater understanding is required around the procedures and processes that should be followed when an issue is identified. All service users stated they felt confident and able to approach staff or the Providers to raise concerns or make a complaint, and that they would be listened to. One service user gave an example of an issue they had raised with the Provider that had been responded to and dealt with. 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The quality of the environment is maintained to a good standard by the service users. EVIDENCE: The home was clean, tidy and hygienic throughout. The service users have sole responsibility for this, and take pride in the standards maintained. The house is homely and comfortable but there is a need for the front garden area to be tidied and better maintained. All the service users stated they were very happy with their accommodation and enjoyed the independence and responsibility it afforded them. 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Positive relations between staff and service users help to ensure that people’s needs are met. Service users are protected by the home’s recruitment policy that complies with the current regulations. Improvements to the induction procedure for new staff should ensure that service user needs are better understood and met by new staff. Steps are being taken by the home to improve the quality and monitoring of staff training. EVIDENCE: All the service users were interviewed during the course of the inspection and all were very positive about the support and advice they receive from the staff team. The home now has a written rota that provides some evening cover and also additional support during the day. People stated that the new arrangements were working well and that they also were able to arrange additional support through discussion with the manager. Service users said that the “staff care about us”, and “always listen to our problems.” One service commented that, “they could not’ wish for better staff”. 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 17 The inspector spoke with two staff who confirmed that the more structured staffing rota now in place was working well for the service users. There was evidence of improved recording and all records examined were up to date. Staff are in the process of archiving certain records and work is soon to begin on improving and updating the care plans. This will be done in a person centred format. The manager has been developing a training matrix to establish when the statutory training requires updating. The home should ensure that people are up to date with fire safety, food handling and first aid training, and a requirement has been made in relation to this. Staff were positive about the recent changes and felt well supported by the management. New staff complete an induction package that is supplied through Learn Direct. This package provides a good value base, but the home needs to develop its own induction process. This should provide specific guidance on practices within the home, the individual support and care services users require, and be competency based. All new staff should also be allocated a mentor, which is a requirement of the regulations. The staff recruitment and personal files are all kept at the main “sister” home, though a list of staff working in the home is maintained. These records were checked and found to be in order. 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Improvements in the administration and structure of care and support should support provide better outcomes for service users. The introduction of formal Quality Assurance systems should further support the improvement in the quality of care and support being provided. EVIDENCE: The current manager was going through the registration process at the time of the inspection. The home is the “sister home” of another registered property owned by the same Provider, and an arrangement is in place that allows them to share the same registered manager. The manager visits the home every week but is delegating certain responsibilities to other staff, who work more shifts in the home. 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 19 The three service users said they were very happy with the new manager who they said they “could talk to about anything that was worrying them” and that she was a “good listener”. Monthly meetings are held with the staff and the service users, which are recorded and minutes kept. These show that service users are kept informed of staff changes and that issues are discussed such as holidays, food, activities and family contacts. All safety checks have been completed and recorded. The home has responded positively to the requirements made in the previous report and made progress within the timescales agreed. There are currently no formal Quality Assurance systems in place, but the Provider visits the home regularly, and in fact called in to the home during this inspection to follow up some maintenance issues. The manager also visits at least once a week. The manager has plans to develop the Quality Assurances process within the home by the use of questionnaires. As part of this inspection the inspector left a number of questionnaires for service users, staff and outside professionals. The feedback from these will help inform the next inspection of the home. There is a requirement made that the home to develop more formal Quality Assurance systems. The manager has an NVQ 4 in Care and will be enrolling on the NVQ Registered Managers course within the next few months. Staff interviewed were positive about the support and direction they have been receiving. 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 20 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 2 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X X 3 x 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 23(2)(b) Requirement Timescale for action 31/08/06 2. YA6 15 The home must produce, and provide a copy to the Commission, of their current admissions procedure 30/09/06 The home must improve the care planning system to ensure that it is person centred and that service users are fully involved in the developing and reviewing of their care plans. (Work ongoing, requirement carried forward from previous inspection) The home must produce 30/09/06 risk assessments relating to the degree of supervision and independence provided in the home. (Requirement carried forward from previous inspection) The home must support service users to access day care activities that are based on their individual DS0000016319.V291589.R01.S.doc 3. YA9 12(1)(a) 4 YA12 12(1)(b) 30/09/06 119 Victoria Street Version 5.1 Page 22 5. 6. YA39 YA42 7. YA35 8. YA28 9. YA23 assessed needs and aspirations (Work ongoing, requirement carried forward from previous inspection) 24 The home must ensure that there are formal quality assurance systems in place. 18(c)(1) The home must ensure that all staff are up to date with the required statutory training in fire safety, first aid and food handling. 18(c )(iii) The home must ensure that all new staff are provided with a mentor from within the staff team for their induction period 23(2)9b) The home must ensure that the front area of garden and patio is properly maintained 13(6)&18(1)(c)(i) The manager and staff must undertake adult protection training and provide (Requirement carried forward from last inspection) 31/12/06 30/09/06 31/08/06 30/09/06 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA19 Good Practice Recommendations The home should provide clarity on the support required for the supporting of medical or health related appointments. 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 119 Victoria Street DS0000016319.V291589.R01.S.doc Version 5.1 Page 24 - 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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