Inspection on 02/03/06 for Victoria House

This inspection was carried out on 2nd March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 09/06/08

Victoria House 20/06/07

Victoria House 11/12/06

Victoria House 13/09/05

Victoria House 28/02/05

Victoria House 12/10/04

Victoria House 23/03/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Victoria House 10 & 11 Victoria Terrace Bedlington Northumberland NE22 5QA Lead Inspector Alan Baxter Unannounced Inspection 2 March 2006 10:00 nd Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Victoria House Address 10 & 11 Victoria Terrace Bedlington Northumberland NE22 5QA 01670 828396 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr F Haley Mrs R Haley Mrs R Haley Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 1 place can be used to accommodate a named service user who has a mental disorder (Excluding learning disability or dementia). 13th September 2005 Date of last inspection Brief Description of the Service: Victoria House was originally two terraced houses and work had been carried out to form one well-equipped house that can provide accommodation for up to six people. A conservatory has recently been built at the rear of the building. At the time of the inspection the Home accommodated six adults with learning disabilities. The accommodation was domestic in nature and was comfortably furnished and appointed. There is a small garden area/patio area to the rear of the property. Victoria House is situated within walking distance of Bedlington town centre and is therefore close to a range of local amenities. Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in March 2006. The main focus of this inspection was to check that the home had carried out the requirements and recommendations of the last inspection report. Therefore this inspection concentrated on a small number of National Minimum Standards, only. Please refer to the last inspection report, dated 13th September 2005, for a fuller picture of the home. What the service does well: The home provides thoughtful and sensitive care to its residents. The registered persons are positive and co-operative with the inspection process. Care records show that the manager and staff are knowledgeable about the residents, their strengths and needs. Residents are part of the local community. Residents’ privacy and dignity are protected. Residents are given choice in most areas of their lives. Residents’ health needs are met at all times. Medicines are properly stored and given. Residents enjoy their food. A visiting relative was extremely complimentary about the standard of care being given in the home. Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 2) No person will be admitted to the home without a full assessment of his or her needs. EVIDENCE: 2) It was a requirement of the last inspection report that the manager must ensure that the Single Care Management (health and social services) Assessment is received before a person is admitted. No new residents have been admitted to the home since this requirement was made. However, Mr & Mrs Haley are fully aware of the need to ensure that a full assessment of need is obtained from the referring social worker/case manager before agreeing to accept the person. Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9. 6) Residents’ needs and personal goals are reflected in their individual care plans. 7) Residents make decisions about their lives with support as needed. 8) Residents are consulted about and take part in all aspects of the home. 9) Residents are supported to take reasonable risks as part of their independent lifestyle, but formal risk assessments are not always carried out, or kept up to date. Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 10 EVIDENCE: 6) It was a requirement of the last inspection report that the home must develop and agree with each resident an individual Plan that describes the services and facilities provided by the Home; and how each resident’s needs, aspirations and agreed goals will be achieved. This requirement has been implemented. A great deal of work has been done on the care records since the last inspection. Mrs Haley has used a descriptive approach to care planning that is informative and quite detailed. The format does not, however, lend itself to the necessary evaluation and updating of the care plan. It is recommended that, as each resident is coming up to the formal six monthly review of her care, her care plan is re-drawn with each identified area of need being addressed with its own care plan. This will allow for the evidence of evaluation and updating of care plans to be clear. 7) There was evidence in the care records and in discussion with Mrs Haley that residents are involved in decisions about a wide range of activities in the home. Examples included residents’ involvement in decisions about menus, trips out, holidays, potential new residents and staff, and social activities. Good individual social activities assessments are carried out. Other systems for involving residents include formal reviews of care, medication assessments, quality assurance systems and advocacy. 8) It was a recommendation of the last inspection report that further development is recommended in consulting with residents regarding the dayto-day running of the home (e.g. menus and social activities). This has been implemented. A ‘residents’ participation book’ has been introduced. This shows that residents are consulted on a range of issues, as noted in standard 7, above, and that their views are recorded. Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 11 There was some evidence of the home acting on the feedback received from residents’ surveys, with changing work/college patterns as an example for one resident. 9) In-house risk assessments were examined. They were comprehensive and detailed. There is an emphasis on managing risks to get the maximum benefits for the resident, rather than trying to prevent all risks. This is good practice. An example of this approach was the gradual reduction in staff support for one resident who works in a shop, with the aim of slowly increasing the resident’s independence. However, some risks clearly described in the care records had not been given a formal risk assessment, leaving all parties vulnerable, should anything go wrong. Also, risk assessments were not being kept up to date. These must be regularly reviewed and updated, where necessary. Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14,16,17. 13) Residents are part of the local community. 14) Residents engage in appropriate leisure activities. 16) Residents’ rights are respected, and their responsibilities are recognised. 17) Records of all meals must be kept to show that there is an appropriate diet available for residents. EVIDENCE: 13) Care records and discussion showed that residents are well integrated into their local community. They use local shops, library, and youth club, as well as a local ‘drop in’ centre for crafts, access to computers etc. Four residents have regular contact with their families. Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 13 Four residents attend college at least one day each week; one attends a local Adult Training Centre; another uses the Redress facility three times per week; and one works two days per week in a local charity shop. 14) It was a requirement of the last inspection report that in-house leisure activities must be made more varied, and must be recorded in detail. This has been partly implemented. There has been improvement, both in the range of leisure activities and in the recording of such activities. Each resident now has a detailed record entitled ‘Client choice of how they wish to spend their in-house leisure time’. Study of the daily recordings in the home showed the following range of recent activities: baking; ‘wordsearch’, ‘frustration’ and other games; music and dancing; ‘soaps’; crafts; karaoke; trips to the cinema, bowling alley and pubs (for bar meals). Discussion with a visiting relative, who said that the home had been “absolutely fantastic from the start” for her relative, indicated that the only improvement she could see would be for more activities during the day. She went on to say that ‘keep fit’, or other exercises, would be welcome, but that she felt that the home had already identified this as being necessary. So, overall progress is noted and complimented, but further thought should be given to this important area. It was noted that the home has avoided having the television on before 5pm, since the last inspection. This is good practice. It was also noted that there is a culture within the home for residents to get changed into their nightwear around 6.30pm. This was challenged, as being unusual practice and inappropriate for the age of the resident group, and as a practice that must limit residents’ ability to go out in the evenings. 16) It was a recommendation of the last inspection report that residents responsibilities for carrying out household tasks should be clearly specified in their individual care plans; and that, where residents have restricted access to areas of the home, such as the kitchen, this should be agreed and recorded in their individual plan and contract. This has been partly implemented, in that a general statement of residents’ household responsibilities has been put on each resident’s file. To fully meet this recommendation, however, there is a need for an individual statement of Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 14 each resident’s responsibilities and a related care plan on each individual resident’s care record. It was agreed that this should be done at the next review of care. 17) No menus were available for inspection. Nor is any record kept of the meals actually taken by residents, as this had never previously been requested. It is a requirement that the home keeps clear and a detailed record of each resident’s meals and other nutritional intake. All residents are asked about their food likes and dislikes, and a detailed record of this is kept. A recently conducted ‘resident satisfaction survey’ showed that residents are happy with the variety, quantity and presentation of the meals. Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 18) Residents receive personal support in the way they prefer. 19) Residents’ physical and emotional care needs are met. EVIDENCE: 18) Care records demonstrated a sensitive and flexible approach to the personal care of the residents. Privacy and dignity are obviously respected by staff. Residents may choose their own clothing, makeup, hairstyles and appearance, although advice would be given, where necessary. Residents may also decide when they rise and retire. Residents are also given some input into the hire of new staff members. 19) Care records showed that each resident has a detailed physical and mental health history, and that the physical and emotional care needs of the residents are regularly re-assessed. Assessed health needs are appropriately met, using appropriate specialist services such as psychiatrists and psychologists, where necessary. Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 16 Good records are kept of regular visits to dentists, opticians and chiropodists, and of appointments with other health professionals. Good support is received from local general practitioners. Medication records are properly kept. Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23. 23) Residents are protected from abuse, neglect and self-harm, but some of the home’s policies in this area need to be revised. EVIDENCE: 23) The home has a policy and procedure for protecting residents, and for responding to any allegations of abuse of residents. This policy needs to be revised, as it states that the manager will conduct an investigation of any allegation before it is reported to Social Services. It was clarified that the home must contact Social Services immediately, and before starting any internal investigation. The home also adheres to the County of Northumberland Practice Guidelines for the Protection of Vulnerable Adults, which is dated September 2003. The manager was asked to check whether this is the version currently in use, and obtain an updated one, if not. The home has a ‘whistle blowing’ policy. This should also be updated, to refer to bad staff practices as well as illegal staff practices. It was noted that the home had properly reported a previous allegation to the resident’s care manager and to the Commission. Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this inspection, but standards 24 and 30 were met on the last inspection. EVIDENCE: Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,35. 32) Residents are supported by competent and qualified staff. 35) Residents’ needs are met by appropriately trained staff. EVIDENCE: 32) It was a recommendation of the last inspection report that at least 50 of care staff should hold National Vocational Qualification (NVQ) level two in care by the end of 2005. This has been implemented. Currently, 71 (five of the seven care staff) hold NVQ level two. 35) It was a requirement of the last inspection report that a training needs assessment must be carried out for the staff team as a whole, and this must be linked to the homes service aims and the needs of the residents. This has been implemented. Each member of staff has been given a range of training, as individually assessed, and a list of future training needs has been agreed. This is good practice. Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 20 It was a further requirement of the last inspection report that all staff must be kept up to date with the required statutory training. This has also been implemented. All staff are now either up to date, or have the required extra training now booked for them. Future training will include Safe Handling of Medicines. Four staff are currently undergoing their LDAF training course, and are due to complete in May this year. Again, good practice. Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39. 39) Residents’ views are canvassed and are being used to review the service being given. EVIDENCE: 39) It was a recommendation of the last inspection report that the results of recent residents questionnaires should be collated, acted upon, and the results and actions published in the Service User guide. This is in the process of being implemented. Each resident’s questionnaire response was on her individual file. These are now being collated and will be sent to the Commission. It was noted that the evaluation of these questionnaires was being taken very seriously and done very thoroughly. The more recently developed and more detailed questionnaires for residents and relatives should be sent out and results collated and published, as above. Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 2 15 X 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X X X 2 X X X X Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 23 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. 2. Standard YA2 YA9 Regulation 16(2) 16(2) Requirement All assessments of need must be signed and dated by the person carrying out the assessment. A formal risk assessment must be drawn up for every identified risk to a resident. Timescale for action 31/03/06 31/03/06 3. 4. 5. YA14 YA17 YA23 16(2) 16(2) 13(5) Risk assessments must be regularly reviewed, and updated as necessary. In-house leisure activities must 31/03/06 be made more varied. A detailed record of the meals 31/03/06 taken by each resident must held in the home. The home’s policy and procedure 31/03/06 on protecting its residents from abuse must be revised to make sure that all allegations of abuse are passed immediately to Social Services, and any internal investigation takes place only when agreed in a strategy meeting. The home must make sure it has the most recent version of the local Social Services practice guidelines for protecting vulnerable adults. Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 24 The home’s ‘whistle blowing’ policy must be revised to include reference to ‘bad practice’, as well as illegal practices by staff. 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 YA6 Good Practice Recommendations At each resident’s next formal six monthly review of care, her care plan should be re-drawn,. with each identified area of need being addressed with its own care plan. This will allow for the evidence of evaluation and updating of care plans to be clear. The practice of residents changing into nightwear at 6.30pm should be reconsidered. Residents responsibilities for carrying out household tasks should be clearly specified in their individual care plans. Where residents have restricted access to areas of the home, such as the kitchen, this should be agreed and recorded in their individual plan and contract. (This is outstanding from 28/02/05.) The results of recent residents questionnaires should be collated, acted upon, and the results and actions published in the Service User guide. The more recently developed and more detailed questionnaires for residents and relatives should be sent out and results collated and published, as above. 2. 3. YA14 YA16 4. YA39 Victoria House DS0000000556.V276226.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 DS0000000556.V276226.R01.S.doc Version 5.1 Page 26 - 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. 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