Inspection on 19/07/07 for Victoria House

This inspection was carried out on 19th July 2007.

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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Victoria House 24/05/06

Victoria House 12/01/06

Victoria House 16/08/05

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 Jane Gurnell Unannounced Inspection 19th July 2007 09:20 Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria House Address 1 Victoria Terrace Plymouth Devon PL4 6BL 01752 661171 01752 661171 victoria_grenville@regard.co.uk 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) The Regard Partnership Limited Mr Keith James Morgan Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25/05/06 Brief Description of the Service: Victoria House is the name of two adjacent terraced houses in Victoria Terrace. Each house has its own communal facilities, kitchen and staffing rota. No.1 Victoria Terrace has accommodation and communal facilities for six people and No.2 Victoria Terrace for four people. Accommodation is provided in single rooms on both the ground and first floors. A small patio area is provided at the rear of No2 and provides a pleasant seating area. The home is situated within walking distance of local shops and amenities and the City Centre of Plymouth. Neither house is suitable for people who have significant mobility difficulties as both are accessed by a short flight of steps. The home is 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 behaviours that challenge services. There were nine people living at Victoria House at the time of this inspection. The weekly fees for this service are calculated on an individual basis depending upon the each person’s support needs. Information relating to the services provided by Victoria House can be obtained directly from the home. Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and undertaken on Thursday 19th July from 9:20am to 3pm. Mr Morgan, the Registered Manager, was present and he and his staff team assisted the inspector throughout the inspection. Significant time was spent with 7 of the 9 people who live at the home and observations were made of how people spend their day and their relationship with the care staff. The organisation’s Quality Assurance Manager was present at the time of the inspection and he was able to contribute to the process. The organisation’s Area Manager was also present briefly but did not take part in the inspection. A tour of both buildings was made and the records relating to the support needs of 3 of the 9 people living in the home were examined in detail, as were the personnel files for 2 staff members. Prior to the inspection the Registered Manager had completed an Annual Quality Assurance Assessment sent by the Commission and which allows the Registered Manager to describe what the service does well and what areas for improvement have been identified. What the service does well: What has improved since the last inspection? People are asked if they are happy and if they are getting the help they need to do the things they want to do. Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 6 The stairs and windows have been made safe. 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 Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 8 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 DS0000044465.V339557.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Visits to the home and pre-admission assessments ensure peoples’ needs are well known prior to deciding on the suitability of Victoria House. EVIDENCE: There had not been an admission to the home since before the previous inspection, however the Registered Manager described the process should there be a referral by someone considering the service: both he and the organisation’s Referral Manager would conduct an assessment and consult with the person themselves, their family or representative as well as others who know the person well such as social workers. The person would be invited to visit the home over a period of time to become familiar with the surroundings, the staff and the other people living in the home. A Service Users’ Guide is provided for people and their families considering Victoria House and tells them about the services provided at the home. The Registered Manager confirmed that he was the process of producing this guide in an easy to read format with photographs of the home and the surrounding area, making it more meaningful for people with a learning disability. Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Low staffing levels have had a detrimental effect upon peoples’ choices and opportunities. Support plans do not provide up to date information about peoples’ needs and how staff should meet these needs in a consistent manner. EVIDENCE: Many of the people living at Victoria House were, due to their level of disability, unable to comment directly about the quality of the support they received. The time spent observing the daily life in the home and staff practices found the staff were very patient and people were treated gently and with respect. Those people who were able to comment about how they found living in the home said they liked living there, were happy and the staff were nice. One person explained his usual routine and staff respected that he wanted to spend time in his room to watch a particular television programme. Staff were found to be very knowledgeable about peoples’ support needs and had a positive approach to ensuring each person had a good quality of life that promoted their independence and empowered them to make decisions about Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 11 lifestyles and daily routines. However, the Registered Manager and staff confirmed that long-term sickness amongst the staff group had led to reduced staffing levels on many occasions. Whilst it was recognised that peoples’ personal care needs were being met, the days when there were fewer numbers of staff on duty, peoples’ opportunities to participate in leisure activities both in and out of the home were reduced. This was a cause of concern amongst the staff team as they were aware that inactivity and boredom may lead to frustration that could cause a deterioration in a person’s well being and behaviour. The support plans for 3 people were examined in detail: these plans are the documents used to describe each person’s support needs, be it personal care or skills development, their likes and dislikes, what is important to them and how they wished to live their lives, as well as any restriction placed upon them to maintain their safety and that of others. All 3 plans contained information about each person’s strengths and needs, a description of the support they required and risk assessments relating to activities of daily living. This information, however, in 1 of the plans was out of date and did not reflect the person’s current situation: the Registered Manager confirmed that this was the case for the other people living at No2 and who had moved to Victoria House last August. None of the plans included the positive support being given by staff to increase each person’s skills and abilities and promote their independence. In 1 plan for a person whose behaviour was known to become aggressive in certain situations, usually around mealtimes, there was no guidance for staff about how to manage these situations nor any conclusions about what triggers the person to become aggressive, for example, the person may be still be hungry. From the examination of the incident forms completed as a result of aggressive incidents it was clear that each staff member was managing the situation differently. This inconsistency can have serious consequences for the person themselves and staff as it leads to uncertainty and possibly anger from the person and fails to address their unmet needs. There was evidence that the plans had been reviewed every 3 months with the person, their family or representative and their keyworker. The reviews contained a more current description of each person’s support and development: this information must be included in the support plan to ensure these always provide the most up to date information of an individual’s support needs and how these are to be met in a safe and consistent manner. Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported be involved in continuing education and their independence is promoted. Opportunities to participate in social and leisure activities were restricted due their being insufficient staff available to offer each person the time to become involved in meaningful activities during the day. EVIDENCE: As identified in the previous outcome group, the staffing levels have had an impact upon the time staff were able to spend with people on an individual basis. Those people who were more able had not had their routines unduly affected but those who were reliant upon staff to participate in meaningful activities had. At the time of the inspection, 2 people who were more able were out of the home at community education and leisure activities and others were seen to participate in household tasks such as laundry, washing dishes, preparing drinks and meals. In the afternoon 2 people accompanied staff to do the shopping. The three people who were more dependent had the company of Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 13 a staff member who was very cheerful and engaged them in conversation but who was not in a position to offer individual attention other then when meeting personal care needs. Weekly keyworker meetings were being held for all those living in the home and identified plans for the forthcoming week, any health care commitments such as GP appointments, and preferences for the next week’s menu. The plan included a timetable of activities that the staff were endeavouring to meet. People were still being supported to have an annual holiday and 2 people had recently returned from theirs and said how much they enjoyed it. Contact with relatives and friends was supported and visits to the home were made in agreement with each person living in the home. Visits to and from family members and friends were recorded in each person’s daily diary. People said the meals were “good” and “nice”. The main meal of the day was in the evening and people were supported to assist with its preparation, as well as preparing their own breakfasts and lunchtime meals. Those people who were able were supported to be as independent as possible with their shopping, menu planning and meal preparation. Due to the open plan layout of No2 Victoria Terrace, those people who were unable to physically participate were able to sit in the kitchen area and still be involved. The staff support people to make healthy choices about their meals and snacks and this was reflected in the menus. One person, who found it difficult to sit in close proximity with others, was able to make a choice at each mealtime where he would like to take his meal; this enabled him to make clear choices about when he wished to join others. The staff member in No2 described that routines and mealtimes were flexible and meal times differed from those in No1 due to the needs of those in each house. In the previous 2 inspection reports the home was commended for the quality of the food and the involvement of people in this area of daily life. This commendation is continued in this report. Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Victoria House receive support in the way, and at the time, that they want and need. Health care needs are addressed as soon as they are identified. EVIDENCE: Those people living at the home and who were able to comment directly about the support they receive said staff helped them to do things for themselves. Those who were unable to comment were seen to be assisted with their care needs in a very respectful and supportive manner. The support plans, although some of which were out of date, did provide descriptions of what areas of their life people needed support, including personal, emotional and health care needs and the goals and aims of this support. Evidence was recorded that people had been supported to see their GP, dentist and optician. One person had recently been unwell and the staff were able to describe the support that both they and he had received from the hospital, GP and physiotherapist. Any medical conditions, such as epilepsy were identified in support plans and a description provided to staff of how this condition affects the person and how they should be supported. People were in good Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 15 health and it was understood by the staff that should a person become ill then they could remain at the home as long as their care needs could be met and the home remains appropriate considering the layout of the building. Medication was stored in both houses and, although no one was managing their own medication, should someone wish to do so and are assessed as safe they would be fully supported by the staff to be as independent as possible. A measured dose system was used for medication administration; this was a system where the local pharmacist prepared each person’s medication into a cassette that separates each day and time of day and which reduces the risk of medication errors. All staff who had the responsibility to administer medication had received training in safe practice and certificates were available in staff files. Medication administration records were clear and neat. Each month a designated member of staff checked the administration records and the balances of medication for accuracy and the Quality Assurance Manager, who visited the home once each month, undertook spot checks to ensure medication practices and storage were safe and in line with the organisation’s policy. Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Concerns and complaints from those living in the home, their relatives and other visitors to the home are listened to and acted upon immediately. EVIDENCE: Neither the home nor the Commission have received any complaints about this service since the previous inspection. Those people spoken to and who were able to comment, said the staff were very nice and they could talk to them if they were unhappy about anything. The keyworker meetings and formal 3-monthly reviews allow people to comment about how they want to live their lives, what plans they have and whether there were any issues of concern. Relatives and social workers were involved for those people who are unable to advocate for themselves. The Quality Assurance Manager visited the home once a month and met with each person. He reviewed whether each person’s support needs were being met and whether the home was being managed in line with the organisation’s policies and procedures. His specific reasonability was to ensure people received a high quality service that promoted their rights and independence. He confirmed that he was working closely with the Registered Manager and the staff team to resolve the issues resulting from the long-term staff sickness. Staff had received adult protection training and were aware of their responsibilities should they suspect someone is at risk of abuse. Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Victoria House provides a comfortable and homely place to live. The planned sensory room will provide additional pleasant facilities for people to enjoy and the new laundry room will address issues of infection control. EVIDENCE: Victoria House offers a spacious and comfortable home to those living there. No1 has a large lounge room at the front of the house and large dining room and kitchen at the rear. The door from the kitchen led onto the patio area that was being used for parking but access was available directly to the pleasant patio area of No2. The lounge room, dining room and kitchen are “open-plan” in No 2 and this allows those living in this house, who are more dependent upon staff, to be involved in the household activities taking place, either actively or passively watching from the seating areas. Office space was provided in each house that did not encroach upon the communal space. Bedrooms in both houses were on both floors and all were personalised and well decorated. Both houses were found to be clean, tidy and free from odours. Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 18 The Registered Manager described his plans to develop a sensory room in an unused room next to the lounge in No 2. This room would provide a place where people could relax, listen to music, enjoy sensory stimulation through the use of lighting and difference tactile items and individual activities with staff, as well as, if wished, time alone. In No2 Victoria Terrace, there were a number of aromatherapy atomisers, in the main communal areas and in people’s bedrooms if wished; the pleasant scent permeated the home. A laundry room was provided in No1 Victoria Terrace but in No2 the washing machine was in the kitchen area. Due to the continence needs of those living in the home, this situation increased the risk of cross infection particularly as it was under the kitchen work surface where food was prepared. The Registered Manager described the organisation’s plans to create a laundry room in the shower room next to the kitchen. Although this would still mean that laundry would be carried through the kitchen area it would reduce the risk of cross contamination and ensure the kitchen is kept free from soiled linen and items of clothing. People would also be able to wash their hands in the laundry room sink rather than the kitchen sink after handling soiled items. The shower room was currently being used by one person who was unable to use the bathroom on the first floor: the Registered Manager explained that firstly an en suite shower room would be built in this person’s bedroom. Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are competent, motivated and committed to providing the people who live at Victoria House with the support they need to live fulfilling lives. However low staffing levels have reduced opportunities for those living at the home. Recruitment practices are safe. EVIDENCE: Those people spoken to and who were able to comment directly about their relationship with the staff said the staff very “great” and “nice”. Those people who were unable to comment were observed being treated with respect and staff were seen to be friendly, cheerful and unhurried. The Registered Manager, staff team and the Quality Assurance Manager were open and honest about the strains the long-term staff sickness had had upon the service. Whilst the existing staff team were willing to cover extra shifts there were times when staffing levels fell to levels sufficient only to offer supervision to maintain peoples’ safety and therefore leisure activities both in and out of the home had to be curtailed for those who required 1:1 support. The Quality Assurance Manager confirmed that there was now an agreement in place to use agency staff but that careful consideration was needed before Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 20 bringing a number of staff into the home that were unknown to the people who live there. The personnel files for 2 staff were examined and these contained the necessary pre-employment checks, including 2 written references and a Criminal Record Bureau Disclosure, ensuring as far as possible only suitable staff were employed in the home. The organisation has its own training department to ensure staff remained up to date not only with the statutory training in first aid, health and safety and fire safety but also in issues relating to the needs of people with a learning disability, such as Autism and dealing with behaviours that challenge. The local Learning Disability Service also provided additional training in matters relating to disability. Each staff member had their own training record which enabled the Registered Manager to identify when updates in training were needed or to plan training resulting from a review of each staff members’ development needs identified through supervision. Supervision is provided both formally and informally to monitor staff performance, identify training issues and deal with any concerns; the Registered Manager was in the home most days and ensured he had contact with each member of staff particularly at this time of extra demand. Formal supervision is shared between the Registered Manager and his deputy manager, although he said that formal supervision had not taken place as frequently as he would have liked at present. Recent supervision records were available however on both staff files examined. The Registered Manager and the deputy manager had received training in the protection of vulnerable adults from Plymouth City Council’s Adult Protection Team; the remainder of the staff team had received this training through the organisation’s training department. Those staff spoken to were knowledgeable about their responsibilities should they suspect someone is at risk of abuse. Certificates were available on the personnel files to provide evidence that this training had been undertaken. Seven of the 11 staff employed at the home had either achieved a National Vocational Qualification (NVQ) or were in training. The NVQ qualification is one that is awarded by an external training provider and for which the staff have had to demonstrate their knowledge and competence in supporting people with a learning disability. Although the majority of the standards in this outcome group have been met, a rating of adequate has been given due to the impact low staffing levels was having on both staff and the people who live in the home. Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 and 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Despite the current problems over providing sufficient staff on duty, the home is generally well run. The Registered Manager and his staff team strive to provide a stimulating, safe environment that respects and protects peoples’ rights. EVIDENCE: Mr Morgan, the Registered Manager, has many years’ experience in supporting people with a learning disability and has successfully registered with the Commission since the last inspection. Staff confirmed that Mr Morgan had an open, positive and inclusive attitude towards involving them in the management of the home; they confirmed that he had worked many of the shifts recently required to reduce the burden upon them and allow them time off. Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 22 The Registered Manager confirmed he was being supported in his role by the Quality Assurance Manager, who visited the home once a month and who had the responsibility for consulting with the people who live in the home regarding the quality of the services provided. The organisation’s Area Manager was the Registered Manager’s immediate line manager and she visited the home once a month. The staff team confirmed that this was the limit of their contact with her and, due to the recent strain upon the Registered Manager and staff team, there was a feeling of being unsupported. This was brought to the attention of the Registered Manager and the Quality Assurance Manager who both confirmed this matter would be brought to the attention of the organisation’s Senior Management Team. A formal Quality Assurance process has been implemented since the previous inspection. The organisation has created a Quality Assurance Team with 5 managers covering each geographical area where the organisation has services; these managers reported to a Quality Assurance Director responsible to the Senior Management Team. At the time of the inspection, the Quality Assurance Manager was in the home to consult with the people who live there and to undertake an inspection of the services being provided. He confirmed that he regularly consulted with relatives and others involved with the support of the people living in the home to ascertain their views regarding the quality of the services. The results of the keyworker meetings and the 3-monthly reviews also contributed to the overall review of the services. During the inspection it was identified that some of the documentation had not been maintained or updated as it should have been, including the support plans, staff supervision records and the fire alarm system testing, which should be done weekly but had not been done since May; the system had been serviced in May 07. The Registered Manager was aware of these shortcomings and confirmed that he had been unable to find the time to undertake his managerial responsibilities as well as working shifts to cover the staffing shortages. The Registered Manager confirmed that he would discuss these matters with the Area Manager and reach an agreement about improving the situation in the home before any serious lapse in either documentation or the support of those people living in the home occurred. Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 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 3 26 3 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 3 2 2 3 Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 24 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 YA6 Regulation 15(2) Requirement Each person’s support plan must contain a current description of their support needs and the actions required by staff to meet these needs. For people whose behaviour is known to become aggressive in certain situations, the support plan must contain information about the circumstances in which it is known that a person may become aggressive and instructions to staff about how this situation is to be managed in a consistent manner. The Registered Provider must take steps reduce the risk of cross infection and contamination from soiled items of clothing and linen being washed in the washing machine in the kitchen at No2 Victoria Terrace. Staff must be employed in sufficient numbers to ensure the welfare of each person living in the home is met. This includes meeting peoples’ personal care needs as well as providing opportunities to DS0000044465.V339557.R01.S.doc Timescale for action 30/09/07 2. YA6 12(1)to (3) 01/08/07 3. YA30 13(3) 31/12/07 4. YA33 18(1)(a) 31/08/07 Victoria House Version 5.2 Page 25 5 YA42 participate in meaningful activities. 23(4)(c)(iv) The fire alarm system must be tested in line with the organisation’s and the local fire authority’s recommendations to ensure it remains in good working order. 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA1 YA14 YA36 YA41 Good Practice Recommendations The service users guide should be made available in a format that is accessible to the residents. All those living in the home should be provided with the opportunity to enjoy appropriate leisure activities. Staff should receive the support and supervision they need to undertake their work. Records held in the home in line with Schedules 3 and 4 of the Care Homes Regulations 2001 should be maintained, up to date and accurate. Victoria House DS0000044465.V339557.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. 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