Inspection on 24/05/06 for Victoria House

This inspection was carried out on 24th May 2006.

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

Other inspections for this house

Victoria House 19/07/07

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 Tina Maddison Unannounced Inspection 24th May 2006 10:00 Victoria House DS0000044465.V292289.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 DS0000044465.V292289.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 DS0000044465.V292289.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Victoria House Address 1 Victoria Terrace Plymouth Devon PL4 6BL 01752 661171 01752 661171 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 Vacant Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Victoria House DS0000044465.V292289.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: Victoria House is made up of two individual terraced houses. Each house/unit has its own communal facilities, kitchen and staffing rota. No.1 Victoria Terrace has accomodation and communal facilities for six residents and No.2 Victoria Terrace, next door to No.1 within a terraced street, has accomodation and communal facilities for four residents. 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. 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. Victoria House DS0000044465.V292289.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced. Preparation for the inspection included analysis of the pre inspection questionnaire and the previous inspection report. An inspection plan was developed from this information. A tour of the two houses was undertaken including a visit to each bedroom. The inspector case tracked three residents, and three residents were interviewed during the inspection. Pre inspection surveys were sent to stake holders including care managers and General Practioners. Five survey questionnaires were received from residents. Care planning files, care delivery records, medication records, health and safety records and general records were inspected. The co-operation and helpfulness of staff was appreciated by the Inspector. What the service does well: What has improved since the last inspection? Victoria House DS0000044465.V292289.R01.S.doc Version 5.1 Page 6 Since the last inspection care plans have continued to be improved and updated, and the office has been re organised effectively. A new service users guide has been developed. The Managers application for registration is nearly complete. 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 DS0000044465.V292289.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 DS0000044465.V292289.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): 1,2,4. Prospective service users are able to visit the home. Pre admission assessments ensure that Victoria House will be able to meet service users care needs. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A service users guide has now been made available, and there is work underway to produce this in a format that is understandable to the service users currently living in the home. The home continues to offer pre admission visits and trial stays to prospective service users and the Manager will undertake a pre admission assessment. One of these assessments was seen on a service users file. This document is comprehensive and informative and enables the home to meet the service users care needs. There have been no new admissions since the last inspection. Victoria House DS0000044465.V292289.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. Service users can be assured that staff will enable them to be as independent as possible and be encouraged to safely participate in all aspects of life in the home. Risks and an independent lifestyle are appropriately balanced. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From examining the files in place for each service user it was evidenced that each service user had a detailed care plan in place that was broken down into a pen picture of each service users strengths and needs and a detailed risk assessment for all activities inside and outside of the home. It was documented that care plans are regularly reviewed and updated. Service users confirmed that they contributed to the choices of routines of daily living, community participation and choices of social, and leisure activities. Service users spoken with confirmed that they had a variety of different leisure activities and day opportunities. Each service user had a daily programme available in their individual bedrooms so that they were aware of daily activities. Service users also confirmed that they are encouraged to participate in all daily living tasks in the home, and it was observed during Victoria House DS0000044465.V292289.R01.S.doc Version 5.1 Page 10 the inspection that a number of the service users were undertaking tasks such as laundry and making hot drinks and washing up. Victoria House DS0000044465.V292289.R01.S.doc Version 5.1 Page 11 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): 12,13,15,16,17 Residents have appropriate activities to ensure a good quality of life. Service users rights are respected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From observations made during the inspection, discussion with staff and information from care plans, it was evident that staff support residents to participate in a variety of activities in the community. Service users confirmed that they use a variety of public transport such as buses and taxis. On the day of the inspection it was observed that service users were taking part in a number of activities outside of the home, such as community education opportunities and leisure activities. One of the service users was on holiday and was accompanied by the Manager, as all service users have one to one staffed individual holidays or day trips over the summer if they prefer. The atmosphere in the house was relaxed on the day of the inspection, and service users were clear about the plans for the day. Service users confirmed that they liked the meals and were able to choose what they ate. They helped plan the meals and undertake the shopping. The service was previously commended for the quality of the food and the Victoria House DS0000044465.V292289.R01.S.doc Version 5.1 Page 12 involvement of the residents in this area of daily life. This commendation is continued in this report. Victoria House DS0000044465.V292289.R01.S.doc Version 5.1 Page 13 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): 18,19,20 Service users physical and healthcare needs are met at Victoria House. Residents and their representatives can be assured that residents prescribed medication is appropriately managed and administered. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Some of the service users have behaviours that challenge the service. Behaviour management plans are in place. Staff have received training in these aspects of care. Therapeutic holds are only used as a last resort, and none have been used since the last inspection. Most service users only require verbal prompts to maintain personal care tasks. Personal care needs and the directions to staff to meet these needs are clearly documented within care plans. Service users stated that they believed that staff were attentive and respectful when giving personal care, and it was undertaken in the manner that the service user preferred. There is a medication policy and procedure in place, and a monitored dosage system of medication administration is in use. All members of staff who administer medication have received accredited training. Medication administration recording was accurate and well kept. Victoria House DS0000044465.V292289.R01.S.doc Version 5.1 Page 14 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): 22,23 Service users can be assured that their concerns and complaints will be listened to, acted upon and resolved. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no complaints reported to CSCI since the last inspection. All staff have a current CRB and POVA check in place. Any concerns or complaints are recorded and actioned. Service users confirmed that they believed that if they did have a concern or complaint that they knew who to go to, and felt confident that it would be acted upon and resolved. Staff have received training in adult protection issues and felt able to follow the company whistle blowing policy if necessary. Victoria House DS0000044465.V292289.R01.S.doc Version 5.1 Page 15 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): 24,25,26,27,28,29,30. The residents benefit from a homely, comfortable clean and well maintained building that has been appropriately adapted to meet their needs. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection a tour of both houses and all bedrooms was undertaken, and found the environment in both houses to be clean, well maintained and comfortable. Service users spoken to commented that they liked their bedrooms, that were individually decorated and reflected their personalities and tastes. In one house the carpet in the downstairs bedroom was being replaced. All toilet and bathroom locks have been replaced and are appropriate locks that can be opened from the outside in an emergency. All windows are fitted with restrictors. However, these restrictors are routinely overridden to open these windows fully. Therefore wherever this type of restrictor is fitted these window openings should be risk assessed and this risk assessment documented. The low banister railing at the head of the stairs has not yet been dealt with as identified at the previous three inspections and by the environmental health officer. A risk assessment must be completed. Both houses have a no smoking policy and any residents who wish to smoke do so outside. The office in both houses is available to provide a staff sleeping Victoria House DS0000044465.V292289.R01.S.doc Version 5.1 Page 16 in facility as well as administration. Staff undertake the cleaning as part of their duties. Victoria House DS0000044465.V292289.R01.S.doc Version 5.1 Page 17 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): Service users benefit from a competent and well trained staff team. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All staff have a job description and are aware of their roles and responsibilities. The staff receive in house training in a number of key areas, such as first aid, challenging behaviour, medication administration, The Learning disability award framework and NVQ qualification. Each house has its dedicated staff team due to the differing needs of the residents. Staffing rotas and discussion with staff evidenced appropriate numbers of staff on duty at all times. In No.1 there is a minimum of 2 staff on duty at all times of the day and at night there is one sleeping in member of staff. In No.2 there are three staff during the daytime and a waking staff member at night. Staff records evidenced that all staff have two written references, a CRB check in place and have undertaken a comprehensive induction procedure. Staff turnover is low, and staff reported that the homes are a happy place to work in. Supervision is regularly given to staff, and the Regard Partnership has its own training office in the area, and regular training in a variety of areas is offered to staff. Service users commented that they thought that the staff were kind, helpful and good fun, and they listened to any concerns that the service user may have. Victoria House DS0000044465.V292289.R01.S.doc Version 5.1 Page 18 Victoria House DS0000044465.V292289.R01.S.doc Version 5.1 Page 19 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): 37,38,39,40,42,43. The management of the home is effective, ensuring that residents needs continue to be met. Development in the quality of care offered at the home would benefit from the introduction of a quality assurance system. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There appears to be open and effective management of the home, and having one registered manager for both houses appears to be effective. The existing Manager, Mr Keith Morgan is nearing the completion of his application to become the Registered manager. Mr Morgan has extensive experience of working with people who have a learning disability and was previously the deputy manager of the home. There is currently no quality assurance system in place at the home. The building and staff have been risk assessed. Radiators are covered, and water temperature regulators are fitted. The accident book was reviewed during the inspection. Notifiable incidents have been reported to the Commission for Social Care Inspection. Since the last inspection the home has had a visit from the Environmental health officer, who advised the Victoria House DS0000044465.V292289.R01.S.doc Version 5.1 Page 20 replacement of the fridge freezer. This has been done. Records evidenced that fire safety equipment is well maintained, and the staff are appropriately trained. Gas and electrical equipment are well maintained. Victoria House DS0000044465.V292289.R01.S.doc Version 5.1 Page 21 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 2 2 x 3 x 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 2 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 3 3 3 x 3 3 Victoria House DS0000044465.V292289.R01.S.doc Version 5.1 Page 22 no 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 Standard YA21 Regulation 23 Requirement The low banister at the head of the stairs must be made safe. Timescale for action 30/09/06 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. 2. 4. Refer to Standard YA1 YA39 YA42 Good Practice Recommendations The service users guide should be made available in a format that is accessible to the residents. A resident focused quality assurance system should be developed and implemented. Risk assessments should be in place for all window openings where the window restrictor can be easily overridden. 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