Inspection on 23/02/06 for Victoria Court

This inspection was carried out on 23rd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Victoria Court 14/05/08

Victoria Court 15/05/07

Victoria Court 13/07/06

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 M. A. Tomlinson Unannounced Inspection 24 February 2006 09:45 th Victoria Court DS0000019766.V284210.R01.S.doc Version 5.1 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.V284210.R01.S.doc Version 5.1 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.V284210.R01.S.doc Version 5.1 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.V284210.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 22nd July 2005 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 double fronted property located in a residential area of Bridlington and is conveniently located for all of the main community facilities including the public transport network. It is registered for nineteen adults, under the age of 65, who have a mental health problem. Three of the current service users who have been accommodated at the home for a considerable number of years are now over the age of 65. The majority of the service users are reasonably independent and require primarily support and guidance and minimal physical personal care. 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 bedrooms. 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’. Victoria Court DS0000019766.V284210.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of two statutory inspections undertaken during this inspectoral year. The inspection was unannounced. The inspection took a total of four and half hours including preparation time. The registered manager was available throughout the inspection. The inspection primarily focussed on the requirements and recommendations made during the previous inspection. This report should therefore be read in conjunction with the report of the inspection undertaken 22nd July 2005. Discussions were held with the staff on duty and the majority of the service users. Several statutory records were examined. Feedback was provided for the registered manager on the completion of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Victoria Court DS0000019766.V284210.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria Court DS0000019766.V284210.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: These standards were not assessed on this occasion. Victoria Court DS0000019766.V284210.R01.S.doc Version 5.1 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Whilst these standards were not fully assessed on this occasion, it was evident from the discussions held with the majority of the service users that they continued to lead reasonably independent lifestyles. It was apparent that they could come and go from the home without necessarily referring to the staff to obtain permission. They confirmed that they were provided with good support from the staff. It was evident from copies of the service users’ meetings that the views of the service users are obtained and, where possible, acted upon. The service users were aware of their care plans but the majority showed little enthusiasm to become involved in the development of their care plan. Victoria Court DS0000019766.V284210.R01.S.doc Version 5.1 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15, 16 and 17. The service users are encouraged to make maximum use of community facilities in order to integrate them within the community. EVIDENCE: The service users confirmed that where possible they had remained in contact with members of their families. Some of the service users had relatives who visited on a regular basis. Others had little or no contact with relatives. The service users confirmed that they had made friends within the community and in some cases met them socially. The registered manager had endeavoured to introduce planned activities such as trips out but the service users had met this with little enthusiasm. The home presents more as a ‘supported living environment’ rather than a ‘traditional’ care home setting with the service users preferring to ‘do their own thing’ in an unstructured way. The service users continued to make use of local facilities including the Resource Centre, various cafes and drop-in centres, pubs and even a betting office. Some of the service users presented as being somewhat apathetic. One service user said, “There is little to do” but when asked what he would like to do, did not have any idea. The service users appeared to get on reasonably well as a group and Victoria Court DS0000019766.V284210.R01.S.doc Version 5.1 Page 10 had a good knowledge of each other’s personal circumstances. The majority of the service users smoked cigarettes. Two service users had ‘agreed’ to have their cigarettes controlled by the staff so that they did not run out of cigarettes and money. A further agreement had been established with another service user who had been displaying behavioural problems. All of these ‘agreements’ were subject to review. It was observed that the service users were spoken to in mature and respectful manner by the staff. All of the service users commended the quality of the meals. Some compared the meals favourably with previous care homes in which they had lived. They confirmed that they were able, as a group, to decide on the menu. This was confirmed by the minutes of the service users’ meetings. The menus indicated that the meals were reasonably balanced between ‘healthy’ food and ‘convenience’ food that was preferred by some of the service users. Several of the service users confirmed that they would also eat out. One of the recent decisions taken by the service users was that all service users should be seated in the dining room before the meals were served. It was apparent that mealtimes were very important to the service users not only from a dietary point of view but also because they gave ‘meaning’ and a ‘timing point’ to the day. One of the elderly service users had recently been discharged from hospital and required assistance with their meals. The staff and a visiting District Nurse were also monitoring his dietary intake. Victoria Court DS0000019766.V284210.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: These standards were not assessed on this occasion. Victoria Court DS0000019766.V284210.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The service users are protected through the availability of a complaints system and good internal and external support. EVIDENCE: The registered manager provided evidence that the home had a complaints procedure and associated policy. The complaints procedure was available to the service users. The service users presented as being capable of making a complaint if they wished. They all had a Care Manager or Care Coordinator allocated by the local authority and felt that they could make complaints, if necessary, directly to these support staff. It was evident that an open relationship existed between the service users and the staff of the home. It was also apparent that the service users felt able to openly voice their views and opinions. This, again, was reflected in the minutes of the service users’ meetings. Since the previous inspection, the registered manager had introduced a ‘suggestion/comments’ box for the service users so that they might raise issues for discussion. Those staff records examined contained evidence that the staff had received Adult Protection training including the types and identification of abuse. The registered manager demonstrated a reasonable understanding of the Adult Protection procedures. It was concluded that the internal and external support network provided for the service users should ensure that alleged incidents of abuse would be quickly identified and acted upon. Victoria Court DS0000019766.V284210.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The service users are provided with accommodation that is appropriate for their needs and therefore allows them to live a reasonably comfortable lifestyle. EVIDENCE: Following the requirement made during the previous inspection, the furniture in the main lounge had been cleaned or replaced. This lounge was used by the service users who smoke cigarettes and on the day of the inspection was uncomfortably full of smoke. At the request of the registered manager a service user opened a window for ventilation and the smoke quickly dispersed. Other parts of the premises did not appear affected by the cigarette smoke. In general the premises were adequately decorated and presented as being an informal and reasonably homely environment. A planned programme of maintenance and redecoration was in place. The service users looked relaxed in their accommodation and expressed satisfaction with it. One service user was accommodated on a respite care basis whilst their Care Coordinator found alternative accommodation. They had been allocated a small single bedroom that was, according to the manager, solely used for short-term care. They appeared to have been accepted by, and integrated with, the permanent service users. The home continued to have a relatively high percentage of Victoria Court DS0000019766.V284210.R01.S.doc Version 5.1 Page 14 shared bedrooms. The service users in these rooms stated that they did not mind having to share. As far as could be ascertained from the home’s records, the premises met the requirements of the Fire Service and the Environmental Health Departments. A discussion was held with the home’s cleaner/domestic. She confirmed that the service users’ bedrooms were cleaned and dusted daily and ‘bottomed’ once a week. There was evidence of this in those bedrooms inspected. It was also evident that the domestic took considerable pride in the standard of cleanliness but acknowledged that it was sometimes difficult to maintain a high standard due to the level of wear and tear caused by the service users. She confirmed that a carpet shampooer was to be obtained. The domestic had good contact with the service users and stated that if she had any concerns regarding an individual, she would immediately inform the registered manager. The manager also confirmed this. Victoria Court DS0000019766.V284210.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 and 35 The staff recruitment and vetting procedure needs to be more robust to ensure that the service users are not placed at risk. EVIDENCE: There had been no regression in terms of the staffing level since the previous inspection. At the time of the inspection fourteen (14) service users were being accommodated. On the day of the inspection the registered manager, a support worker and a domestic were on duty. Following the recommendation made during the previous inspection, the support staff hours had been increased thereby enabling the manager to spend more time on their managerial remit. Three staff records were examined. Only one new staff member had been recruited since the previous inspection. They contained evidence of references and CRB/POVA (Criminal Record Bureaux/Protection of Vulnerable Adults) checks. The registered manager did, however, admit to having difficulties in obtaining CRB/POVA checks within a reasonable timescale in spite of a complaint made to the CRB by the Registered Provider. She was unable to obtain ‘POVA First’ checks, as she did not have access to email/computer facilities. The consequence of this was that the most recently employed member of staff had not been fully vetted but reliance had been placed on the use of ‘close supervision’ to overcome the problem until formal vetting had Victoria Court DS0000019766.V284210.R01.S.doc Version 5.1 Page 16 been completed. This shortfall in procedures, which was also identified during the previous inspection, was discussed with the registered manager. The manager was consequently advised to look at the need for changing the ‘Umbrella Scheme’ who currently undertook the vetting of staff at Victoria Court to one that was more efficient. Evidence was available to confirm that the staff had continued to receive formal supervision. Victoria Court DS0000019766.V284210.R01.S.doc Version 5.1 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 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): 38 and 42 The service users and staff are supported by a competent manager who understands the needs of the services users and endeavours to provide them with a reasonable quality of life. EVIDENCE: The registered manager had achieved a National Vocational Qualification at level 4 in care and was in the latter stages of achieving the Registered Manager’s Award. The registered manager demonstrated a sound understanding of the service users’ needs and particularly of those elements, such as choice and independence that go to provide them with a reasonable quality of life. It was evident that the manager employed an open and democratic managerial style and encouraged the involvement of the staff and the service users in the home’s decision making processes. Those areas of the premises inspected presented as being safe and appropriate for the use of the service users. As previously mentioned in the report, smoking was restricted to one designated lounge on the ground floor. Current Victoria Court DS0000019766.V284210.R01.S.doc Version 5.1 Page 18 safety certificates confirmed that the electrical and gas systems had been services by a qualified person. The fire and accident records were examined and proved to be complete and up to date. As identified in the previous inspection report, the temperature of the hot water was not controlled. The decision not to fit control valves had been taken by the Registered Provider based on a risk assessment of the service users. Victoria Court DS0000019766.V284210.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 1 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X 3 X X X 3 X Victoria Court DS0000019766.V284210.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 YA34 Regulation 19(1)(b) Requirement No person may commence employment in the home without being fully vetted including the completion of a CRB/POVA check. Timescale for action 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA34 Good Practice Recommendations To consider providing the registered manager with access to the Internet and email so that they may undertake ‘POVA First’ checks on-line. 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