Inspection on 13/07/06 for Victoria Court

This inspection was carried out on 13th July 2006.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Victoria Court 14/05/08

Victoria Court 15/05/07

Victoria Court 23/02/06

Victoria Court 22/07/05

Victoria Court 29/03/05

Victoria Court 18/11/04

Victoria Court 02/03/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Victoria Court 39-41 Victoria Road Bridlington East Yorkshire YO15 2AT Lead Inspector Mr Tom Tomlinson Key Unannounced Inspection 13th July 2006 09:40 Victoria Court DS0000019766.V303488.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 Court DS0000019766.V303488.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 Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Court Address 39-41 Victoria Road Bridlington East Yorkshire YO15 2AT 01262 676205 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 Arthur Lindley Ms Sheila May Wilson Care Home 19 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (19) of places Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd February 2006 Brief Description of the Service: Victoria Court was first registered with the local authority in 1988 and has been subsequently operated as a family concern. Victoria Court is a large detached double fronted property located in a residential area of Bridlington and is conveniently situated for all of the main community facilities including the public transport network. It is registered for nineteen adults who have a mental health problem and require primarily personal care such as support and guidance. Nursing care is not provided. Should such care be required then it will be provided by the community health care services. The service users (residents) accommodation is located on three floors. The care home does not have a passenger lift and is therefore only considered suitable for service users who are reasonably ambulant. There are five single and seven double or shared rooms. The double rooms are only shared with the expressed agreement of the occupants. There are three lounges on the ground floor, two of which are designated smokers lounges. There is a large secluded garden that provides the service users with reasonable privacy. The stated aim of the care home is, To provide a homely environment where the residents can feel comfortable and secure whilst receiving the support and guidance they need to achieve their goals. The accommodation fee is £305 a week. This, however, is negotiable prior to a service user’s admission into the home and is based on their assessed needs. Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit made to the home by an inspector of the Commission for Social Care Inspection (C.S.C.I.) during this inspectoral year. The visit formed an integral part of the ‘key inspection’ process. This report has been based on information obtained during the visit from discussions with the service users, the staff and the Registered Manager. Survey forms were received from all of the service users and three health and social care professionals prior to the visit. Reliance was also placed on observation of the service users and staff, an examination of several statutory records, including three care records, and an inspection of the premises. The report also incorporates information received by the C.S.C.I. prior to, and subsequent to, the inspection visit. What the service does well: What has improved since the last inspection? Since the previous inspection the registered manager has reviewed the majority of the policies and procedures to ensure that they remain relevant and meaningful. The requirement identified during the previous inspection has been addressed. The manager continues to promote training for the staff. The staff who are designated ‘key workers’ have been further encouraged to spend ‘quality time’ with the service users to endeavour to find ways of providing them with meaningful and stimulating activities. Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Victoria Court DS0000019766.V303488.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 Victoria Court DS0000019766.V303488.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service”. The service users and their placing authority are provided with adequate information on which to make a considered decision regarding a proposed placement in the home. EVIDENCE: No new service users had been admitted over the past year. The home had an admissions policy and the manager stated that it was usual for a prospective service user to be assessed by the registered manager in addition to any assessment provided by a placing authority. The manager provided examples of where prospective service users had been refused admission as it had been considered an inappropriate placement. The service users’ care records confirmed this. Nine service users confirmed in the survey document that they had received sufficient information prior to being admitted into Victoria Court on which they could make a considered decision as to whether it was the right place for them. One service user confirmed that they had ‘viewed the property beforehand’. Service Users comments included “ I’m quite happy really”; “I’m quite happy here but £22 a week doesn’t go far – the staff are ok – they treat us well”; “I’ve been here a long time and I like it. I get on with the staff especially Sheila” (manager); “I’ve been here about seven years. The staff are ok. I don’t have any problems”. Victoria Court DS0000019766.V303488.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service”. The service users’ care plans provide the staff with sufficient information through which they are able to meet the service users’ assessed needs. EVIDENCE: All of the service users had been provided with a care plan by the home. It was evident that they had been based on the assessments of the service users. The ‘internal’ care plans were in addition to any care plans provided by a placing authority. The care records were split into two. The ‘working’ file was available in the dining room and the more detailed and comprehensive record was retained in the manager’s office. It was evident from the working files that the care plans were closely monitored by the staff and regularly updated to take into account any significant changes in the service users’ needs. The care plans were basic in content and clearly identified the service users’ primary needs and the actions to be taken by the staff to meet those needs. A particular example of this related to a service user who had a possible alcohol problem. For ease of use by the staff, the care plans were Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 10 subdivided into elements of care that addressed the service users physical, emotional and social needs and abilities. The service users spoken to were aware of their care plans and confirmed that they were involved in the review of the plans. The care plans had been signed by the service users in agreement. The home used a system of ‘key-workers’ with members of the support staff having responsibility for monitoring the well being of specific service users. The service users were aware as to who was their key-worker. The compatibility of the service user and their key-worker had been taken into account. From a discussion with a member of staff it was evident that they fully understood their role as a key-worker. It was apparent from discussions held with service users that they were encouraged by staff to make decisions for themselves. An example of this was observed when a service user wished to make an appointment with a medical practitioner. Other service users provided examples of how they decided to spend their personal money and their control over their daily routines. Where restrictions were in place they were implemented with the written agreement of the service user concerned. An example of this was the agreement for two service users to have their cigarettes issued to them by the staff. There was evidence that such restrictions were regularly reviewed. The home presented as being more like a ‘hostel’ or ‘supported living unit’ rather that a ‘traditional’ care home. This was evident from the way the service users led relatively independent lifestyles and could come and go as they pleased without necessarily asking the permission of the staff. Victoria Court DS0000019766.V303488.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service”. The service users are provided with a lifestyle that meets their needs and at the same time promotes their independence and encourages them to become an integral part of the local community. EVIDENCE: As previously stated in the report, the service users were relatively independent and generally ‘did their own thing’. From the discussions held with the service users it was evident that they were satisfied with this arrangement. On the inspector’s arrival at the home he was greeted by two service users who were sitting in the sun at the front of the house. One of the service users went to find the manager before the inspector was admitted into the home. The service users present at the time of the visit looked relaxed and at home in their environment. A comment received from a Social Care professional indicated that there was little support provided by the staff to assist the service users to access community activities or provide them with Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 12 one to one activities. Those service users spoken to, however, did not agree with this comment. Comments received from the service users to the contrary included: “It’s ok here – I can come and go as I please” and “I go on train journeys (alone) – I have been to Driffield where they’re re-doing the locks – I find this interesting. I would like to go on longer journeys”. The last point was discussed with the manager. And, “I lead a very independent life compared to many of the other Victoria Court residents”. It was observed that several of the service users spent time reading newspapers or watching television. Others came and went during the period of the inspection with majority going into the local town. The service users appeared rather less apathetic than they did during the previous inspection. According to one service user their moods were directly linked with the weather. None of the service users indicated that they wished to have paid employment, access to educational courses or a programme of structured activities although some made use of the local resource centre. The registered manager provided evidence that proposed activities was regularly discussed at the service users’ meetings. It was observed that several of the service users had social contact with neighbours and that the conversations with them were natural and courteous. It was evident that these service users felt an integral part of the local community. A number of the service users had retained contact with their family. Whilst it was evident that the daily routines promoted the service users’ independence, those service users in shared bedrooms, could, it is argued, have their independence and privacy undermined. None of the service users spoken to objected to sharing a bedroom. Whilst the bedroom doors had locks fitted these were not generally used by the service users. In addition to this the locks were of an inappropriate design. The registered provider was in the process of converting an unused lounge into a single bedroom. One service user indicated their frustration with regard to communal living and commented “ Constant interruptions spoil my T.V. viewing by another resident”. The home had two lounges with a television in each. Several of the service users had a television in their room. Another service user objected to service users smoking in the home particularly, they alleged, as some service users would light a cigarette in the dining room before going to the dedicated smoking lounge. This issue was discussed with manager who subsequent to the inspection visit had taken action to resolve it. A policy on smoking was available and a dedicated lounge was available to those service users who smoked. All except one of the service users expressed satisfaction with the meals provided. One service user stated, “The food is great here – it’s as good as my mum did and that’s saying something”. There was evidence that the meals were regularly discussed at the service users’ meetings and that the menus endeavoured to take into account their preferences. A member of staff provided written evidence of this. The service user who expressed dissatisfaction with the meals wanted to be on a Vegan diet and not a Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 13 vegetarian diet as at present. This was discussed with the manager and it was suggested that a review of this service user’s dietary needs be held with, if necessary, input from a dietician. Confirmation was received subsequent to the inspection from the service user concerned that a review had been arranged that would also involve their Social Service’s Care Coordinator. Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service”. The staff meet the service users’ health and social care needs with good support from external social and health care professionals. EVIDENCE: With the exception of one service user the service users all expressed satisfaction with the support provided by the staff. They also provided examples of support provided by external health and social care professionals. These included a service user who had a routine hospital appointment that day and another who discussed his general health with the manager and agreed to a visit to his General Practitioner. All of the service users were registered with a local medical practice. Obtaining dental treatment for the service users was, according to the manager, difficult in so far as no local dentists were registering NHS patients. Use had therefore to be made of the emergency dental service. One service user had possible alcohol problems and was receiving support from the local Substance Abuse Team. The care records confirmed that the service users’ health needs were monitored and that appropriate action had been taken when necessary. One service user felt that the staff were reluctant to make ‘physical contact’ with the service users, such Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 15 as giving them a cuddle, as it could be seen as being inappropriate and unprofessional. This issue was discussed at length with the service user concerned and the manager. The service users confirmed that there were no specific times for going to bed or getting up in the morning although they were expected and encouraged to attend appointments. One service user said that they would often watch the late night film. Some were still in the process of getting up at the start of the inspection visit. The service users were dressed in clean and appropriate clothing. Several of the service users confirmed that they bought their own clothes. Where they shopped, and how often, depended upon their financial circumstances although, according to the manager, the service users were often subsidised by the Registered Provider. One service user stated, “ I am quite happy here although £22 a week doesn’t go far. A shirt can cost more that that. I try to save my money up and then spend it on what I want. Luckily I don’t smoke”. Assurance was provided by the manager that the service users could have a bath whenever they wished and were in fact encouraged to do so. This was evidenced on the day of the inspection when a service user informed the manager that they were having a bath just before lunchtime. One health care professional stated in the comment card that ‘there is not always a private room available to see clients’. This could well be correct as the manager’s office is very small and not suitable for meetings and several of the service users share bedrooms thereby limiting any guarantee of privacy. The administrative side of the inspection visit was by necessity conducted in the dining room, which provided adequate space. The home continued to use a monitored dosage system for the administration of the service users’ medication. The medication was appropriately secured and the administration records were complete and up to date. No controlled drugs were in use. The staff who were responsible for administering medication had received appropriate training on the safe handling of medication. It was the normal practice for medication to be administered from the dining room. The service users were expected to attend at designated times to receive their medication. The rationale given for this approach was that it encouraged self-discipline in the service users and made them partially responsible for ensuring that they had their medication. One service user partially self-administered their medication on a daily basis. Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): “Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service”. The internal and external support provided for the service users should ensure that any concern would be quickly identified and acted upon. EVIDENCE: The home had an appropriate complaints procedure. The majority of the service users indicated in the Survey Card that they felt confident that they could make a complaint if necessary albeit with the assistance of staff in some cases. The minutes of the service users’ meetings indicated that concerns and issues were discussed openly. The service users confirmed this. One service user, however, felt his complaints and suggestions were, on occasions, overridden or dismissed by the home’s management. Such suggestions included re-pointing the external walls, purchasing a barometer as the weather conditions could affect a service user’s moods and the banning of smoking in the home. The manager denied minimising these suggestions and said that they had not been addressed due to cost or because they were impractical. The issue of service users smoking outside of the designated areas has been addressed subsequent to the inspection. The staff had been provided with training on Adult Protection including the types and indications of abuse. A procedure for reporting alleged abuse was available. The majority of the service users had the ability to report such incidents either to the staff or to external agencies. Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service”. Whilst the environment is appropriate for the needs of the service users, the relatively poor standard of décor undermines the quality of the service. EVIDENCE: An inspection was undertaken of the premises including the service users’ private rooms. At the time of the inspection an underused lounge was in the process of being converted into an additional single bedroom. The majority of the bedrooms were for shared occupancy, which, it is suggested, limited the privacy and independence of the service users using these rooms. The bedrooms had been personalised by the service users and several had drinkmaking facilities. These had been risk assessed. The locks on the bedroom doors were of an inappropriate design and were generally not used. The home did not have a passenger lift. Some of the bedrooms required redecorating. In one, for example, bits of the wallpaper had been torn off and there were unsightly cracks in the ceiling. The communal space consisted of two lounges; one designated a smoking lounge, and a dining room. These were located on the ground floor. Whilst these areas were adequate for the service users, they Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 18 looked ‘tired’ and in need of refurbishment and redecorating. The kitchen was clean and hygienic. The kitchen door was generally kept locked for reasons of safety and hygiene when a member of staff was not present. The service users had unrestricted access to all parts of the property including the external areas. There was a large area at the rear of the property with seating for the service users. The service users also used a patio and garden area at the front of the property. Two floodlights were located in the front garden. The glass cover in one was broken. A service user raised concerns regarding the standard of the pointing in the external walls. This was discussed with the manager. Overall the home was clean and totally free from any unpleasant odours. One health care professional stated that it was sometimes difficult to have privacy when visiting a client. Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service”. The service users are provided with good support from the staff in order that they live a reasonably independent lifestyle. The level of the day staffing could, it is suggested, limit the amount of support and guidance provided by the staff. EVIDENCE: According to the registered manager the level of staffing had been based on the current needs of the service users. At the time of the inspection visit thirteen service users were being accommodated in the home. The service users had few physical care needs but primarily required social and emotional support. On the day of the inspection visit three staff were on duty. These consisted of the manager, an experienced support worker and a domestic. The manager was of the opinion that this level was adequate. The service users felt that they had reasonable access to the staff. A discussion was held with the support worker. She demonstrated a good understanding of the service users’ needs and held the view that it was important to enable the service users to act and think independently. She provided examples of choices and decisions made by service users. She Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 20 provided confirmation that support staff had good access to the service users’ records, policies and procedures and that key workers had direct involvement in the service users’ care planning and reviews. She stated that key workers were expected to spend ‘quality time’ with their respective service users in order to identify and resolve any problems they may have. She said, “ We treat them (service users) like people – with respect”. It was observed during the inspection visit that the staff spoke to the service users in an adult and respectful manner. They also ensured that they had time for the service users and saw their needs as being more important than the inspection. It was also observed that a formal ‘handover’ took place between staff at the change of shifts. The staff, and the staff records, provided confirmation that they had been provided with training, in statutory and professional subjects. The manager had been endeavouring to obtain staff training specifically on mental health but with little success. Less that 50 of the staff had achieved a National Vocational Qualification (N.V.Q) although some staff had other relevant qualifications and competences. The manager stated that she had experienced difficulty in registering them on a local N.V.Q. programme. In general feedback from health and social care professionals expressed satisfaction with the quality of the staff but there was in one case some concern regarding the staffing level as it was felt that it limited the service users ability to access external activities. The home had an appropriate staff recruitment and selection procedure that included a reasonable vetting process. The registered provider had experienced considerable difficulty in obtaining a CRB check for two existing staff as their application had been returned several times by the CRB who had questioned the payment method. The registered provider had formally complained to the CRB and had provided the Commission for Social Care Inspection with a copy of the complaint. Confirmation was provided that the staff received regular supervision from the manager. Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): “Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service”. The service users and staff are provided with good support from a knowledgeable and qualified manager. The lack of a formal quality assurance monitoring system, however, limits the manager’s ability to identify strengths and weaknesses in the service. EVIDENCE: The registered manager had successfully completed the Registered Manager’s Award and a National Vocational Qualification at level 4 in care. The manager had considerable experience in working with the service users and demonstrated a sound understanding of the needs and of the elements of care, such as independence and choice that go to provide them with a good quality of life. It was evident that the service users had established a good relationship with the manager and openly discussed problems with her. It was also evident that she endeavoured to get them to make decisions and assisted Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 22 them in understanding the consequences of a decision. The manager had continued to review the home’s policies, procedures and records and provided examples as to where they had been changed. She did not have access to a computer and was therefore unable to access the Commission for Social Care Inspection’s (C.S.C.I.) website or use the POVA first procedure. The manager saw Victoria Court more as a supported living environment where the service users were able to do as they pleased. She felt that an overly structured environment would be detrimental to the service users. Whilst she had endeavoured to get the service users involved in a range of social activities, she had only achieved limited success. She consequently endeavoured to promote and encourage the service users to follow their personal interests. The manager had introduced several elements of Quality Assurance such as reviewing policies, procedures and records and providing questionnaires for service users and their families. There was not, however, a formal Quality Assurance monitoring system that enabled the manager and registered provider to audit the ‘whole’ service provided, assess whether the stated aims of the home had been achieved and identify any weaknesses in the system. A number of statutory records were examined including three of the service users’ care records, the fire record, accident record and the servicing certificates of the electrical and gas systems. It was noted that several accidents/incidents had taken place where service users had required medical assistance or had sustained an injury but a report had not been provided for the C.S.C.I. From an examination of the records, an inspection of the premises and discussions with staff, it was apparent that the manager had taken reasonable steps to ensure a safe environment for the service users and the staff. The service users had been assessed by the manager as being capable of safely using hot water without it being restricted in temperature. A letter signed by eight of the service users stating this was received by the C.S.C.I. prior to the inspection visit. Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 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 1 25 X 26 2 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 1 X 3 1 3 Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 24 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 YA24 Regulation 6 Requirement The following environmental issues must be addressed: • A programme of redecoration must be developed with timescales as appropriate. The broken floodlight at the front of the property must be repaired or removed. Timescale for action 31/08/06 • 2. YA39 8 A formal Quality Assurance monitoring system must be developed based on a systematic cycle of planning-action-review, thereby reflecting the aims and outcomes for the service users. 31/10/06 Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 25 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. Refer to Standard YA17 YA26 YA32 YA33 Good Practice Recommendations The dietary needs of the identified service user should be formally reviewed and action taken to address their assessed dietary needs if possible. Consideration should continue to be given to providing the service users with single bedrooms to further promote their independence. The staff should be encouraged to undertake an appropriate National Vocational Qualification at level 2 or above. The day staffing level should be kept under review, as an integral part of the Quality Assurance process, to ensure that it remains appropriate to meet all of the service users’ assessed needs in particular their social needs To consider providing the registered manager with access to the Internet and email so that they may undertake ‘POVA First’ checks on-line and have direct access to information provided by the Commission for Social Care Inspection. .5. YA37 Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Victoria Court DS0000019766.V303488.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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