Inspection on 26/09/07 for 9 Victoria Street

This inspection was carried out on 26th September 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

9 Victoria Street 08/12/06

9 Victoria Street 01/02/06

9 Victoria Street 09/11/04

9 Victoria Street 30/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Victoria Street (9) New Brimington Chesterfield Derbyshire S43 1HY Lead Inspector Angela Kennedy Key Unannounced Inspection 26th September 2007 10:30 Victoria Street (9) DS0000035806.V345471.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 Street (9) DS0000035806.V345471.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 Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Street (9) Address New Brimington Chesterfield Derbyshire S43 1HY 01246 347590 02146 347594 Not given www.derbyshire.gov.uk Derbyshire County Council 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) Linda Hurst Care Home 18 Category(ies) of Learning disability (16), Learning disability over registration, with number 65 years of age (2) of places Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2006 Brief Description of the Service: 9 Victoria St is a care home registered to provide personal care and accommodation for up to 18 adults between 18 - 65 and up to 2 adults over 65 with learning disabilities. The home is located in the village of Brimington on the outskirts of Chesterfield. A number of shops, pubs and other amenities are nearby. Derbyshire County Council owns the home. The accommodation is on two floors. There is a stair lift provided. 16 of the bedrooms are single accommodation, 4 of which provide ensuite facilities. One-bedroom is double accommodation. There are three communal dining and lounge areas. There is also a flat where service users can make drinks and snacks. There is a spacious garden to the side and rear of the building. Some limited car parking space is provided, although cars can also park on the road. Each service users contribution for staying at 9 Victoria Street was dependent on the service users age and their length of stay. Further information regarding these fees can be obtained by contacting the service by telephone or via Derbyshire County Councils website. There are no extra charges as service users access services in the community for hairdressing, chiropody, etc. Service users are expected to pay for taxis out of their mobility allowance. The amenities fund usually pays for transport for outings, with meals etc. being paid from personal allowances. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection visit was unannounced and took place over six and a half hours. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with service users and their representatives. The inspection was focused on assessing compliance with defined key National Minimum Standards. The commission had requested the service to complete an Annual Quality Assurance Assessment and the information provided within this assessment has also been used within this inspection report. Surveys were sent out to a number of service users at 9 Victoria Street and the information provided in the returned surveys has been used to inform this report. The registered manager was not available at this inspection. Both deputy managers were on duty and the registered manager from another local authority service, who was providing managerial support to 9 Victoria Street, was also present at this inspection. Staff opinions were also sought to ascertain their views of the service and their opinion of the training and support provided to them. Two service users were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at care plans and other documents relating to that persons care, talking to staff regarding the care they provide, talking to the service user if they are able to communicate or observing the care they receive. Both of the service user’s case tracked and other service users at 9 Victoria Street were spoken to on the day of this inspection visit. What the service does well: The staff team at 9 Victoria Street provide a caring and supportive environment for the people that live there. The age and needs of each service user vary and the staff team work hard to meet individual social and emotional needs. Many of the service users due to the circumstances around their admission did not choose to live at 9 Victoria Street, however the comments from service Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 6 users were generally positive regarding their stay at Victoria Street and several service users stated that they wished they could stay at Victoria Street on a permanent basis, as they liked living there. What has improved since the last inspection? What they could do better: The other two requirements have been part met but still require some further work to be undertaken, these requirements relate to; The Statement of Purpose, which now states that the service provides accommodation for people who are in crisis and need to be somewhere safe. It also confirms that emergency admissions are taken and directs the reader to the Service User reference guide at the home, regarding the policy in relation to emergency admission. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 7 In general the Statement of Purpose had been updated to reflect the purpose of the home and the services provided. However it is important to remember that this document will require continuous review to ensure it provides up to date and accurate information. Areas such as staff qualifications need to be reviewed on an ongoing basis, it was noted that the figures given in the Statement of Purpose regarding staff that had achieved a NVQ at level 3 in care were not accurate. The care plans and risk assessments relating to personal and social care needs had in general improved, but some could be further developed to ensure all of the relevant information is recorded. Written risk assessment must be in place to demonstrate that any risk identified has been assessed and that measures have been put in place to ensure the risk is minimised. 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 Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. In general the information provided to service users was up to date and the service ensured that the needs of individual’s was assessed before an agreement was made regarding admission. EVIDENCE: The written information provided by the service prior to this inspection stated that: We promote opportunities for people admitted in crisis to be able to return to the community. We aim to minimise the need for people to be admitted to residential or nursing care for long term support. In the last twelve months nine people have been discharged into a range of supported living arrangements, which range from; returning to the family home, individual tenancy and supported living arrangements. On the day of the inspection visit: At the last inspection it was noted that the Statement of Purpose for the service did not accurately describe the purpose of the service in relation to the types of admissions to the home. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 10 The Statement of Purpose now states that the service provides accommodation for people who are in crisis and need to be somewhere safe. It also confirms that emergency admissions are taken and directs the reader to the Service User reference guide at the home, regarding the policy in relation to emergency admission. Although this policy was not looked at during the inspection visit, discussions with one of the deputy managers confirmed that no emergency admission was agreed before a completed needs assessment had been undertaken by the individuals care manager and received by the home. This ensured that the service could determine, before agreeing to admission that they could meet the needs of the individual, and that their needs and the support they required would not have a detrimental impact on the services users already living at 9 Victoria Street. In general the Statement of Purpose had been updated to reflect the purpose of the home and the services provided. However it is important to remember that this document will require continuous review to ensure it provides up to date and accurate information. Areas such as staff qualifications need to be reviewed on an ongoing basis, it was noted that the figures given in the Statement of Purpose regarding staff that had achieved a NVQ at level 3 in care were not accurate. Although 9 Victoria Street has a changing group of service users which reflect its primary purpose, there is one service user who has lived at 9 Victoria Street for a considerable number of years and it has now been agreed by the local authority that for this service user to move from 9 Victoria Street would be detrimental to their health and well being. Two service users spoken with said that they liked staying at 9 Victoria Street. One of these service users had been admitted as an emergency admission and therefore confirmed that they didn’t have an opportunity to visit the service prior to moving in. But said “ I like living here it’s a shame it can’t be permanent”. Copies of assessments and care plans, carried out by the service users care managers prior to admission was seen within the two service user’s files case tracked. Copies of individual service user contracts were in place on the two service users files seen. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The care plans and risk assessments relating to personal and social care needs have in general improved, but some could be further developed to ensure all of the relevant information is recorded. This will provide detailed instruction to staff to enable needs to be met within a risk management framework. EVIDENCE: The written information provided by the service prior to this inspection stated that: We support people to make choices about how they spend their time. Personal service plans include the express choices of individuals and people can choose to stay out overnight at their friends or family. People are supported to choose the time they go to their bedrooms at night. A choice of meals is always available. We encourage people to manage their finances. An advocate chairs residents meetings. Individuals are involved in the review process and the meetings. We encourage people to identify Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 12 community activities they want to take part in. We have photos on display of the activities undertaken. On the day of the inspection visit: Annual reviews were in place within one of the service users files seen. The other service user had not been at 9 Victoria Street long enough for an annual review to be undertaken. One of the deputy managers confirmed that prior to an annual care plan review, a meeting known as ‘my meeting’ was held with the service user to look at any issues the service user wanted to address and to determine who they would like to invite to their review. As some service users did not feel comfortable attending a whole review each person was asked before the meeting if they wished to attend all or part of their review meeting. There were no records in place within the two service users files seen to demonstrate that this meeting took place. It is therefore recommended that these notes/ records be held on individual files to demonstrate that this practice is undertaken. Care plans were in place within the two service users files seen. These care plans were used at each service users annual review. ‘Personal service plans’ were also in place. Which provided a more detailed description of each person’s needs and the level of support they required in order for their needs to be met. However it was noted that one of the personal service plans seen provided more detailed information on the strengths of the individual, such as activities or tasks that they were able to undertake independently. It is important to remember the purpose of documenting all information is to provide a complete ‘picture’ of each individual’s strengths and needs. This ensures that all staff, including new staff, have clear instruction as to how needs are to be met and provides the service with evidence of how service users needs are met and their independence and development promoted. The personal service plans and care plans seen had been signed by the service users. Three monthly reviews had been undertaken on one of the personal service plans seen. The other service user had not being staying at 9 Victoria Street long enough for a three monthly review to be held. Service user meeting were held each month with an independent advocate. Records of the meetings were seen and had been produced in an appropriate Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 13 format. The manager met with the advocate after the meeting to discuss any concerns or suggestions raised and how these can be actioned. One of the service users case tracked stated that they did not participate in the group meeting but preferred to speak with the advocate an a one to one basis. This person stated that they found the advocate very useful. The majority of the service users looked after their own rooms and this was confirmed by service users spoken with and during a general tour of the building. The risk assessments seen were detailed but were limited for the service user that was well known to the staff. Risk assessments not only direct the staff as to the actions that need to be taken but also demonstrate that each persons independence is promoted within a risk management framework. Discussions with one service user confirmed that the stair lift was at present out of order. This service user confirmed that although they were able to climb the stairs unaided they required supervision to do so, to ensure they didn’t lose their balance. Although it was confirmed by the staff team that this service user was able to climb the stairs with supervision, there was no risk assessment in place to support this. Owing to the important health and safety implications of this matter a risk assessment was completed during this inspection visit. The deputy manager confirmed that none of the other service users independence or mobility needs were affected by the stair lift being out of order and stated that the stair lift had been reported as out of order and confirmed that the engineer was awaiting parts to repair this. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 14 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): 12,13,15,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements have been made to the support provided to service users to enable them to access appropriate activities and facilities both within the home and the local community. Services users were offered a healthy diet and alternative meals were available for those that required them. EVIDENCE: The written information provided by the service prior to this inspection stated that: Individuals visit primary health services in community and have their own G.P. Public transport is encouraged and we ensure we have up to date information on public transport in the area. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 15 Individual appointments are made for hairdressing. 3 people do voluntary work- 1 based in a charity shop and 2 based in youth club coffee bar. 1 person has been at college during the last 12 months and robust risk assessments have been put in place to ensure the college placement was not undermined. Educatuional opportunities are accessed through day service and people have completed courses through the day service On the day of the inspection visit: From discussions with staff and the records held, it was confirmed that some service users attended a day service, some had no day placements and other service users chose not to attend their day placement every day, but went when they chose to. At the time of this inspection no one attended college, although there was one service user who had attended college but this person was no longer staying at 9 Victoria Street. Service users maintained good links with the local community and accessed community services, such as local public transport, shops and hair salons. Additional staffing hours were now in place of 18.5 hours a week and these hours were used to support service users in activities throughout the day. One of these activities being the use of the training kitchen in the flat which allowed service users to plan, shop, prepare and cook their own meals. Staff were observed consulting with service users on a number of occasions regarding their preferred lunchtime meal and the activities and events they wished to take part in. An example of this was two of the service users had chosen to attend a fete at the local day centre and a member of staff supported them to do this. Another service user was heard talking to staff about a shopping trip they were planning and advice was being given regarding budgeting for the items this person wished to purchase. Comments from service users included “ staff take me out for meals, we go shopping and to the garden centre and we go on trips” and “ I keep myself busy, I enjoy doing jigsaws and reading, but go out with staff too.” Service users were able to maintain friendships and the majority of the service user had a group of friends, who they had developed relationships with through the day centre or Victoria street. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 16 The inspector took lunch with some of the service users and found it to be of a good quality. Service users were consulted regarding their preferred choice of meal. All of the service users spoken with said they were happy with the meals provided, however one service user did say that they felt there could be a wider variety of meals to choose from. Menus ran over a three-week rolling menu and included a ‘take away night’, where service users could chose their preferred take away and a BBQ night. The deputy manager confirmed that residents discussed their preferred choices at the service user meetings with the independent advocate; this information was then fed back to the management team. Service users spoken with confirmed this. At the time of this inspection there was no catering staff on duty. The deputy manager stated that one of the kitchen staff was off sick and the other post was vacant and being advertised. This meant that care staff were preparing and cooking meals. The deputy manager did not appear unduly concerned regarding this and indicated that staff were able to manage this additional role, in the short term. However, if this situation continues for any length of time, consideration should be given to the amount of time care staff spend in the kitchen, to ensure the care and support provided to service users is not affected. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 17 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 health care needs were met and in general the medication practices in place were satisfactory, however further development is required to demonstrate that assessments have been undertaken. EVIDENCE: The written information provided by the service prior to this inspection stated that: There is access to community resources. Individuals choose how they wish to look and what makes them feel goodclothes, hair, nails. Individuals shop for personal items on their own or are offered support. All bedrooms have keys and individuals can choose to have a key unless risk assessment tells us something different. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 18 Service users have been encouraged to be involved in the identification of their health care. I.e. chiropodist, dentist, optician. Service users have been able to ask for support if and when needed for health care appointments. Chiropody is provided at Victoria Street. This needs to be reviewed to ensure individuals access community resources. Individuals are assessed to ensure they are able to self medicate and do so wherever possible. On the day of the inspection visit: Service users spoken with felt that staff supported them in any personal care needs they had and confirmed that they were treated respectfully. Service users were supported to make decisions regarding their appearance and the day-to-day choices they made. Comments from one service user were, “I choose what to wear, what to have for breakfast and whether to go to the centre or not”. This service user did however comment that they weren’t always able to choose what time they got up in the morning. More flexibility was in place regarding the times service users went to their rooms in the evening. Staff cover at night now consisted of one waking night staff and a member of staff who slept in, to provide support as required. All of the service users had two designated key workers, which enabled more consistency for the service users, as often at least one key worker would be on duty. Key workers were responsible for organising care reviews in conjunction with the service users care manager. Records were in place within the service users files seen to demonstrate that health care needs were met. This included visits from health care professionals and assessments undertaken by psychologists and primary care teams. Service users accessed community health care services for dental and eye care. Records were seen of chiropody appointments that had taken place at the home. The deputy manager stated that the services of the chiropodist may be accessed within the community rather than in- house. However it was confirmed that one of the service users was apprehensive regarding accessing some community health care services and this therefore needs to be taken into consideration before a decision is made regarding in- house chiropody services. The medication practices at 9 Victoria Street were assessed. Medication was stored correctly and records of administration were satisfactory. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 19 A photograph of each service user was in place on the medication administration records, to enable each service user to be clearly identified, and a list of staff signatures and initials was also in place to ensure all initials could be identified on medication administration records. The service had informed the commission of a medication error that had taken place prior to this inspection and the commission were satisfied that the correct procedures and guidelines had been undertaken following this error. More stringent practices have since been put into place to ensure that medication administered is checked by a second member of staff, and this practice was seen on the day of inspection. A clinical fridge was in place within the duty office, however this fridge was not plugged in, as it was not in use at the time. However this was discussed and it was advised that the clinical fridge is kept on at all times to enable the fridge to be kept at the required temperatures, to ensure it is ready for use at any time and enable any malfunctions in temperature to be detected and rectified. One service user had chosen to administer their paracetamol, which they purchased from the local chemist. No risk assessment was in place to demonstrate that this service user had the capacity to administer and store this medication safely. The deputy manager stated that this service user did have the capacity to administer this medication and store it safely. This had been apparent to staff from discussions they had undertaken with this service user. It was stated that this service user was clear as to the amount and times this medication could be taken, and though further discussion this service user had demonstrated to the staff their awareness of the dangers of mixing this medication with other pain killing drugs. The deputy manager also stated that this service user’s GP had been made aware of the service users decision and was in agreement. This information demonstrated that an assessment has been undertaken as to this service users ability to self administer medication, but in order to make the assessment valid this information needs to be recorded and signed by the service user and the member of staff that undertakes the assessment to demonstrate their agreement. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 20 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 good. This judgement has been made using available evidence including a visit to this service. Improvements in the record keeping of complaints and comments from service users indicated that any issues raised would be acted on effectively and promptly. Safeguarding adults procedures are in place to ensure service users safety is maintained EVIDENCE: The written information provided by the service prior to this inspection stated that: We have a complaints file that tells us what complaints have been made and what we did about the concerns. We have an accessible format for individuals to make a complaint and display the complaints booklet. We support people to tell us when they are unhappy and we tell them what we are going to do about their concerns. Advocacy support residents meetings that are minuted and we have access to advocacy support for individuals. Individuals have contact information for their care coordinator to enable them to share any concerns independently On the day of the inspection visit: The home has a complaints and compliments book. There were several recent letters and cards expressing thanks for the service provided, and concerns and complaints had also been recorded in this book. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 21 Eleven concerns had been recorded since the last inspection,staff had recorded discussions and the actions taken. However the recording sheet didn’t provided a ‘formal’ identified area for staff to record outcomes. Therefore all actions taken and the outcome of complaints had been recorded on the back of each form. A complaints workbook was in place for service users to assist them in making a complaint and expressing any concerns they had. This workbook was provided in a pictorial format and included an area for the service user to draw what had happened. Comments from service users indicated that the majority new how to make a complaint and who to speak with if they had any concerns. Service users were also given an opportunity to discuss any concerns they had either within a group discussion or on an individual basis with the independent advocate who chaired the monthly service user meetings. The advocate would then feed any issues back to the management team for action. At the last inspection visit it was noted that regulation 37 notices that related to the welbeing of a service user had not being sent to the comission. However since the last inspection visit the comission has recieved information that related to service users well being. One being an allegation regarding the way a member of staff spoke to a service user and the other related to a medication error. Both of these incidents were dealt with appropriately and satisfactory action was taken to address these issues. The safeguarding adults arrangements were discussed and it was confirmed that the home followed the Derbyshire County Council Procedures. The inspector was informed that all staff have had undertaken training in safeguarding adults and were provided with refresher courses as required. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 22 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 9 Victoria Street provides a comfortable environment for the people that live there. EVIDENCE: The written information provided by the service prior to this inspection stated that: We ensure decoration is maintained to a high standard. Individuals are involved in a selection of colours and textures for individual rooms. Communal areas are made homely. We have a patio area with garden furniture. We enter a local ‘best kept garden’ competition with the involvement of the people who stay at Victoria Street. We have refurbished a kitchen with domestic goods for independence planning work. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 23 We have robust maintenance procedures for the building and keep records of maintenance work On the day of the inspection visit: A tour of the building was undertaken, the building is large and accommodation is arranged on two stories. Generally the building is maintained satisfactorily. The deputy manager confirmed that an Environmental Health Inspection had been undertaken approximately two months prior to this inspection visit and no requirements had been left. There is a choice of dining/lounge areas and all residents have their own room. There were pictures of the garden displayed, everyone worked hard in the summer to make the garden a pleasant area to enjoy The laundry area was seen and housed sufficient equipment to meet the required disinfection standards. A member of staff was employed to undertake general laundry tasks and care staff at night also undertook any laundering required. Service users were supported to undertake their washing if they were able and chose to do so. One service user confirmed this saying “ I enjoy doing my washing with the staff”. Some service users bedrooms were viewed and demonstrated that service users were able to personalise their rooms to reflect their taste and style. Two domestic staff were employed throughout the week to undertake general cleaning, and one service user commented that “the cleaners treat this place like it’s their own home, it’s always clean and tidy”. As stated in standards 6- 10 the stair lift was out of order and the service was waiting for this to be repaired. This affected one of the service users who used this lift to access their bedroom. However this person was able to climb the stairs with staff supervision and by the end of this inspection visit a risk assessment was in place to demonstrate this. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 24 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The staff team have the competencies and skills required for service users needs to be met And the recruitment practices in place enhance the safety of the service users. EVIDENCE: The written information provided by the service prior to this inspection stated that: All staff attend skills for care programme on appointment and over 50 of direct care staff are trained to NVQ 3 level. We have a training planner to ensure staff training is up to date and staff have personal development plans.Certificates for completed courses are on staff files On the day of the inspection visit: An additional 18.5 care staff hours a week has been provided to support service users in social, leisure, recreational and their development of daily living skills. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 25 From 9am to 3pm two care staff were on duty and were supported by a member of the management team. From 4pm to 10pm three care staff were on duty. The management team also worked afternoon shifts and participated in sleep in duties. The deputy manager confirmed that when none of the management team was on duty, a management on call system was in place to support the staff on duty. Since the last inspection visit improvements have been made to the staffing levels on duty at night and there is now one waking night staff and a member of staff who sleeps – in at 9 Victoria Street, this enable a more flexible approach to be provided to service users during the evening and night. In general the comments regarding the staffing levels at 9 Victoria Street were positive, however one service user did state that there were occasions when the staff were very busy and they had to wait to speak with them. However it wasn’t made clear if this was due to staffing levels. Staff spoken with were complimentary regarding the support provided by the management team and comments made regarding the staff team included “ staff are lovely here, there’s good team working” Three staff files were looked and all of the required recruitment records were seen, this demonstrates that a thorough recruitment practice is in place to protect service users welfare. Training records were seen and evidence of induction training was also looked at. The majority of mandatory training was up to date and evidence was in place to demonstrate that for those staff requiring refresher training this had been booked or requested and the management team were awaiting training dates. Eight of the care staff team had achieved a National Vocational Qualification (NVQ) at level 3 in care. Four staff were working towards this qualification at the time of this inspection visit. One of the deputy managers had achieved an NVQ at level 4 in care and the other deputy manager was working towards this qualification at the time of this inspection visit. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 26 Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 27 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 adequate / good?. This judgement has been made using available evidence including a visit to this service. The management team have worked hard to support service users and staff in ensuring the service is well run, but vigilance must be maintained in all areas of health and safety. EVIDENCE: The written information provided by the service prior to this inspection stated that: An annual quality assurance exercise is completed called ‘your views’. Training is provided for all staff to ensure safe moving and handling techniques are used including appropriate risk assessment. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 28 Training is provided to ensure that all staff understand the principles of fire safety and procedures to follow. Two sessions a year are given to staff on fire safety and moving and handling training is refreshed annually. On the day of the inspection visit: The commission had been informed in August 07 that the registered manager had been off sick for nearly three months, and at the time of this inspection had not returned to work. Interim arrangements had been put in place to provide the two deputy managers with support. At the last inspection visit Quality assurance systems had not been formally completed. At this inspection evidence was seen of questionnaires that had been completed by service users with the help of Derbyshire Advocacy services. All of the service users had been asked to participate and eleven had responded. The results of the questionnaires had been audited, and in general the responses from service users were positive. Information obtained from the questionnaires sent by the service or from the service users meetings, was discussed with the management team and any changes required were addressed, such as more variety at meal times. Service users meetings were held each month and chaired by an advocate from Derbyshire Advocacy services. Service users spoken with stated that the advocacy meetings and questionnaires were helpful in allowing them to express their views and the majority felt the staff team were responsive to their requests and opinions. At previous inspection visits discussions have taken place regarding the small office space available for staff which is used as a medication room, managers office, handover office, and is the only office space available to other care staff members. The above arrangements is still in place and discussions took place regarding this. It was confirmed that space could be allocated in either the sleep-in room or within the domicillary care teams office to write up logs and care plans. Some of the service users managed their own monies and for those service users who were unable or chose not to, their monies was held by the service. The system for handling service users personal monies was examined and there was confirmation that there were suitable accounting procedures in place. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 29 The deputy manager confirmed that all of the care staff team had undertaken a basic first aid training course, which enabled them to provide first aid in an emergency situation and one member of staff had undertaken a full first aid training course. The guidance regarding care homes providing first aid has recently been amended and allows services to undertake a first aid risk assessment specific to their individual service. Information pertaining to the factors that can be taken into account and the criteria for who can be regarded as a qualified first aider were given to the management team at this inspection visit. However if a risk assessment is not in place the Commission will require that someone who has undertaken a suitably approved first aid at work qualification be on duty at all times. Fire training records were seen and were up to date with the last fire training being undertaken in June 2007. A fire risk assessment was in place and this had been completed in February 07. Monthly checklists were in place for visual checks on fire fighting equipment and weekly records were maintained of fire alarm checks. The Annual Quality Assurance Assessment informed the inspector that all equipment had been serviced. No maintenance or service records were looked at. As already stated within this report the stair lift was out of order. A risk assessment had been completed before the end of this inspection to address the health and safety implications of the service user affected by this. However staff must remain vigilant in ensuring that any matter that may or will affect the health and safety of service users is addressed immediately and the necessary measures put in place to address any risks and how these are to be minimised. Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 30 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 2 2 3 3 X 4 X 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 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 2 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 2 X 3 X 3 X X 3 X Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 31 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 YA1 Regulation 4 Requirement The Statement of Purpose must be updated as and when required to ensure service users and prospective service users have the correct information at all times. Timescale for action 26/01/08 2. YA6 15 3. YA20 13 Personal Service plans must 26/01/08 include details on how assessed needs are to be met, and risk assessments must include details on how identified risks are to be managed. (Previous timescale 30.04.07) Risk assessments must be 30/11/07 undertaken for any service user who chooses to retain and selfadminister medication to demonstrate that they have the capacity to do so safely. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000035806.V345471.R01.S.doc Version 5.2 Page 32 Victoria Street (9) 1. 2. Standard YA6 YA8 Records of meetings held with service users prior to annual reviews should be retained within service users files, to demonstrate their involvement in the review process. The registered manager should consider ways that service users can further participate in the day-to-day running of the home and to contribute to the development and review of the service. (Recommendation from previous inspection) There should be an assessment of individuals’ independent living skills and provision for development of these skills to be made. (Recommendation from previous inspection) The home should be organised into clusters of up to 10 people by 1 April 2007. (Recommendation from previous inspections) The registered manager should be able to demonstrate development for each service user, linked to implementation of the individual plan. (Recommendation from previous inspection) A designated area should be available on complaints recording forms to document the actions taken and the outcome of the complaint. The home should give consideration to extending the office so that managers and other staff are able to carry out their administrative and other duties (e.g. handover meetings, medication administration) in privacy and without overcrowding. The manager should undertake the registered managers qualification 3. YA11 4. YA24 5. YA39 6. 7. YA22 YA37 8. YA37 Victoria Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Street (9) DS0000035806.V345471.R01.S.doc Version 5.2 Page 34 - 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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