Inspection on 20/09/05 for 119 Victoria Street

This inspection was carried out on 20th September 2005.

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 no outstanding requirements from the previous inspection report, but made 1 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 13/06/06

119 Victoria Street 25/02/06

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 Richard Leech Announced Inspection 20th September 2005 14:00 119 Victoria Street DS0000016319.V250238.R01.S.doc Version 5.0 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.V250238.R01.S.doc Version 5.0 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.V250238.R01.S.doc Version 5.0 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.V250238.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23/03/05 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. 119 Victoria Street DS0000016319.V250238.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began at 2pm and lasted until late afternoon. All three service users were spoken with, as well as two regular staff members and the manager. Some risk assessments and service users’ financial records were looked at. This was a brief inspection focussing mostly on requirements and recommendations from the last report and on speaking with service users and staff. What the service does well: What has improved since the last inspection? 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.V250238.R01.S.doc Version 5.0 Page 6 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.V250238.R01.S.doc Version 5.0 Page 7 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): None of the standards in this section were inspected on this occasion. EVIDENCE: In the last report a recommendation was made to ensure that the text of the Service Users Guide was clear, as there were some statements that could be improved. The manager said that he reviewed the Statement of Purpose at the start of the year, though has not yet reviewed the Service Users Guide. The recommendation is not repeated. The manager is aware of the need to review both documents periodically. A recommendation was also made to collect contributions to transport costs from DLA more regularly than every six months, to avoid large sums being taken and to give a clearer picture of how much service users have in their accounts to spend. The manager said that this had been discussed with service users and the providers and it had been decided to keep deductions at this frequency. 119 Victoria Street DS0000016319.V250238.R01.S.doc Version 5.0 Page 8 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): None of the standards in this section were fully inspected on this occasion. EVIDENCE: Care plans were not checked during this visit since the manager said that they had not changed significantly. However, there are plans for a senior member of staff to fully review and update the care plans, including changing their format. In the meantime the recommendations about care planning are repeated. In the last report a recommendation was made to consider the possibility of service users opening their own bank accounts without the manager/provider being signatories. The manager said that this had been discussed with the service users and that they were happy with current arrangements. Service users confirmed this. See also standard 23. Risk assessments were not checked. As with care plans, a senior care worker will be reviewing and updating these. The manager said that a risk assessment on a medical condition experienced by one service user had been reviewed. There was evidence on file that a GP’s view had been sought. The manager described how there were no longer such expectations on other service users’ to support the person, as discussed during the last inspection. 119 Victoria Street DS0000016319.V250238.R01.S.doc Version 5.0 Page 9 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. Support is provided for service users to find out about and take part in a range of activities which reflect their choices and interests. This includes accessing nearby facilities, helping them to become part of the local community. Service users are supported to maintain and develop important relationships in their lives as much as possible. Service users’ right to determine their own routines is respected, and support is provided for them to meet the responsibilities associated with their independent lifestyles. A varied diet is provided which respects service users’ preferences. EVIDENCE: Service users described their activities, including plans for college courses starting from September. They expressed satisfaction with how they spent their time and the support they received from staff around finding out about, and taking part in, different opportunities. Staff felt that service users enjoyed their activities and described how their choices were respected. One person 119 Victoria Street DS0000016319.V250238.R01.S.doc Version 5.0 Page 10 has reduced the range of community activities they take part in. The manager said that they are working with the person to establish the reasons for this and look into other options that would meet their needs and interests. The inspector agreed that it would be preferable to find some more activities based away from the home or sister home which reflect the person’s interests and provide opportunities for developing new skills and meeting people. The manager, staff and service users described a number of day trips that took place over the summer, as well as a weekend away on the coast. Service users indicated that they had very much enjoyed these excursions. Service users described going into town, meeting friends and using public transport as part of their daily routines. Some of the service users volunteer at a local leisure facility. They described their social and family networks and how staff supported them. Service users described their routines, providing evidence that they were in control of how and where they spent their time. They have front door keys and are offered keys to their rooms. They also manage their own post, asking staff for assistance if they want. Service users are involved in doing shopping, cooking, cleaning and laundry with minimal staff support and supervision. One person indicated that they no longer did much cooking due to a particular medical condition. It was suggested to the manager that they could be offered the chance to do more cooking with staff supervision, particularly once a senior staff member increased their hours from October. Discussion with the service users provided evidence that they were happy with the food served in the home. Comments included that it was ‘brilliant’. They participate in writing the menus. The manager and staff said that the menus are not always adhered to, for example if people decide that they would like something different. The service users often eat at the sister home. They all indicated that they were happy with this arrangement. Menus provided evidence that a reasonably balanced diet is provided. 119 Victoria Street DS0000016319.V250238.R01.S.doc Version 5.0 Page 11 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): None of the standards in this section were inspected on this occasion. EVIDENCE: In the last report a recommendation was made to ensure that records for routine healthcare appointments in service users’ files are kept up to date and provide a complete record. This was not checked on this occasion. However, the manager said that this had been done. He indicated that there had been difficulties accessing dental care locally, resulting in some service users reregistering at a different dental surgery. They are now waiting for a routine check-up. 119 Victoria Street DS0000016319.V250238.R01.S.doc Version 5.0 Page 12 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 Service users feel able to express their thoughts and opinions, helping them to feel listened to and valued. EVIDENCE: The manager has amended the complaints procedure to include the correct telephone number for CSCI. Copies were seen in service users’ rooms. Service users indicated that they felt able to raise things with the manager and staff and expressed confidence that they would be listened to and the issues resolved. Records of service users’ finances were checked along with some receipts. The tin contained a number receipts for items purchased through petty cash, records for which are apparently kept at the sister home. It was agreed that these should be cleared out and stored in the appropriate place. It was suggested that the system for handling service users’ money could be made clearer by: • • • Numbering receipts and creating a cross referencing system by then also numbering the entry made in the record. Consistently writing the name(s) of the person(s) to whom the receipt relates on the actual receipt. Storing old receipts together in envelopes for each month. The manager and staff said that there will often not be a receipt as service users are given money on request and will spend this independently. It was agreed that it is their right to spend their money as they wish and that there 119 Victoria Street DS0000016319.V250238.R01.S.doc Version 5.0 Page 13 was no need to ask them to bring receipts to staff for their own purchases (unless, for example, they wanted it held for safekeeping if there was a possibility they may want to return the item). The system above would therefore relate to purchases made by the staff on behalf of service users with their consent. There was a record of wages service users had received for part-time work, along with deductions corresponding to spending or a transfer to the system for handling service users’ money described above. This record was written on an envelope, which the manger said was probably used to store the money for safekeeping. The manager said that no wages are received now since the service users have given up those sources of income. However, it was agreed that should anybody have an income through a part time job in the future and request that this be held for safekeeping it should be entered into the usual system for handling service users’ money rather than an ad-hoc parallel system being operated. Other areas relating to Standard 23 will be considered during the next inspection. 119 Victoria Street DS0000016319.V250238.R01.S.doc Version 5.0 Page 14 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, 26 & 30 Victoria Street provides a clean, homely and pleasant environment in which to live. Some minor maintenance work is required in one part of the kitchen. EVIDENCE: Since the last report two of the bedrooms have been redecorated. Service users confirmed that they had been fully involved in this and had chosen the décor. They expressed satisfaction with their bedrooms. The third person confirmed that they had chosen to keep their room as it was. Other areas of the home were clean, comfortable and reasonably decorated. Communal areas are homely and welcoming. Some work has been done to further tidy up the front and back gardens and the manager said that this would continue. Some of the dials for the gas hobs were loose and did not sit in the same ‘off’ position. These must be attended to, particularly given that the service users are involved in cooking on a regular basis. There was a discussion about whether the kitchen would benefit from some more thorough cleaning. In a subsequent telephone conversation the manager said that he would arrange for the units to be steam-cleaned. 119 Victoria Street DS0000016319.V250238.R01.S.doc Version 5.0 Page 15 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): None of the standards in this section were fully inspected on this occasion. EVIDENCE: The manager said that the senior staff member would begin to take on the role of coordinating training in Victoria Street and the sister home. Two recommendations from the last report about supervision are repeated. The manager indicated that he was still considering how to address them, and was likely to change the supervision format. Service users were very positive about the manager and the staff working in the home as well as the support they received. 119 Victoria Street DS0000016319.V250238.R01.S.doc Version 5.0 Page 16 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): None of the standards in this section were fully inspected on this occasion. EVIDENCE: There is a new senior worker in the home. They are undertaking NVQ level 4 in care. They will have the title of ‘head of home’. There was a discussion about their role and whether or not in due course they will register as manager for the home. In the action plan following the report the manager indicated that the person may become manager in the future (including taking the registered manager’s award) but that this would not be the case at present. A log of weekly tests of the (mains powered) smoke alarms was viewed. Service users are involved in conducting these checks. The manager said that he had considered the recommendation for service users to have a food probe to use but decided that this would not be helpful. In the last report a requirement was made to ensure that all significant risks to service users’ safety and well-being were assessed, with particular reference to 119 Victoria Street DS0000016319.V250238.R01.S.doc Version 5.0 Page 17 times when the home was unstaffed. Some risk assessments were viewed. These included consideration of these issues. As noted, the new senior carer is reviewing risk assessments, and indicated that this will include developing knowledge of service users’ routines and the issues which arise when the home is not staffed. Service users talked through some scenarios such as when a stranger comes to the door. They indicated that they felt safe in the home. 119 Victoria Street DS0000016319.V250238.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 119 Victoria Street Score x x x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x DS0000016319.V250238.R01.S.doc Version 5.0 Page 19 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 Standard YA24 Regulation 12(1)a 13(4)23 (2)c Requirement Undertake any necessary work on the dials for the gas hobs in the kitchen, such that they are secure and clearly indicate (and rest in) the ‘off’ position. Timescale for action 31/10/05 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 Aim to adopt a more ‘person-centred’ care planning approach. Consider accessing training on this concept and on ways of approaching it. • Through the review process ensure that care plans are sufficiently clear about care and support provided and the aims & objectives of each plan. Continue to work with one person to identify activities and opportunities based away from the home or sister home which reflect their interests and provide opportunities for developing new skills and meeting people. Offer one person the chance to do more cooking (with staff supervision as per a risk assessment), particularly once a staffing support increases from October. • Clear out any receipts from the home which relate to DS0000016319.V250238.R01.S.doc Version 5.0 Page 20 • 2 YA12 3 4 YA16 YA23 119 Victoria Street • 5 YA36 • • accounts administered at the sister home. Consider implementing the bullet points in the text relating to purchases which staff make on behalf of service users with their consent. Supply copies of supervision notes to staff in order that they also have a record of what is discussed and agreed. Ensure that the supervision format includes (as a minimum) the points in Standard 36.4. 119 Victoria Street DS0000016319.V250238.R01.S.doc Version 5.0 Page 21 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.V250238.R01.S.doc Version 5.0 Page 22 - 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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