Inspection on 14/11/05 for Victoria House

This inspection was carried out on 14th November 2005.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Victoria House 08/11/06

Victoria House 04/05/05

Victoria House 12/10/04

Victoria House 12/05/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Victoria House 63 Victoria Road Chester Cheshire CH2 2AX Lead Inspector Mr Val Flannery Unannounced Inspection 15:00 14 and 17th November 2005 th Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 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 House DS0000006548.V264513.R01.S.doc Version 5.0 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 House DS0000006548.V264513.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Victoria House Address 63 Victoria Road Chester Cheshire CH2 2AX 01244 382897 01244 381773 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) www.macintyre-care.org MacIntyre Care Mr William Parker Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. This home is registered for a maximum of 8 service users in the category LD (Learning disability) The registered provider must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection Staffing must be provided to meet the dependency needs of the service users at all times and must comply with any quidance which may be issued through the Commission for Social Care Inspection 4th May 2005 3. Date of last inspection Brief Description of the Service: Victoria House is a large two-storey detached building with a passenger lift to the first floor. The home can care for six adults with a learning disability. Located in Chester the home is within walking distance of the city centre and other local amenities. All the service users are physically able and can move about the home without mobility aids. The bedrooms are single, five of them are on the second floor of the main building. An adjacent building has been adapted to provide a self-contained flat for one service user. Two of the bedrooms have en-suite toilet and bathing facilities. The home provides a communal bathroom and toilet on the ground floor and two toilets, a bathroom and shower on the second floor. Staff are on duty twenty-four hours a day to deliver care to service users. Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over five and half-hours on the 14th and 17th November 2005. Feedback following the inspection was given to the registered manager on the 17th November 2005. One hour was spent reading the previous inspection report and reviewing the service history for the home. During the visit six service users, three staff (including the registered manager) and one parent were spoken with. Two service user records were seen as were a number of the homes records. A partial tour of the building was carried out. What the service does well: MacIntyre have provided a statement of purpose and service user guide that shows the service, and facilities, offered by the home. The manager reviews these annually. A comprehensive induction to the home is offered to prospective service users before they make a decision about moving in. Individual assessment of need is provided on service users as part of the preadmission process. Service users and the relative spoken with said they are able to make decisions about their daily lives. They said staff help and support them to ensure their well-being and safety. Two service users were able to go through their individual plans of care and were also able to access their personal care files. Service users said they use local community facilities, with varying levels of staff support. Person Centred Plans seen during the visit showed that service users maintain close contact with their families and friends. The relative spoken with said she is kept informed of any events affecting her daughter. She also said she is able to visit the home and see her daughter on a regular basis. The location and appearance of the home is in keeping with the local community. Service users are accommodated in single bedrooms, most have en-suite bathing/toilet facilities. Service users said staff ‘help them with any problems’, also that the manager and staff listen to them and respects their opinions. Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 Page 6 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 House DS0000006548.V264513.R01.S.doc Version 5.0 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 House DS0000006548.V264513.R01.S.doc Version 5.0 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): 1/2/3/4/5/ Information is available that informs service users and their representatives of the services offered by the home. EVIDENCE: A copy of the statement of purpose and service user guide to the home was available on the day of the inspection. These contained information about the service offered by the home and details of the organisation’s commitment to ensuring their needs are met. Records on the service user who has most recently come to live in the home showed that a planned introduction took place. This included an overnight stay and visits to meet the service user group and staff. A copy of the statement of the terms and conditions of residency, between individual service users and MacIntyre, should be included on their files (See Recommendation Number 1) Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 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): 6/7/8/9/10 Service users’ plans of care reflect their assessed needs. This ensures service users are able to make decisions about their lives and take responsible risks. Service users are fully involved in the decision making about the overall running of the home. EVIDENCE: Service users spoken with confirmed that their individual needs are discussed with them. They also said that staff sit down with them and discuss how their personal goals can be met. This can include attendance at college, day centre and work placements. Person centred plans and essential lifestyle plans showed that service users are consulted on issues that affect the overall running of the home. Included were meals, household chores, holidays and attendance at medical appointments. During the visit staff were observed talking with service users and responding to their requests for assistance with personal and social care tasks. Services users are encouraged and supported to take responsible risks, for example, using community facilities without staff supervision, helping with meals, managing their finances and crossing busy roads. Staff said that central to helping service users be independent is to encourage them to take such risks. During the inspection two service users were able to read their own care plans and discuss them with the inspector. Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 Page 10 MacIntyre have improved the lay out and information contained in the person centred plans. These include more detailed information on services users and how they wished to be cared for. The organisation has provided a policy on maintaining the confidentiality of information a copy of which is kept in the home. Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 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): 11/12/13/14/15/16/17 Service users are actively involved in community events and are enabled to use local shops and services. However, this involvement can be affected when there is only one support staff on duty. EVIDENCE: Service users said they attend college and are offered employment opportunities in the local community, for example, working in a garden centre, charity shop and other care homes within MacIntyre. During the inspection service users were seen returning from their various activities including swimming and shopping. One service user is involved in a personal relationship, care plans showed that advice and staff and other professionals offered guidance. A relative spoken with said she is kept informed of events/accidents that affect the service users. Also that she feels staff encourage her to be more involved in the care offered to the service user. Service users said they are involved in the preparation of their meals, they were seen preparing their evening meals with the help of staff. Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 Page 12 The home currently has three and half permanent support staff. They are heavily reliant on agency and relief staff. Written comments seen showed that service users, and staff, have made comments that daily living could be affected by the lack of staff to provide support to service user. Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 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 the following standard(s): 18/19/21 The physical and emotional health needs of service users are met by the home. Risk assessments are carried out to ensure the safety and well-being of service users. EVIDENCE: Risk assessments are carried out that ensure the safety and well-being of service users. For example, a service user was receiving support and assistance from staff to help cross roads safely. Service users said they are able to see doctors and other healthcare professionals if they are unwell. The person centred plans also showed that other professions are involved in the care of service users. MacIntyre have provided a policy on caring for service users who are ill, a copy of which is kept in the home. Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 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 the following standard(s): 22/23 Satisfactory arrangements are in place to respond to complaints and adult protection issues. The procedure enables service users, relatives and others to raise concerns with the manager and staff. EVIDENCE: Services users spoken with said they know how to raise concerns with the manager and staff. They also said that any complaints/issues raised are taken seriously and acted upon by the home. During the visit service users were observed sharing worries and concerns with staff. Since the last inspection CSCI have not received any complaints about the home. The complaints procedure includes details on how to contact CSCI. The complaints procedure has been provided in picture format, this helps service users if they wish to complain. MacIntyre Care has provided an adult protection procedure that includes the government guidelines ‘No Secrets’. Copies of these are kept in the home. Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 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 the following standard(s): 24/25/26/27/28/29/30 The home provides a safe and comfortable standard of accommodation for service users. Service users are accommodated in single bedrooms. The layout of the home allows service users to maximise their independence. EVIDENCE: The home provides service users with a homely and comfortable environment. Decoration and furnishings are of a high standard, maintenance issues are addressed promptly. Service users said they are satisfied with the appearance of the home – both inside and out. The bedrooms seen were individually decorated and furnished. Services users, including the most recent admission, said they had been involved in choosing the décor and furniture in the rooms. Service users were seen moving freely between their bedrooms and communal area. All the service users have keys to their bedrooms. This helps promote their independence. The home provides a comfortable lounge and separate lounge/dining room, these are located on the ground floor. Beside the two en-suite bathing and toilet facilities a bathroom and toilet is provided on the ground floor and a bathroom/shower/toilet on the first floor. The self-contained flat provides bathing and toilet facilities. Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 Page 16 Service users are able to use the well-maintained gardens to the front and rear of the home. The home was clean and free from unpleasant odours. Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 Page 17 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): 31/32/33/34/35/36/ Service users are receiving support and guidance from the staff. However, the number of permanent staff available to ensure continuity in the delivery of care is at a minimum level. EVIDENCE: The home currently has three full time support workers plus nineteen and a half hours support worker hours that are part of the manager’s contract of employment. The staff rotas showed that there are occasions when there is one person on duty, particularly during the evenings and at weekends. Agency and relief staff are employed to fill gaps in the rota and to provide ‘enhanced’ support hours to three of the service users. On the day of the inspection the member of staff on duty had to leave the home to collect service users from their daily activity. This left a student nurse, who was on placement, in the home with the service users. On other occasions when the member of staff has to collect service users the home is left without staff and with one or two service users in the home. A record was seen of comments made by service users and staff about the non-availability of staff to escort service users to various community events. On the day of the inspection the afternoon/evening shift was staffed by relief staff. Although these staff have worked in the home before and have an awareness of service users’ needs they are not part of the staffing compliment for the home (See Recommendation Number 2) Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 Page 18 Two of staff personnel files seen contained the required information. However, these files are normally kept at the local office for MacIntyre and brought to the home for inspection. Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 Page 19 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): 37/38/39/40/41/42/43 The manager works hard to ensure service users’ care needs, and how these are to be met, are central to the overall running of the home. Service users are listened to and are consulted on all aspects of life in the home. EVIDENCE: Service users and staff said the manager will listen to their concerns/worries and will take action to address these worries. They also said they are consulted about the day-to-day running of the home. During the inspection service users were seen talking to the manager about various issues surrounding their care. MacIntyre have provided a range of policies and procedures, copies of which are kept in the home. During the inspection the following health and safety records were seen and were satisfactory: • Accident/Incident • Fire safety Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 Page 20 • Portable Appliance Tests. A partial tour of the building showed that a safe environment is provided for service users. The manager has a contract of employment for thirty-nine hours per week. Nineteen and a half of these hours are allocated to allow him to complete his day-to-day management responsibilities. The remaining nineteen and a half hours are allocated for him to provide support and personal care to service users. However, as the staffing compliment in the home consists of three permanent full time staff achieving a balance between his joint roles can be difficult. (See Recommendation Number 3) The staffing information required to be kept in the home was not available on the day of the inspection (See Requirement Number 1). Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 Page 21 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 3 3 3 3 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 2 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Victoria House Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 2 3 3 2 3 3 DS0000006548.V264513.R01.S.doc Version 5.0 Page 22 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 YA41 Regulation 17(2) Schedule 4(6) Timescale for action Staffing records on each member 31/03/06 of staff must be kept in the home. Requirement 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 Refer to Standard YA5 YA33 YA38 Good Practice Recommendations A copy of the statement of terms and conditions of residency should be kept on individual service user’s files. The number of permanent staff should be increased in order to ensure service users’ benefit from the continuity and stability of a stable staff team. The manager’s role and responsibilities should be reviewed to ensure the continued effective day-to-day running of the home. Victoria House DS0000006548.V264513.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 House DS0000006548.V264513.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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