Inspection on 08/09/05 for Venetia House

This inspection was carried out on 8th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 but made no statutory requirements on the home.

Other inspections for this house

Venetia House 13/10/09

Venetia House 09/01/08

Venetia House 31/08/06

Venetia House 24/01/06

Venetia House 25/10/04

Venetia House 16/04/04

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Venetia House 348 Aylestone Road Leicester Leicestershire LE2 8BL Lead Inspector Ruth Wood Unannounced 08 September 2005 10:15 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 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 Stationary 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. Venetia House 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Venetia House Address 348 Aylestone Road Leicester Leicestershire LE2 8BL 0116 2837080 None None Mrs Phyliss Turner Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Valerie Moseley Care Home 12 Category(ies) of LD Learning Disability(12) registration, with number MD Mental Disorder(12) of places Venetia House 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25 October 2004 Brief Description of the Service: This is a well established home for people with learning disabilities and mental health problems. It is located in the Aylestone area of the City and is on a main bus route. The homes accomodation is over three floors, the first floor being accessible by stair lift. There are three double and six single rooms. One double room is located on the ground floor and there is also a ground floor bathroom. There is a large lounge on the ground floor and a small non-smoking lounge on the first floor. The dining room is located near to the kitchen on the ground floor. Service users are encouraged to use the kitchen to make snacks and drinks with the appropriate support of staff. There is a large, well maintained garden to the rear of the home with three patio areas where service users can sit outside. Venetia House 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection took place during a weekday between 10.15 and 16.45. Two subsequent shorter visits were made to discuss the way residents’ monies are administered, confirm the appropriateness of a new financial procedure and to view evidence of one resident’s expenditure. Planning for the inspection took approximately 1 hour and included reviewing the PreInspection Questionnaire completed by the Registered Manager and the 7 resident, 2 relative and 1 professional’s Comment Card. The Inspection included a tour of the home, a review of records and discussion with residents, staff, the manager, provider and visiting professionals. What the service does well: What has improved since the last inspection? What they could do better: Although the manager and staff displayed a good knowledge of residents’ needs and how these were met this information was not clearly documented, neither were all residents’ records dated and signed appropriately. On the first inspection day it was noted that the audit trail for some residents’ finances was unclear. This was promptly clarified by the Registered Provider but indicated that current practices and procedures could be improved and administered more thoroughly. A new procedure has been introduced and the Manager and Provider must ensure that this is successfully implemented. Venetia House 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 Page 6 Some staff who administer medication require appropriate training and improvements are needed in how medication not regularly prescribed is recorded when received. Clear procedures need to be in place stating under what circumstances some residents should be given prescribed ‘as required’ medication and the dose allowed within any given period. The fire risk assessment still requires updating to include a plan of where fire equipment and exits are located in the building and some fire door closures need adjustment. A Criminal Records Bureau check is needed for two staff and some staff require training in food hygiene. 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. Venetia House 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Venetia House 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 The home assesses and meets the needs of residents well. EVIDENCE: A copy of the placing social worker’s assessment is on file together with the home’s own assessment. The Registered Manager demonstrated a good understanding of residents’ needs and interests, which were confirmed in discussions with residents themselves. A comment card from one of the home’s General Practitioner’s stated, “staff always know what’s going on and the quality of care is excellent.” Venetia House 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7, Care plans contain insufficient detail and do not accurately reflect residents’ changing needs or care given. Improvements are needed in how residents are supported to manage their finances. EVIDENCE: The Registered Manager gave clear details of how a resident with diabetes’ condition was monitored but this did not appear in the care plan. Incidents of challenging behaviour were recorded in daily records for one resident and there had been an acknowledged change in their condition leading to a change in their CPA status. However this was not reflected in the resident’s care plan. Some care planning documentation was not dated and it was difficult to distinguish current from previous care plans. Although the basic care plan template was good, plans lacked sufficient detail. Information re advocacy services is in place and some residents have actively used these services. Some residents’ files contained signed agreements limiting some aspects of their behaviour; advocacy services had been involved in this process, which is good practice. However there was no clear procedure stating how and when these agreements would be reviewed and some of the original agreements were undated. Venetia House 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 Page 10 Neither the Registered Person or Manager is the appointee for any service user. Four residents administer their own finances without support; the remainder receive differing levels of support from staff. A record is kept of all transactions where staff are involved in supporting residents. Changes in the way benefits were paid recently resulted in the Registered Person having to loan money to some residents until their own money was accessible. The audit trail relating to this was not clear because of poor recording. The Registered Person agreed that the home’s systems needed improving and promptly instigated a new policy on administering residents’ finances which should rectify the issues identified. Evidence of a residents’ expenditure on a holiday not available on the first day of inspection was made available at a subsequent visit, as requested. Venetia House 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15,16,17 Service users’ access to leisure, work and education, facilitates their personal development and they receive good support to maintain appropriate relationships. Food is varied, nutritious and healthy. EVIDENCE: Menus showed that a good variety of food was served with a choice available. Fresh fruit and vegetables are regularly served. A particular feature is home made puddings which several residents said they enjoyed. Appropriate alternatives are available for residents with diabetes. Residents were very positive about the food describing meals as “very good”. The Registered Manager and several staff members hold a ‘Certificate in Nutrition in the Care Setting’. Residents are involved in many aspects of the home such as helping with meal preparation and laundry and watering the garden. There is a rota of jobs and residents said they were happy with this. Residents undertake a wide range of daytime activities including college attendance paid & voluntary employment. Most travel independently to these activities, some using scheduled public transport. Social events arranged Venetia House 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 Page 12 include going to a local disco, video evenings and day trips. Some residents said that they liked to play dominoes and other indoor games. Seven residents returned Comment Cards and all said that they felt the home provided suitable activities. Residents also have the opportunity to go on an annual holiday. Staff are very supportive of residents in maintaining contact with family and friends (one resident described how staff took them to see their mother on a regular basis) and there are no restrictions on when people can visit. Venetia House 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20 Residents’ physical and emotional health needs are well met. Some improvements are needed in how medication is managed. EVIDENCE: The pharmacist from Boots conducted an inspection of the medication system which the Inspector observed. All medication being used was in date and excessive medication was not being stored. The GP reviews all service users’ medication every 6 months. The pharmacist recommended that prescribed creams should have the oening date written on them. Where medication administration sheets are handwritten (such as when an antibiotic had been prescribed) the date received and quantity of medication must be entered together with the dosage to be administered. Some staff currently administering medication have not received formal training. No homely remedies are used with the exception of paracetamol; a protocol is in place written by the GP for this. There was no clear protocol stating under what circumstances a resident should be given ‘as required’ medication and how much should be administered within a given time period. Information on residents’ files showed that they have access to chiropodists, dentists and opticians on a regular basis. Discussion with the manager and staff demonstrated that a resident with diabetes was well supported in managing their condition. As part of this, regular monitoring of blood sugar levels is undertaken and it is recommended that these be documented on the resident’s medication administration record. Venetia House 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These Standards were not inspected but will be assessed at the next Unannounced Inspection later in the year. EVIDENCE: Venetia House 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 30 Service users live in a homely and comfortable environment, which is clean and hygienic. EVIDENCE: The home was clean and tidy. Mops and buckets are clearly labelled to prevent cross contamination. All staff have received training in infection control. There is a daily cleaning schedule and dedicated cleaning staff. Smoking is permitted in the main lounge and a large extractor fan is in place. There is a small non-smoking lounge upstairs. Residents’ rooms are highly personalised and many residents have chosen the décor of their rooms. Some door closures in the home needed readjustment – these should be monitored on a regular basis. The environmental health officer made an unannounced visit one month ago and recommended a cooker hood be installed in the kitchen when the cooker is replaced. No further recommendations or requirements were made. The garden is well maintained and has three patio areas with comfortable furniture. Residents enjoy watering the garden but a professional gardener maintains it. It is recommended that the patio slabs be monitored for movement to ensure that the area continues to be accessible to all service users. Venetia House 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34,35,36 Residents are supported by competent staff who are well supervised. Recruitment practices need some improvement to ensure residents’ protection. EVIDENCE: There are two staff on each day shift and one waking night staff. In addition there is a cleaner Monday to Friday. Care staff on duty are responsible for meal preparation and serving. The Registered Manager plays an active part in the care rota and has little dedicated management time. When not on duty the Registered Manager is on call should any additional input be required. The home has two relief staff who have previously worked at the home. A formal handover discussion takes place each day. Records show that staff have undertaken induction training and that some are involved in Learning Disabilities Award Framework Training as well as undertaking National Vocational Qualifications. Staff Recruitment files were examined; these contained two written references, evidence of staff identity and a copy of the Criminal Records Bureau check. Two care staff do not have current Criminal Records Bureau checks. Staff receive regular supervision which is documented. It is recommended that supervision between the Registered Person and Registered Manager is also documented. Venetia House 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Improvement is needed in some areas to fully ensure that residents’ health and safety is promoted and protected. EVIDENCE: Water temperatures were taken at random points and were below the safe level of 43 degrees centigrade; water has been tested for Legionaires compliance. All radiators have suitable covers and all windows are fitted with appropriate restrictors. Risk assessments relating to safe working practices were clearly displayed in the kitchen. Some staff members responsible for the preparation and serving of food have not received training in food hygiene. All staff have received training in moving and handling. Electrical appliances were tested in May, 05 and gas systems were checked in March ‘05. A requirement made at the previous inspection for the fire risk assessment to be updated is still outstanding. This should include a plan showing the location of fire equipment and exits in the building and must be easily accessible. The fire system and extinguishers were serviced in August this year. The Registered Person visits the home regularly and completes a detailed report. It is recommended that a copy of these reports be forwarded to the Commission. Venetia House 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 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 3 x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 2 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Venetia House Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 Page 19 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 6 Regulation 15 Requirement The Registered Person must ensure that all residents care plans reflect their current needs and care given, in sufficient detail. All care planning documentation must be dated and signed by the assessor and the resident. Agreements limiting the behaviour of some residents must be regularly reviewed The Registered Person must ensure that the revised policy dealing with the administration of residents finances is implemented. The date and quantity of all medication received into the home must be entered on the medication administration record together with the dosage to be administered All staff who administer medication must receive appropriate training. Clear protocols must be in place stating under what circumstances a resident should be given as required medication and the dose that can be administered within a given time 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Timescale for action By 31.10.05 2. 3. 4. 6 7 20 15 15 13 From 08.09.05 .From 08.09.05 From 27.09.05 5. 20 13 From 08.09.05 6. 7. 20 20 13 13 By 11.11.05 By 20.10.05 Venetia House Version 1.40 Page 20 period. 8. 9. 10. 24 34 34 23 17 17 All fire door closures must be correctly adjusted and periodically monitored.l Criminal Records Bureau checks must be obtained for the two identified staff members. No member of staff must work at the home until their Criminal Records Bureau check has been obtained. All staff involved in the preparation and serving of food must receive training in food hygiene. The fire risk assessment must be updated to include a plan of the location of fire equipment and exits in the building and must be easily accessible (Previous timescale of 25.11.04 not met.) From 08.09.05 By 31.10.05 From 08.09.05 By 11.11.05 By 31.10.05 11. 42 13 12. 42 23 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. 2. 3. 4. 5. 6. Refer to Standard 20 19 23 36 33 42 Good Practice Recommendations Prescribed creams should have the opening date written on them as recommended by the visiting pharmacist. It is recommended that blood sugar levels taken as part of monitoring a residents diabetes be documented within the medication administration record. The patios paving slabs should be monitored to ensure that they do not present a risk to residents with reduced mobility. It is recommended that supervision between the Registered Person and Registered Manager be documented. It is strongly recommended that the Registered Manager be allocated dedicated management time on the staff rota. It is recommended that a copy of the Registered Providers reports on the home be forwarded to the CSCI. Venetia House 20050908 Venetia House X10023 UN Stage 4 S6380 V228398 C51.doc Version 1.40 Page 21 Commission for Social Care Inspection The Pavilions 5 Smith Way, Grove Park Enderby, Leicester LE2 8BL 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. 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