Inspection on 02/11/06 for Victoria House

This inspection was carried out on 2nd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

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Snydale Care Home

Abbey The

Whiteley House

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Beeches The - North Yorkshire County Council

The Grove Waltham

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

CARE HOMES FOR OLDER PEOPLE Victoria House 2 Nostell Lane Ryhill Wakefield West Yorks WF4 2DB Lead Inspector Gillian Walsh Key Unannounced Inspection 2nd November 2006 10:00 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 DS0000066614.V307744.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 DS0000066614.V307744.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria House Address 2 Nostell Lane Ryhill Wakefield West Yorks WF4 2DB 01226 727179 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) Helpcare Ltd Mrs Tina Rowley Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (30), Old age, not falling within any other category (30), Terminally ill (2), Terminally ill over 65 years of age (2) Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 23 February 2006 Brief Description of the Service: Victoria House, located in the village of Ryhill, is a former vicarage which was converted and was originally registered as a nursing home in 1989. The home was registered again under new ownership in 2006 but retained the existing manager and staff team. It is situated next to the church and within easy walking distance of local shops and amenities. The home provides care, including nursing, for up to 30 older people. The home is on two levels with two separate lounges, dining room and conservatory to the front of the home which extends the lounge area. There is another conservatory built on to the back of the building extending the dining room area. There is a car park at the rear of the building. The majority of the bedrooms are single occupancy, service users are encouraged to personalise their rooms and are able to bring with them small items of furniture and personal possessions. Service users enjoy activities provided by care staff as time allows, outside entertainers, trips out and input from the local churches. Information about the home is available within the Statement of Purpose and Service User Guide, both of which are available on request from the home. All new residents are provided with a copy of the Service User Guide immediately prior to, or on, admission. A copy of the summary of the last inspection report is also included in the Service User Guide. At the time of the inspection the manager said that fees for care at the home ranged from £359 to £492 depending on the needs of the resident. Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection made of Victoria House since the home has changed ownership. As part of this full inspection, an inspector from the Commission for Social Care Inspection (CSCI) undertook a visit to the home. The visit started at 10am and finished at 4pm. Time was spent speaking with residents, relatives and staff, reviewing documentation and taking a tour of the home. Alongside this, the service provider was asked to complete a pre-inspection questionnaire which was returned prior to the site visit. Questionnaires were sent to residents, their relatives, visiting professionals and GPs. 10 residents’ questionnaires were sent out with 4 received back. Of the 10 relatives’ questionnaires sent out, 4 were returned. Of the 3 General Practitioner questionnaires sent, 2 were returned, and both of the social worker questionnaires were returned. All of the questionnaires returned gave positive feedback with no concerns identified. Relevant comments made within these questionnaires have been included within the body of the report. In writing this report, information and evidence was not only obtained by way of visiting the home but also from notifications and information obtained by CSCI and from the last CSCI inspection report. In gathering evidence, CSCI undertook case tracking, reviewed documentation, sought feedback from residents and their families, staff, the home’s manager and other relevant stakeholders, and undertook relevant observations and discussions appropriate to the needs of the service users taking into account their needs and communication abilities. The inspector would like to thank residents and their relatives and staff for their time and assistance during this very positive inspection. Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: More emphasis needs to put on the importance of residents’ social and recreational needs through the care planning process. Although residents are happy that their needs in this respect are being met, documentation needs to be in place to evidence this. Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 7 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 DS0000066614.V307744.R01.S.doc Version 5.2 Page 8 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 DS0000066614.V307744.R01.S.doc Version 5.2 Page 9 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): 3. Standard 6 is not applicable, as the home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Before moving into the home, all prospective residents are visited and assessed to ensure that the home will be able to meet with their assessed needs. EVIDENCE: All of the residents’ files seen included the pre admission assessment completed by the home prior to the resident being admitted. The assessments are based on the activities of daily living and included good information in each area. The findings from the pre admission assessment are then used to formulate an initial care plan on admission to the home. The manager said that Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 10 all prospective residents are visited and assessed prior to admission by either her or one of the home’s staff nurses and that, wherever possible, they and their families visit the home to have a look around and meet other residents and staff. One relative who was visiting during the inspection said that they had found the initial visit to the home very helpful and that staff had been very welcoming and supportive and had really alleviated any worries they had about their relative going into a care home. Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 11 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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are set out in care plans although more attention needs to be given to documenting social care needs. Health care needs are met appropriately and residents feel that their care is given in a respectful and sensitive manner. Residents are protected by systems for dealing with medications. EVIDENCE: During the visit, four residents’ care plan files were examined. All of the files contained a range of assessments and risk assessments relevant to the individual, all of which had been properly completed and reviewed. Where an assessment had indicated the need for a specific care plan to be formulated, this had been done. Care plans are developed based on the activities of daily living, with additional specific plans in place for specific and individual health care needs. All of these care plans were well written and gave clear Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 12 instructions to staff about how individuals’ physical needs should be met, taking into account their personal preferences and need for privacy and dignity. Discussion took place with the manager about how only one of the files seen included a care plan outlining residents’ social care needs and that this could be an indication that staff do not consider social needs to be as important as physical needs. The manager agreed that these plans needed to be formulated and gave assurance that staff did appreciate residents’ social needs. Wherever possible, care plans had been signed by either the resident or their representative. One relative said during the visit that they were aware of their relative’s care plan and that any changes to the plan were discussed with them. All of the residents’ questionnaires completed and returned to the Commission indicated that they were happy with the care they receive at the home and comments made by residents during the visit were very positive with one person saying “you couldn’t get better anywhere”. Daily records and professional visitors’ records show that staff at the home ensure that residents’ health care needs are met, either through visits to the home or through residents attending local hospital clinics. A visiting GP said that he was happy with the care provided by the home and had faith in the home’s staff to provide good care to his patients. All of the residents spoken with said that they were treated with respect and that staff ensured that their needs for privacy and dignity were respected. Records and systems relating to medication were checked and found to be in good order. Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 13 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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are, on the whole, happy with the lifestyle they experience in the home and enjoy the activities and company of their friends and families. Food is of good quality and choice is available. EVIDENCE: The manager said that the home employs an activities person to work approximately twenty hours on a flexible basis each week within the home. The activities programme includes things like movement to music, regular coffee mornings and Bingo. A visiting relative said that they act as the Bingo caller and that everybody seems to enjoy it. On the day of the visit, a keyboard player who visits on a weekly basis was providing entertainment with staff and residents joining in with singing and dancing. Parties, outings and other activities are planned on a regular basis. Photographs of a recent Halloween party showed how staff and residents had dressed up and enjoyed the evening. One person, who stays in their room most of the time due to Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 14 particular medical problems, said that they did sometimes feel lonely but acknowledged that they could be reluctant to spend time in the communal areas when staff suggested this. During the visit, relatives of a person recently admitted to the home asked about the possibility of their relative going to Church. The manager said this was not a problem at all as another resident was already supported to attend church on a regular basis. Relatives visiting during the inspection said that they were made to feel very welcome at the home and that their visits often turned into a social occasion involving other residents and their visitors. All of the residents spoken with said they were supported to make choices and decisions about how they lived their lives within the home. More reference about this and social activities needs to be included in care plans and daily records. All of the residents spoken with about the food at the home said it was very good. One person said, “there is all you want and more” and a visitor said, “If Dad likes it, it must be good!” The lunchtime meal on the day of the visit was very appetising, well presented and could be taken either in the dining area which extends into a conservatory, or wherever the resident felt most comfortable. Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 15 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 and 18. Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Residents and their relatives are confident that any concerns or complaints they have will be taken seriously and acted upon immediately. Systems and staff training is in place to protect residents from abuse. EVIDENCE: The manager said that no complaints have been received since the last inspection and no complaints have been received by the Commission about the home. The manager has, however, documented where residents or visitors have made suggestions or have expressed minor concerns. Although the details of the concern or suggestion have been recorded, the actions taken as a response have not. The manager agreed that it would be advantageous to do this. One relative said that if they ever have any concerns they discuss it immediately with the manager and have confidence that, wherever possible, actions will be taken to remedy or improve the situation. Residents also said that they would discuss any worries or concerns with staff. The manager said, and training records evidenced, that all staff have recently had training in protection of vulnerable adults. Staff spoken with were able to Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 16 say what they would do, in line with local procedures, should there be any suggestion of abuse within the home. Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 17 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and provides residents with a clean and comfortable home. EVIDENCE: A tour of the home and discussion with residents confirmed that the home is well maintained and that staff, particularly domestic staff, work hard to keep the home clean and tidy. Communal areas have a homely and comfortable feel and bedrooms are nicely personalised. Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Staff are suitably checked, inducted and trained and are available in sufficient numbers to meet with the needs of service users. EVIDENCE: Residents spoken with said that staff were always available when they needed them. Two residents said in questionnaires that staff were “usually” available when they need them. Evidence available during the visit was that staff are available in sufficient numbers at the moment but the manager should keep this under review, taking into account the changing needs of residents. Information from the manager, and staff training and supervision records, showed that over 50 of care staff hold the NVQ level 2 (in care) award with one person holding the level 3 award and one person studying for it. Mandatory training is up to date and staff have recently undertaken further training in health and safety and infection control. Staff said that they were happy with the training they receive and that training is organised for them as needed. Training had recently been delivered to staff from a specialist nurse to support staff in caring for a resident with a particular physical condition. All new staff follow the skills for care induction process along with the home’s own induction programme. Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 19 Staff records indicated that proper recruitment processes are being followed to protect residents. Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 20 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, 33, 35 and 38. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home’s manager is an experienced person who ensures that the home is run in the interests of the residents. Procedures are in place to ensure that residents’ financial interests are safeguarded and that the health, safety and welfare of residents and staff are protected. EVIDENCE: The home’s manager is a registered nurse who has been managing the home for many years. As well as undertaking mandatory and other training, the manager has also completed NVQ level 4 in management and is about to complete the registered managers award. One relative said in a questionnaire Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 21 “I am very impressed with the overall running of Victoria House. Tina is a very caring Matron & a valuable friend to all”. Regular resident and resident/relative meetings are held and minutes are available of these meetings. A system is in place for quality monitoring within which questionnaires are sent to residents and their relatives and professionals who visit the home. The second round of questionnaires are about to be sent out and the manager said that she is to prepare a report with the outcomes of the quality monitoring and action plan in response to any comments made. Monitoring visits to the home, by the provider or his representative, have not been made on a monthly basis as required under regulation 26. However, the manager said that the provider has now appointed an operations manager and these visits are now taking place. A system is in place at the home for residents to have small amounts cash held on their behalf in the home’s safe. Systems and records relating to this and balances for a sample of residents were checked and found to be correct. The manager gave information within the pre inspection questionnaire that appropriate checks and servicing of equipment and systems in the home have taken place as required by regulation. Records of fire drills and training were seen and evidenced that these are being done appropriately. The manager has produced risk assessments for all areas within the home and has sought input from other agencies such as the fire authority to ensure that the risk assessments are appropriate. Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 22 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP33 Regulation 26 Requirement The registered provider must make sure that monthly, unannounced quality monitoring visits are made to the home. This must be undertaken either by himself or a representative. A previous timescale of September 2005 has not been met. Timescale for action 30/11/06 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 OP7 OP12 Good Practice Recommendations Care plans should include detail of residents’ social and recreational needs and daily records should evidence how these needs are met. Victoria House DS0000066614.V307744.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Area Office St Pauls House 23 Park Square (South) Leeds LS1 2ND 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 DS0000066614.V307744.R01.S.doc Version 5.2 Page 25 - 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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