Inspection on 22/06/07 for 119 Victoria Street

This inspection was carried out on 22nd June 2007.

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 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 13/06/06

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 22 & 25th June 2007 09:00 nd 119 Victoria Street DS0000016319.V334645.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 119 Victoria Street DS0000016319.V334645.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. 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 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 Mrs Elaine Elizabeth Watkins Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 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. 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 is between £307.50 and £859.34 per week. 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 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 inspection was undertaken over two days. The inspector met with the Provider, Registered Manager, care staff and all of the service users. This inspection was undertaken in conjunction with the inspection of the larger home that is run and managed by the same Registered Manager and Provider. Records relating to medication, staff recruitment and training, health and safety and care planning were examined. The environment was also inspected. As part of the inspection process a number of surveys were distributed and returned to the Commission. What the service does well: What has improved since the last inspection? What they could do better: The home could further develop the care planning in relation to the involvement and ownership by the service users in the process. Increased structured approaches to developing independence skills could be further improved. The home should ensure that all staff undertake the Adult Protection training provided by the local area team. 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 Page 6 The home needs to develop its quality assurance process to ensure there is genuine evaluation of progress and that staff, service users, relatives and outside professional have an opportunity to provide feedback about the service. 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. 119 Victoria Street DS0000016319.V334645.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 119 Victoria Street DS0000016319.V334645.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission procedure when used should ensure that people’s needs and aspirations are assessed prior to moving into the home. EVIDENCE: There have been no admissions to the home for several years but there is a policy and procedure in place, which would ensure that all prospective service users would have the opportunity to visit and stay overnight before moving in on a trial basis. 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans ensure that the service user’s needs are documented and guidance is available to staff but service users would benefit from greater ownership and involvement in the planning and reviewing process. EVIDENCE: The home have introduced a more person centred approach to care planning over the past twelve months and continued improvements were observed during this inspection. Attempts are made by the staff team to engage with the service users in the planning and reviewing of their care plans. All service users have person centred care plans in place that they have been involved in developing and reviewing. People expressed satisfaction with these but it is the view of the inspector that more ownership, in line with person centred principles, could be taken of these by the service users. This is relevant in view of the degree of independence that is enjoyed and the identified future aspirations of the service users. The care plans cover a range of needs but could be improved by containing some more specific goals and objectives relating to the future ambitions of the 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 Page 10 service users. The plans could identify specific skills that are being worked on to improve independence. It would also be useful to have more detail about how the plans are reviewed, who was involved and the decisions that were made. One plan did not contain any clear review dates or follow-ups. Whilst people were aware of their plans and there purpose it is evident that people have the ability to develop their understanding of the care planning process and to take more ownership of it. The Inspector acknowledges the improvements that have been made over the previous twelve months and that the plans generally reflect the needs of the service users. Service users were also positive about the support their keyworkers had provided in working on their plans. Risk assessments are in place relating to some potential behaviours, and also to independence. There was evidence of regular recording but some of this is limited in context, simply referring to meals that have been eaten. Service users themselves are able to write in the daily log, which covers all the people living in the home. It is recommended that the individual files have sections for recording any personal or confidential entries that people may want to make. Service user confirmed they are involved in all decisions made in relation to the daily running of the home. 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 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. 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 this service. Service users are supported to pursue their interests and hobbies, and are able to access the local community independently or with minimal support. Service users appear confident about their right to make choices and decisions about their lives. EVIDENCE: All three service users were very positive about the lifestyle they are supported to follow and examples were given of the various activities that are undertaken within the home and in the community. People all undertake regular weekly work in the local community, which they were very positive about. It was also explained how they are undertaking an NVQ qualification in relation to their employment. All can travel independently and are supported and encouraged to do this safely. Examples were given of trips into the local town as well as bus trips to Gloucester and visits to friends and relatives. 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 Page 12 Service users are responsible for cleaning and housework and this is being done to a good standard. People are also being supported to grow some of their own vegetables in the rear garden. People stated that they felt they received sufficient staff support to undertake the activities they wish to do and that they had a, “good balance between relaxing in their home and going out and about.” This view is supported by the evidence in the daily log of any activities that have been undertaken. 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to access the healthcare professional they require to ensure that physical and emotional health needs are met. Satisfactory arrangements are in place for the handling of medication, promoting service users’ wellbeing and, where appropriate, their independence. EVIDENCE: The service user who receives help with their personal care stated they were very happy with how this was delivered by the staff. People confirmed they are supported to attend various health appointments and checkups and that the staff help them to maintain their health. All the service users work some of the time at a local gym and all demonstrated a good awareness of the components of a healthy lifestyle. One service user is supported to self-medicate and the arrangements for this were satisfactory, with medication being appropriately stored and the correct recording completed. 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 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. 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 this service. The home provides a safe environment for service users in which they are respected and treated with dignity. Service users views are listened to and acted upon but additional training for staff in the area of Adult Protection is recommended. EVIDENCE: The staff have completed a distance learning course about Adult Protection but a recommendation is made that the home also access the training provided by the local Adult Protection Team. People were able to clearly state how they would report a complaint or a concern and all said they would be confident about approaching staff, the Manager or the Provider about any issue that concerned them. The service users were all very positive about the staff and the response they get when they raise issues that worry or concern them. The home has a complaints procedure in place and all staff questioned stated that they were aware of the procedure and that they would be confident about approaching either the manger or Provider if any issue concerned them. 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 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. 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 this service. Service users benefit from a home that is well maintained and decorated throughout and that provides a comfortable homely environment. Service users are supported and encouraged to personalise their living space and are involved in decisions relating to the redecoration of the home. EVIDENCE: The environment is maintained to a good standard and the service users do an excellent job in relation to housework and other domestic chores. The home was very clean and hygienic throughout, and all the rooms are personalised according to personal taste or preference. The front of the property has been converted to a patio area and the rear garden has been improved to provide an area where one service user can grow some of their own vegetables. The home provides safe, comfortable and homely environment. 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a staff team that relates well to them and has a positive approach to their care and support. Formal supervision of staff and improved care planning have helped produce a more professional service. EVIDENCE: The home has improved its induction training and process for new staff. New staff receive mentoring from an experienced staff member, supervision from the manager and have various competencies signed off as they progress. Basic statutory training is also undertaken as part of this. One staff member interviewed stated that the induction was very appropriate and that they were well supported by the staff team and the management during this period. Staffing files all contained the required information and there was evidence that all employment checks had been completed on new staff. Not all files have photographs in place but the Manager stated they were addressing this. All staff have now been receiving formal recorded supervision, which was a requirement from a previous report. The manager is also undertaking staff appraisals 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 Page 17 All service users were very positive about the support and care they receive from the staff who work at the home. One commented, “they are brilliant, I cannot fault them” and another said,“they always listen and they understand some of the problems I have.” The home now has a more structured rota that provides cover for some of the week and also provides time when the home is un-staffed, but with on-call facilities being provided. All service users expressed confidence and satisfaction with this system. All stated that they considered that the staffing levels were satisfactory. 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a home that is well managed and organised and committed to good quality care and support. However a structured and effective quality assurance system is needed to ensure that the outcomes of these standards are fully met. EVIDENCE: The Manager has developed an open and transparent approach to the running of the service. All staff spoken to were positive about the approachability of the management and the support that is provided. Service users interviewed also 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 Page 19 stated they were happy to approach the Manager or Provider on issues that concerned them. The Manager has provided leadership and direction on various improvements that have been introduced to the home, including care planning, training and staff supervision. The manager stated that they had regular, often daily contact with the Provider, who plays an active role in the life of the home. They have now started having monthly recorded meetings, were ongoing issues and plans are discussed more formally. There is a significant shortfall still in terms of the self-monitoring, review and development of the service. Whilst some efforts have been made to incorporate the views of service users, the home is yet to develop a fully functional quality assurance system and a discussion was had with the manager about how this must be progressed. This needs to be in place to improve the quality rating of the Management standards. All fire safety testing and servicing has been completed and the home has completed a fire risk assessment. 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 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 X 2 3 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 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 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 x 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 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 YA39 Regulation 24 Requirement The home must ensure that there are formal quality assurance systems in place. This requirement is repeated from previous inspection (previous timescale 31/12/06) Timescale for action 31/12/07 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 The home should provide the facility for confidential recording in the individual files when it is not appropriate for information to be put in the communal log 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 119 Victoria Street DS0000016319.V334645.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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