Inspection on 17/07/08 for Victoria House

This inspection was carried out on 17th July 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Victoria House 24/07/07

Victoria House 22/08/06

Victoria House 02/02/06

Victoria House 26/04/05

Victoria House 03/08/04

Victoria House 13/04/04

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Larchfield Manor

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The Grove Waltham

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Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Victoria House Low Grange Crescent Belle Isle Leeds West Yorkshire LS10 3EG Lead Inspector Mary Bentley Key Unannounced Inspection 17th July 2008 09:30 X10015.doc Version 1.40 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 DS0000001519.V368645.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 Older People. 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 DS0000001519.V368645.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria House Address Low Grange Crescent Belle Isle Leeds West Yorkshire LS10 3EG 0113 270 8529 0113 2765090 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) Mrs Mary Margaret Lavelle Mrs Mary Margaret Lavelle Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th July 2007 Brief Description of the Service: Victoria House provides personal care to 36 older people. Nursing care is not provided. It is set in its own grounds, situated centrally in Belle Isle, a suburb of Leeds. There are three floors. The main living accommodation is on the ground and first floors and consists of a large reception area, three lounges, three dining areas, and a small library/visiting room. An activity/games room is planned for the lower ground floor. There is a passenger lift between the ground and first floor, with plans being considered to extend this to the lower ground floor. There are 33 bedrooms, 30 single and 3 double rooms, all of which have ensuite facilities. Local amenities, such as shops and a post office are nearby. The home is on a bus route with buses running regularly into the centre of Leeds. Outdoor seating is provided at the front of the home. In July 2008 the weekly fees ranged from £409.99 to £422.20. Additional service such as hairdressing and chiropody are not included in the fees. Copies of previous inspection reports are available in the reception area of the home. Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The inspection process included looking at the information we have received about the home since the last key inspection in July 2007. We did this unannounced visit in one day. One inspector visited the home, and was there between the hours of 9.30am and 5.30pm. During the visit we spoke to people living in the home, visitors, staff and management. We looked at various records including care records and looked at parts of the building. No surveys were sent to the home on this occasion. However the home leaves some of our survey cards in reception for people to complete if they choose to. Two were returned before our visit, they showed people are happy with the service. We gave survey cards to 3 relatives we met in the home, one had been returned at the time of writing. The home completed an annual quality assurance assessment (AQAA) and sent it to us when we asked for it. We got good information from the home’s self assessment, it was very detailed with clear evidence of how the service has improved since the last key inspection. What the service does well: One relative said, “I think they are doing a good job, I haven’t anything to complain about, I think this care home is well run”. People said the staff are “kind”, “caring” and “helpful”. The home has good pre-admission procedures that take account of the needs of people already living in the home as well as the needs of the prospective clients. For example, people were consulted when someone wanted to bring their cat. The home provides a good range of social activities and people living there are consulted about what they want to do. People are supported in exercising choice and control over their lives. For example, two of the people who live in the home are on the interview panel for new staff. Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 6 People told us the food is good and there is plenty of it, they have a choice of meals and are able to contribute to planning the menu. The home provides a comfortable and safe place for people to live, it is clean and well maintained and people said there are never any unpleasant odours. There is a good programme of staff training, which means that staff have the knowledge, and skills they need to meet people’s needs. 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. The summary of this inspection report can be made available in other formats on request. Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 5 Standard 6 does not apply. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are given information about the service and their needs are assessed before they move in. EVIDENCE: The home told us people are encouraged to look around and whenever possible they prefer people to stay for a few days before making a decision about moving in permanently. This gives both parties the opportunity to decide if the home is suitable to meet the person’s needs. Two relatives told us they had visited the home when looking for a place for family members and both said the home had lived up to their expectations. Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 9 One person who has recently moved in has been able to bring her cat with her. Other people living in the home were consulted about this before it was agreed. The records showed that people’s needs are assessed before they are offered a permanent place and that people are given information about the terms and conditions at the time of admission. Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s needs are met in a way that takes account of their individual preferences, and abilities and respects their privacy and dignity. EVIDENCE: Everyone living in the home has a care plan. Since the last inspection the home has introduced a new format for care planning and when we visited approximately two thirds of the care plans had been transferred to this new format. The new care plans are well set out and information is easy to find. The care plans address all areas of people’s needs including personal, health, and social care. Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 11 Nutritional assessments are completed and people’s weights are recorded every month. If there are any concerns about nutrition appropriate action is taken, for example we saw that some people have been prescribed dietary supplements. Discussions with the cook confirmed that she knows when people are at risk nutritionally and knows how to add extra nutrition to food, for example by adding cream and/or cheese to mashed potatoes. We saw that people living in the home or their relatives are consulted about how care needs will be met. For example, one persons care plan stated that they preferred to be helped by a male carer when receiving personal care. The records also showed that people have access to a range of NHS services such as district nurses, GPs, and opticians. Visitors told us they are kept informed about anything that affects the well being of their relatives. People are consulted about how they wish to be cared for in the final stages of life and this is recorded. We saw that staff were kind and respectful in their interactions with people. Information provided by the home shows that the management team place great emphasis on making sure that care is provided in a way that promotes peoples right to privacy and dignity. Since the last inspection the home has made improvements to the way medicines are managed. There are detailed procedures for staff to follow to reduce the risk of error. We saw staff giving out medicines in the morning and the correct procedures were followed. Staff have to do extra training before they are allowed to help people with their medicines. Overall, the medicine records were satisfactory. An air conditioning unit has been fitted to the medicine storage room to make sure medicines are stored at the correct temperature. Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are supported in exercising choice and control over their daily lives and are able to take part in a varied range of social activities, which reflect their preferences and abilities. EVIDENCE: People said daily routines are flexible, for example people go to bed and get up when they choose. People can choose whether to spend their time in one of the lounges or in their bedrooms, one person said she always has her meals in her room because she prefers it that way. Two people living in the home are involved in staff recruitment. They are on the interview panel when prospective staff are being interviewed and ask questions related to care. All the staff have had training in culture and diversity and this has helped them to have a better understanding of people’s individual needs. The home told us Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 13 they are making some changes to their assessments to help promote equality and diversity. For example, in the section that asks about marital status they will add a question about significant partnerships or relationships to enable people to be more open about their sexual orientation. There is a regular programme of activities. On the day we visited there was an entertainer in the morning and most people went to the “blue” lounge to join in. Initially some people were reluctant to take part. We saw that staff were good at persuading people to join in while respecting people’s wishes when it was clear they really did not want to take part. The home told us they consult with the people who live there about the activities. We saw evidence of this in the notes of meetings held with people in the home. Changes are made to the activities programme in response to feedback from people. For example, when people said they would like something to do which they could get involved in the home engaged the services of an outside company that does this by using quizzes and games to get people moving. In another example some of the men in the home said they would like to see a John Wayne film instead of the usual musicals and this was arranged. The home has an open visiting policy and people told us they are always made welcome. People living in the home said the food is good and there is plenty of it. At lunchtime we saw that people were offered a choice of 2 main courses as the meal was being served. Staff said they used to ask people the day before what they would like for lunch but this got very confusing, as people had forgotten what they ordered. They said it is much better for people having a choice when they are having their meal. The meal was nicely presented and staff were available to help people if necessary. People’s views about the food are discussed at meetings in the home, at a recent meeting one person said, “you certainly can’t complain about the food here”. The cook also sees people individually to discuss their food preferences. While in the home we saw the cook talking to two new people about what they liked to eat. Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Complaints and concerns are dealt with appropriately and people living in the home are protected from abuse. EVIDENCE: Information about the complaints procedure is made available to people in the home. Since our last visit the home has improved the way it records complaints. The records show that any concerns are dealt with appropriately. The home told us they encourage people to tell them if they have any concerns. People told us the found the management and staff approachable and helpful. The home has procedures in place to make sure people are protected from abuse. The staff we spoke to had a good understanding of people’s rights and know what to do if they have any concerns about people’s welfare. It is some time since staff have had formal training on the protection of vulnerable people and the manager agreed to arrange this. There have been two referrals to the local adult protection team since the last inspection. One was made by the home and the other was an anonymous referral. Both have been dealt with. Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 25 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home provides a pleasant, comfortable, and safe place for people to live. EVIDENCE: When we visited the home was clean, people told us it is always clean and never has unpleasant odours. The home has a close circuit television system, which monitors the outside areas for security purposes. The standard of décor is good and the home is suitably furnished to meet the needs of the people living there. There are 3 lounges on the ground floor and the larger of these is used for group activities such as visiting entertainers. Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 16 The bedrooms are suitably furnished and we saw that people are able to have some of their personal belongings, such as photographs and ornaments, in their rooms. There is an ongoing programme of refurbishment; one of the bathrooms was being upgraded when we visited. Regular maintenance checks are done to make sure that the home continues to provide a safe place for people to live. Hot water temperatures are controlled by thermostatic valves to make sure they are maintained at a safe level in areas used by people living in the home. We recommended that bath thermometers be used to check bath water temperatures before people get into the bath to further reduce the risk of scalding. There are good systems in place to reduce the risk of cross infection and a clinical waste bin has been provided in the laundry. Most of the staff have done training on the control of infection. The home has been given a 3 star rating (the best is 5) by environmental health for its standards of food safety and food hygiene. The home is working to improve this rating. Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are cared for and supported by a staff team that is well trained and competent. However, there are some shortfalls in the recruitment procedures, which mean that people could be put a risk. EVIDENCE: There are usually 6 care assistants during the day, until 4.00pm. Between then and 9.00pm there are 4 care staff and overnight there are 3. People described the staff as “kind”, “caring”, “helpful”, and no one raised any concerns about the availability of staff. Staff said they do a lot of training. All new staff have a detailed induction and are allocated to work with a senior carer until they are considered competent. Following induction staff are encouraged to train for a National Vocational Qualification (NVQ). Of the 21 care staff employed 10 have an NVQ level 2 in care. Nine other staff are working towards achieving this qualification. Two of the senior carers are doing NVQ level 4 in care. Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 18 The Statement of Purpose has detailed information about the training done by each member of staff. This helps to assure people that they or their relatives will be cared for by suitably trained staff. Training is provided on a variety of subjects including fire safety, moving and handling, food hygiene, infection control, and dementia care. Records of staff training were available. We looked at the files of 3 new staff and in all of them we saw that staff had started work before the PoVA (Protection of Vulnerable Adults) checks had been completed. Other checks such as references had been completed before the start date and they were working under supervision. However, the law relating to PoVA and CRB (Criminal Records Bureau) checks for new care staff is clear. In order to protect people a PoVA First must be obtained before new staff start work in the home. They may then work under supervision until a full CRB disclosure is obtained. This was discussed with the management team. Other records relating to staff employed in the home, such as details of their contacted hours, were available. Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People have confidence in the care home because it is led and managed appropriately. The environment is safe for people and staff because appropriate health and safety practices are carried out. EVIDENCE: The home is a family run business; Mrs Lavelle is the registered owner and manager. Other members of the family are involved in the administration and maintenance of the business. The management structure is clearly defined and staff are clear about their roles and responsibilities. The home is planning to improve this by developing the roles of the deputy manager and senior care assistants. There are staff meetings, staff are also given a monthly newsletter Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 20 to keep them up to date with changes, and other information such as planned training events. The management approach is open and encourages people to share their views of the service. There is a lot of informal consultation with people living in the home and their relatives and there are formal meetings twice a year. The home has devised questionnaires but has not yet sent them to people. They agreed this would be done in the next couple to months. The questionnaires will help the home in developing a more structured approach to quality assurance. The home does not collect pensions and does not get involved with managing money on behalf of the people living there. The home does keep some small amounts spending money for people. There are records of all transactions and receipts are available for any money spent on people’s behalf. The money is stored safely. We looked at a selection of maintenance records and they showed that equipment and installations are serviced and maintained at the required intervals. We looked at the accident records. In order to comply with Data Protection laws accident records should be stored in each individuals file rather than in a book. We recommended that the home should audit the accidents so that they can identify any common or recurring problems; this will help them to put systems in place to reduce the risks to people. Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X 4 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 19 Requirement New staff must not start work until a PoVA (Protection of Vulnerable Adults) First has been completed and that member of staff must then work under supervision pending receipt of a full CRB (Criminal Records Bureau) check. This is to protect people lining in the home from possible abuse by people that are not suitable to work with vulnerable adults. Timescale for action 19/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Victoria House DS0000001519.V368645.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000001519.V368645.R01.S.doc Version 5.2 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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