Inspection on 24/07/07 for Victoria House

This inspection was carried out on 24th 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Victoria House 17/07/08

Victoria House 22/08/06

Victoria House 02/02/06

Victoria House 26/04/05

Victoria House 03/08/04

Victoria House 13/04/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Victoria House Low Grange Crescent Belle Isle Leeds West Yorkshire LS10 3EG Lead Inspector Hebrew Rawlins Key Unannounced Inspection 24th July 2007 09:00 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 DS0000001519.V342951.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Victoria House DS0000001519.V342951.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria House Address Low Grange Crescent Belle Isle Leeds West Yorkshire LS10 3EG 0113 270 8529 0113 2765090 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Mary Margaret Lavelle Mrs Mary Margaret Lavelle Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Victoria House DS0000001519.V342951.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2006 Brief Description of the Service: Victoria House provides residential care, without nursing, for 36 older people of both sexes. It is set in its own grounds, situated centrally in Belle Isle, a suburb of Leeds. There are three floors. The main living accommodation, which consists of a large reception area with a bar, three lounges, three dining areas and a small library/visiting room, is on the ground and first floor. An activity/games room has recently been opened on the lower ground floor. There is a passenger lift between the ground and first floor, with plans being considered to extend this to the lower ground floor. There are 33 bedrooms, 30 single and 3 double rooms, all of which have en-suite facilities. Local amenities, such as shops and a post office are in close proximity and the home is on a bus route with buses running regularly into the centre of Leeds. Outdoor seating is provided at the front of the home and landscaping is taking place. On the 24th July 2007 the administrator confirmed that the fees were £297.71p to £422.20p per week. Copies of previous inspection reports are available in the reception area of the home. Victoria House DS0000001519.V342951.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. Information about the inspection process can be found on our website www.csci.org.uk This visit was unannounced and carried out by one inspector who was at the home from 09.00 until 16.30 on 24th July 2007. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who use the service and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. During the visit a number of documents were looked and all areas of the home used by the people living there were visited. A good proportion of time was spent talking with the people who live at the home as well as with the management and staff. The manager had completed an Annual Quality Assurance Assessment (AQAA) before the visit to provide additional information about the home. Survey forms were sent out before the visit to the people who use the service, relatives, carers, general practitioners (GPs) and other healthcare professionals. Several were returned and information provided in this way will be reflected in the report. Feedback at the end of this inspection was given to the management team. Thanks are extended to everyone who contributed to the inspection and for the hospitality during the visit. What the service does well: The home provides good care for people and supports them to maintain their independence. The staff provides a clean, warm and comfortable home for people to live in. Victoria House DS0000001519.V342951.R01.S.doc Version 5.2 Page 6 Comments from relatives/visitors and a visiting health care professional were all positive. Relatives made comments such as “the place is always clean” “you can talk to the staff they understand” “there is no bad smell when you come here”. A visiting health care professional said “this is a good home, it is kept very clean and there are never any odours and the staff are very helpful”. People who use the service confirmed that they could see visitors at anytime helping them keep in contact with family and friends. Staff were seen helping people retain their independence in daily tasks. A person living at the home said, “The people who work here are really good”. What has improved since the last inspection? What they could do better: The home must provide evidence to show all people using the service have been given a written contract. This will give a clear understanding of what people using the service can expect from the provider and the rights and obligations of the individual. Medication practices must always be delivered/followed according to the home’s policy; otherwise people who use the service are at risk. Victoria House DS0000001519.V342951.R01.S.doc Version 5.2 Page 7 The room used for storing medication should not exceed the temperature of 25oC as this could make the medication held in that room unsafe to use. The home must make sure all forms relating to the health/well being of people living in the home are completed fully. Without these in place there is no guarantee that all the needs of the people will be met. The home must make sure it’s robust complaints procedure is followed through to the full. Otherwise people will feel their complaint is not taken seriously by the home. Recruitment files must have a job description, a photograph and staff starting date. An accurate job description clearly defines the roles and responsibilities of staff. The manager needs to make sure staff training records are kept up-to–date at all times. This will show the management recognise the benefits of a skilled, trained workforce. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Victoria House DS0000001519.V342951.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 DS0000001519.V342951.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): 1, 2, 3, 4 and 5. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The information provided about the service is good and gives people that are considering using the service the opportunity to decide whether or not the home can meet their needs. The assessment procedure is thorough and people can be sure that the home will not offer to provide a service unless the staff are able to meet their needs. EVIDENCE: A person living at the home, admitted since the last inspection, said he had looked at other homes before visiting Victoria House, and was given written information about the home and the facilities provided. Victoria House DS0000001519.V342951.R01.S.doc Version 5.2 Page 10 The Statement of Purpose and Service User Guide provides good information about the service, which helps people decide whether or not the home can meet their needs. The people living in the home and their relatives have been consulted and contributed to the assessment. Records sampled showed assessment details with sufficient information about the person’s needs and strengths in all aspects of their care to form the basis of a care plan. In the survey returned a relative said “ the manager always keep me informed about any “problems” i.e. health wise or worries mum may have and they try to sort things out swiftly and efficiently”. The manager said all the people living in the home or their representatives have been issued with written contracts. This document states the terms and conditions of occupancy and the weekly charges made by the provider. However this was not evident in the files looked at. The management agreed to rectify this. People feel the care home meets their needs. In a survey returned a relative said, “ Although mum has dementia she often remarks to other people how nice Victoria House is. It is a friendly environment for people”. Victoria House DS0000001519.V342951.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. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s privacy and dignity is respected and staff are aware of the specific needs of people living in the home. People’s health care needs are met, however medication practices are not always delivered according to the home’s policy placing people at risk. EVIDENCE: Throughout the inspection staff respected the privacy of people living at the home and always knocked before entering bedrooms. Medication administration sheets were not always completed for each person. The records should show when people refuse their medication and why. If this persists the GP should be informed. People’s medication was placed on the dining table and staff walked away leaving people unobserved to take their Victoria House DS0000001519.V342951.R01.S.doc Version 5.2 Page 12 medication. This creates a risk where others may take that medication or the person themselves store up their medication. In the survey returned a relative said “ On an occasional visit I have noticed tablets under the table or on the carpet, more so at weekends. But this is not on a regular basis”. The medication room was hot exceeding the temperature of 25o c used for storing medication. Although there is a request list on people’s files in the event of death it was not filled in so there was no evidence the home could meet the wishes of people. There was evidence in records that people have access to GPs (General Practitioner), chiropodody, dental and optical services. Survey forms returned from GPs state that the home manages peoples’ health care needs well and always seek to give clients privacy. From discussions with people living at the home and from the returned completed survey forms it is clear that they feel that their dignity and privacy are respected. A relative said “ Recently mum had 2 falls, on both occasions we had a phone call within a short period of time. Also the local GP was asked to check her over ”. Victoria House DS0000001519.V342951.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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are consulted about how they wish to live their life on a daily basis. They are supported to maintain contact with family and friends. Visitors are made to feel welcome and a good and varied diet is provided for people. EVIDENCE: Relatives said they are always made welcome and informed of anything that affects their relative. The home has organised and planned activities from outside agencies on a weekly basis, and in-house activities are planned around people’s wishes. Extra staff are on at peak times to allow stimulation and activities. All events are displayed around the home on a notice board, so that people know when and where they are taking place. Victoria House DS0000001519.V342951.R01.S.doc Version 5.2 Page 14 Menus are varied and nutritionally balanced. Menus are developed after consultation with people in the home at meetings or on an individual basis. Menu boards are in each dining room, displaying daily choices. The cook meets 3 monthly with people who use the service for suggestions and to try and encourage new tastes. Meals are served in the dining rooms or people may have their meals in their own room. The dining room tables are arranged in small group setting that encourages conversation and makes meal times a social occasion. Everyone said they enjoyed the food. The lunchtime meal seen on the day was attractively presented. The mealtime was relaxed and anyone who needed assistance was given this discreetly and with courtesy. In the survey returned relatives said “ meals are very good”, “mum has gained a stone in weight” All visitors are offered meals if required with their relative or friend and birthdays and special occasions are celebrated with a cake and drinks supplied by the home. In the survey returned a relative said “If individuals prefer their own rooms to sitting in the lounges they are not pressurised to do what the others are doing”. Victoria House DS0000001519.V342951.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. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is a robust complaints procedure, however this is not always followed. As a result people will feel their complaint is not taken seriously by the home. People in the home are protected by the adult protection procedure and by a staff team that are aware of what to do if abuse is suspected or reported. EVIDENCE: A complaints procedure is available to all the people living in the home. It is displayed in everyone’s bedroom and is part of the service user guide. A visiting relative said she was aware of how to complain if needed. A number of people living in the home said they had never had to complain but would go to the manager if they needed to. In the survey returned a relative said “ I have not had any reason to complain about mums care over the last 2 ½ years”. Another said “ Anything arises is dealt with promptly”. However on checking the complaint book there was no evidence to show that a complaint was taken seriously and acted upon. Is was agreed that on that occasion the home had not follow it’s procedure. Victoria House DS0000001519.V342951.R01.S.doc Version 5.2 Page 16 The management of the home is aware of their responsibility to report any serious complaints to the Commission for Social Care Inspection. Staff were familiar with the adult protection procedures and have received training on abuse and the protection of vulnerable adults. When a person living in the home was asked if she knew how to make a complaint about the care provided she said, “ I see the boss and tell her” “I don’t have any problems”. Victoria House DS0000001519.V342951.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, 20, 23, 24, 25 and 26. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is clean and tidy throughout and offers a safe environment in which people who live in the home are able to live in comfort. EVIDENCE: The home is very well maintained. Routine maintenance of the building is documented on a monthly basis. The home has now employed a maintenance person. Communal areas are furnished and decorated to a good standard providing light and spacious accommodation. Bedrooms seen were decorated and furnished to a good standard. People living in the home said that they were pleased with their rooms and were glad Victoria House DS0000001519.V342951.R01.S.doc Version 5.2 Page 18 to have many of their own personal belongings with them. All areas of the home were clean, tidy and free of unpleasant odours. In the survey returned a relative said “ I visit very regularly at different times and find the rooms fresh, clean and more important Odour free”. “ When mum had her own house, she lived in exactly the same standard as the home, so in my opinion Victoria House is ideal for mum”. The laundry is suitably equipped to meet the needs of people living at the home. Clothes are washed, ironed and returned to them in their individual basket. Victoria House DS0000001519.V342951.R01.S.doc Version 5.2 Page 19 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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Competent staff meets the needs of the people living in the home. People are protected by the recruitment procedures and staff receive training relevant to their job. EVIDENCE: Duty rotas indicated that there are sufficient care staff on duty to meet the needs of people in the home. The home has a comprehensive training programme for all staff. All new starters are on an induction programme. In the last few months’ staff have attended a number of training courses including infection control and food hygiene. The manager said staff have done other training, however staff and tutors did not always sign the workbook that has been designed for staff to work through and other record of training was not always updated on their file. The staff team reflect the culture and gender of people in the home. However staff have not had any training on culture and diversity, which was raised at the last inspection. The management stated this is to be arranged. Victoria House DS0000001519.V342951.R01.S.doc Version 5.2 Page 20 46 of the care staff have achieved National Vocational Qualification (NVQ) level 2 or above and a further seven are undertaking this qualification. From information supplied in the Self Assessment staff have received training in protection of vulnerable adults. The recruitment files looked at on the day of the visit for recently employed staff did not have a job description, a photograph and their starting date. Victoria House DS0000001519.V342951.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well organised and the management provides effective leadership. The interests of the people who use the service are very important to the management and the staff are safeguarded at all times. EVIDENCE: The registered manager has many years management experience. The home is well organised. There is an established system in place for the supervision of staff. There are clear records of all peoples’ money and the home has clear policies and procedures about handling people’s monies. Victoria House DS0000001519.V342951.R01.S.doc Version 5.2 Page 22 Staff spoken with were clear about their roles and responsibilities. They said that they enjoyed working in the home and worked well together as a team. The home is now recognising individual’s hard work/initiative by having an Employee of the Month. The home is working on a Quality assurance system where questionnaires are sent out to relatives and health professionals to get their views of the home. Health and safety information is displayed throughout the home and a whole range of risk assessments are carried out for the building and working practices. Health and safety of people who uses the service and staff is promoted and protected. Victoria House DS0000001519.V342951.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 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 3 2 3 3 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 17 X 18 3 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Victoria House DS0000001519.V342951.R01.S.doc Version 5.2 Page 24 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 OP2 Regulation 5 Requirement The home must provide evidence to show all people using the service have been given a written contract. This will give a clear understanding of what people using the service can expect from the provider and the rights and obligations of the individual. Timescale for action 30/09/07 2 OP9 13 Medication practices must always 30/09/07 be delivered/follow the home’s policy. The room used for storing medication should not exceed the temperature of 25o c; otherwise people who use the service are at risk and medication held in that room could be made unsafe to use. The home must make sure all forms relating to people in the home health/well being are completed fully. Without these in place there is no guarantee that all the needs of the people will be met. The home must make sure it’s DS0000001519.V342951.R01.S.doc 3 OP11 15 30/09/07 4 OP16 22 30/09/07 Page 25 Victoria House Version 5.2 robust complaints procedure is followed through to the full. Otherwise people will feel their complaint is not taken seriously by the home. 5 OP29 19 Recruitment files must have a job description, a photograph and staff starting date. An accurate job description clearly defines the roles and responsibilities of staff. The manager needs to make sure staff training records are kept up-to–date at all times. This will show the management recognise the benefits of a skilled, trained workforce. Staff must have some training on culture and diversity. 7. OP26 13 (3) This is unmet from 31/12/06 A clinical waste bin must be provided in the laundry. This is unmet from 2.2.06. 30/09/07 30/09/07 6. OP12 OP30 12, 18 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Victoria House DS0000001519.V342951.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Victoria House DS0000001519.V342951.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!