Inspection on 16/08/05 for Victoria House

This inspection was carried out on 16th August 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 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Victoria House 19/07/07

Victoria House 24/05/06

Victoria House 12/01/06

Victoria House 31/01/05

Victoria House 29/09/04

Victoria House 13/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Victoria House 1 Victoria Terrace Plymouth Devon PL4 6BL Lead Inspector Tina Maddison Announced 16 August 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Victoria House Address 1 Victoria Terrace, Plymouth, Devon, PL4 6BL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01752 661171 01752 661171 john@the regardpartnership.com The Regard Partnership Limited Vacant Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27/1/05 Brief Description of the Service: Since the last inspection Victoria House and Grenville House have combined, become one registration, with one Manager. An application to increase the number of service users living in Grenville House from three to four has recently been approved. Both Grenville and Victoria Houses are small care homes situated within walking distance of local shops and amenities and the City Centre of Plymouth. Victoria House is able to accommodate up to six service users and Grenville up to four service users. Both houses are not suitable for anyone who has mobility difficulties. The homes are owned by the Regard Partnership Limited. Both houses are registered for people aged between 18-65 years who have a moderate learning disability and may have behaviour that challenges services. Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 16th August and commenced at 0945. A tour of both Victoria and Grenville house took place, and discussions were held with the Manager, staff and four service users. Records and documents for a variety of topics were inspected. What the service does well: What has improved since the last inspection? The Manager and staff team have undertaken and completed a great deal of improvements since the last inspection. The lounge in Victoria House has been completely refurbished to a high standard. The statement of purpose has been updated and the Registered Provider is now providing monthly monitoring visit reports. Window restrictors have been fitted to all upstairs windows. Building work at Grenville House is generally now complete and an increase in service users by one has been approved with the building of a fourth bedroom. Carpets have been ordered. A large piece of work has been undertaken by staff to update and improved individual care plans. Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 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 House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5. Prospective service users are able visit the home. Pre admission assessments ensure that Victoria House will be able to meet service users care needs. Service users guides are not yet available to prospective residents. EVIDENCE: The statement of purpose has been updated, but a service users guide is still not yet available. The home has an admissions procedure and a pre admission assessment process that was available on a prospective service users file, and was holistic and comprehensive. The organisation carries out an assessment of any prospective service user, and they are offered a trial visit and trial stay at the home if they wish. All residents have a contract in place. Statements of terms and conditions are not yet available to residents who are funded by a local authority. Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9. Service users can be assured that staff will enable them to be as independent as possible and be encouraged to safely participate in all aspects of life in the home. Risk assessments are not available for all activities outside of the home. EVIDENCE: For each service user there was a service user plan in place covering identified areas of need, and these plans have recently been updated and reviewed. The process of development of the care plans and risk assessment should continue to be developed until complete, in order to give comprehensively detailed risk assessments and detailed directions for staff. The Regard Partnership service policies define the frequency of reviews for individual plans. The frequency of review as given in this standard is met. Routines of daily living, community participation and social/leisure activities were all present in these plans. In all these areas substantial detail should be added. All agreed restrictions of choice or facilities should be thoroughly documented within service user plans and risk assessments. Service users commented that they shop, prepare meals and clean their rooms. Service users meetings are held monthly, or service users can comment via their key worker meetings that are held regularly. The home has a comprehensive missing persons policy that was seen to have been followed recently. Overall, levels of participation in the home depends on the Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 10 level of abilities, but service users are encouraged to participate in all aspects of life in the home. Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,17 Service users enjoy a range of activities. Personal development is encouraged enabling service users to develop their independent living skills. Meals are nutritious and varied. EVIDENCE: Programmes of personal development are continuing, and have been documented. Service users are involved in skill development programmes covering domestic activity and education. It was evidenced from discussion with service users and care plans, that staff do support service users to participate in activities in the community. Service users are encouraged to use various forms of public transport such as buses and taxis. They also access ordinary community facilities such as further education colleges and shops. Service users confirmed that they enjoyed a holiday earlier in the year, and some service users have enjoyed visits to their families with the assistance of staff. The atmosphere in the houses was relaxed and service users spoke freely about their lives. Service users commented that they enjoyed the meals, and helped to plan the menus, shop, prepare and cook the food. All service users have made a list of their likes and dislikes. A food record is maintained in the daily planner. There is a four week menu planner to use as a guide. Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 12 Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20. Service users can be assured that staff will treat them with respect, and their personal care needs will be given in the way they prefer, and their health care needs will be met. EVIDENCE: Some service users have behaviour that may challenge services, and although empowerment is difficult, it is being promoted, along with a valued lifestyle within necessary behaviour boundaries. Most service users need only verbal prompts to maintain personal care tasks. Health needs are met, and service users are registered with local GP practices, and access dentists, opticians and health services in the area. There is an existing medication policy in place. A monitored dosage system is in place. All members of staff who administer medication have received accredited training. Appropriate controlled drug storage is in place. Medication administration recording was accurate and well kept. Further training in dementia care is being sought in order to meet one service users needs. Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 Service users can be confident that their concerns will be listened to, taken seriously and acted upon. EVIDENCE: There is a organisational complaints policy. Neither home has not received any complaints since the last inspection. The home has company policies regarding the protection of vulnerable adults, whistleblowing and staff have attended abuse awareness training. If the service users are able to, they handle their own finances, and one service users family handles finances. Financial records were found to be accurate and were up to date. Service users spoken to confirmed that they knew who to speak to in the event of a complaint, and felt that their complaint would be listened to and acted upon. The home has a no restraint policy, and staff appeared clear about how any aggression towards staff would be handled. Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,30. A considerable amount of internal alterations and refurbishment since the last inspection have ensured a comfortable and safe environment for service users. EVIDENCE: A great deal of refurbishment and interior building alteration work has been completed since the last inspection on each house. At Victoria House, the lounge has been redecorated to a high standard, and at Grenville, a fourth bedroom and additional bathroom have been built. At the time of the inspection the carpets had not been laid, but the Manager confirmed that they are ordered. One of the service users said they did not mind the disruption that the building work has caused. The conservatory roof at Grenville has not yet been replaced, but this work is planned. The banister railing at the head of the stairs has not been blocked by a large piece of furniture as identified at the last inspection and by the environmental health officer. The Manager has agreed to risk assess this. Toilet and bathroom locks have now been replaced by locks that can be overridden from the outside. All windows have now been Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 16 fitted with window restrictors. In both houses, bedroom doors are lockable, and service users have been offered keys. All bedrooms were personalised, and service users said that they really liked their rooms. A sink has yet to be installed in one bedroom in Grenville House. Both houses provide adequate numbers of toilets and bathrooms. Both homes have a no smoking policy, and any service user who wishes to smoke does so outside. The office in both houses is used as a staff sleeping in room as well as administration. The laundry has been moved in Victoria House into an internal room. It has been recommended that the washer and dryer be vertically stacked to promote the use of the laundry by the service users. All bathrooms were equipped with soap and towels and both homes, despite the building work in Grenville were very clean on the day of the inspection. Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34,35,36. The home has a robust recruitment procedure and this offers protection to service users. There is a staff team in both houses who are committed, caring and appropriately skilled to provide care to service users. EVIDENCE: All staff have a job description and are aware of their roles and responsibilities. The staff team are trained in a number of key areas, such as first aid, challenging behaviour, medication and Learning disability award framework. NVQ training is available. Staff records contained all required documentation including 2 references and CRB checks. Rotas evidenced adequate numbers of staff on duty at all times in both houses. There is a company policy not to use agency staff to cover unfilled shifts, and in the event of staff not being able to cover then there is an expectation that the Manager will cover. The Manager has a duty responsibility out of hours for the home. The home has regular staff meetings. A team training plan and development plan should be produced. The staff have been appropriately trained to work with service users whose behaviour challenges services. This training is given to all staff and is renewed annually. Supervision records were seen, and evidenced that supervision occurs on a regular basis. Service users all commented that they liked the staff and found them “patient, kind and easy to get on with.” Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,40,42. There is a clear management structure operating in the home. Health and safety issues are generally well managed. EVIDENCE: The position of registered manager is formally vacant at present. The Manager, Mr Keith Morgan will be applying for registration in the near future for both Victoria House, and Grenville House, as they are now both registered under one registrtion as Victoria House. Mr Morgan has 12 years experience as support worker, senior support worker and deputy manager. He is currently pursuing the Registered Managers award. It was observed during the inspection that there was an open and direct style of management being used in the home. It was evident from communication between staff and service users that there is a good relationship between the staff and service users. CSCI is now receiving regulation 26 visit reports from the Provider. An annual development plan reflective of service users aims and outcomes should be developed. The management should introduce a quality assurance system. Health and safety is generally well managed in both houses, and health and Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 19 safety issues identified in the previous inspection have been addressed, such as the installation of window restrictors. An accident book is maintained. Radiators are covered, and hot water outlets have temperature regulators fitted. If they are not fitted then a risk assessment is in place. Evidence of appropriate insurance was seen. The electrical safety testing of portable electrical equipment is taking place. Checks were made of the fire protection records, and these were in order. Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 20 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 2 2 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 2 2 3 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 2 2 3 4 Standard No 31 32 33 34 35 36 Score 2 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Victoria House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 3 x D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5 Requirement Timescale for action 30/9/05 2. YA6 15 3. YA24 23 4. YA26 23 The service users guide must be updated to become compliant with standard 1.2 of the National Minimum Standards. The service users guide must be available in the home. Service users plans and risk 30/9/05 assessments must be detailed and comprehensively reflect all the service users identified needs and the directions given to staff to meet these needs. The roof of the conservatory 30/11/05 lounge extension must be effectively repaired to prevent continued water damage to the lounge area. A wash hand basin must be in 30/11/05 place in all bedrooms. 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 YA1 Good Practice Recommendations The service users guide should be made available in a format that is accessible to the service users. D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 22 Victoria House 2. 3. 4. YA5 YA39 YA31 A statement of terms and conditions from the Regard Partnership should be issued to all service users in the home. An annual development plan and service user focused quality assurance system should be developed and implemented. Adequate staff numbers should be employed or an alternative sought so that there is not a reliance on the Manager to cover vacant shifts in the absence of a staff member. Victoria House D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 D52-D04 S44465 Victoria House V232646 160805 Stage 4.doc Version 1.40 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!