Inspection on 28/02/06 for Victoria House

This inspection was carried out on 28th February 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Victoria House 05/09/06

Victoria House 31/01/05

Victoria House 12/07/04

Similar services:

Snydale Care Home

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

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

CARE HOME ADULTS 18-65 Victoria House Maldon Drive Victoria Dock Hull East Yorkshire HU9 1QA Lead Inspector Angela Sizer Unannounced Inspection 28th February 2006 09:00 Victoria House DS0000000908.V263709.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 DS0000000908.V263709.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 DS0000000908.V263709.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Victoria House Address Maldon Drive Victoria Dock Hull East Yorkshire HU9 1QA 01482 213010 01482 216310 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 Disabilities Trust Mr Richard Hardman Care Home 24 Category(ies) of Physical disability (24) registration, with number of places Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To retain one service user over the age of 65 years. To obtain NVQ Level 4 Managers Award Date of last inspection 27th June 2005 Brief Description of the Service: Victoria House is situated on a large housing development on the banks of the river Humber, just to the east of Kingston Upon Hull. The purpose built home opened in 1993 offers permanent accommodation to a maximum of 24 residents with a physical disability. The home is owned by the Disabilities Trust which is a national organisation. All of the bedrooms are single occupancy with en-suite toilet and shower, and have views across the well-maintained garden and the river Humber. There is a large dining room on the ground floor, with a small sitting area and a large lounge on the first floor, again offering views of the river. There are two assisted bathrooms and two rehabilitation kitchens where residents can prepare their own snacks and breakfasts. All bathrooms and en-suite bedrooms are appropriately designed and equipped. There is a sensory room on the upper floor, which is regularly used. A passenger lift, external ramps, wide corridors and doorways, and automatic doors to the entrance enables service users access to all parts of the building. Local facilities on the fast developing and expanding housing development include a community centre, public house, chemist and a primary school. Residents have access to local transport into the town centre and the home has its own mini bus transport, which is run by a transport committee made up of residents. There is a large car park to the front of the home where visitor’s cars and the home’s mini buses park. Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and lasted for 6.5 hours, prior to the visit 2 hours preparatory work was undertaken. Several of the key standards were looked at and progress on the requirements and recommendations made during the last inspection visit. Judy Hughes, Assistant Manager (Finance) assisted with the inspection process as the registered manager was unavailable. A tour of the premises was undertaken, several of the residents were spoken to and some communicated verbally others used non-verbal techniques to talk about what the home was like and whether there were any problems. Lunch was observed. Two staff members were interviewed and practice observed, also three residents and three staff files were looked at and some policies and procedures were inspected. The inspector would like to thank the residents, relatives, assistant manager and staff for welcoming her into their home and contributing to the content of this report. What the service does well: The home continues to offer a very good standard of basic care to the residents. Residents stated that, “the home is very nice”, “the staff are good and if I need anything they help me”. One visiting relative spoke highly about the home stating that he is “very happy with the standard of care and that the manager and staff are always friendly”, also that “my son goes out three times a week to various classes as he enjoys computers and writing. The support offered enables residents’ to live a full and stimulating life, with some moving toward rehabilitation. All residents are able to be individual in style and appearance and it was clear that this was their choice, staff were observed when interacting with the residents and this was carried out in a caring and enabling way, support was offered where required. The atmosphere was warm and welcoming and it was clear that residents are able to communicate both verbally and non-verbally well with staff and could express their views without being judged. Overall the environment is well maintained and the health and safety of the residents is on the whole promoted. The menu offered is varied and nutritious, all residents confirmed that the food was of a very high standard and that a good choice was offered. Some Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 6 comments included, “the food is very nice, if I don’t like anything the cooks will do something else”, “I have no complaints about the food, I think it is good”. The staff have undertaken the basic food hygiene training and the home has achieved the Heartbeat Award for healthy food. What has improved since the last inspection? What they could do better: The registered provider must vary the registration to keep it relevant to the residents currently in the home. The home is registered for 24 people who have a physical disability, but several of the residents also have a learning disability and three are over the age of 65. Attention continues to be needed with regard to some design features in the building to enable residents’ independence and safety, particularly the bedroom and external doors that are very heavy and difficult to open and close. Monitoring is required in relation to the cleaning of the home and care staff could be more vigilant and report any concerns/spillages immediately. To further enhance the knowledge and competence of staff by providing specific training in relation to physical and learning disabilities, and mental health awareness this would better equip them to provide a more holistic and enabling approach. Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 7 Some of the procedures require further amendment including; risk assessment documentation to cover all areas including alcohol misuse/dependency, medication misuse prescribed and non-prescribed. The medication recording requires ongoing monitoring to ensure that the residents are fully protected. 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 DS0000000908.V263709.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 4 The service provider must ask for a variation of registration in order that the homes registration fully reflects the residents currently receiving care. All residents have a full needs assessment carried out and are given enough information about the home and it’s facilities before admission, for them to be confident that their needs can be met by the service. EVIDENCE: During the last inspection it was identified that the home’s registration did not reflect accurately the needs of the residents and a requirement was made to vary the registration to include those residents subject to a learning disability and those who are over 65 years, the home’s statement of purpose and service user guide will also require amendment to clearly state how those additional needs are to be met and how the staff will be trained in those areas to ensure the health and safety of residents and that any care being delivered is done so by competent and skilled staff. Each resident has their own individual file and from the three looked at all contained a full community care assessment that had been undertaken by the Local Authority who was funding the place, in addition the home undertakes a pre-admission assessment or if not possible an admission assessment of their own this enables the home to build up a holistic picture of the person and what their needs are. From the assessment process a care plan is then drawn up which describes the needs in more detail. From speaking to several residents, a relative and staff members it was clear that prospective residents are invited to visit the home prior to admission. Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 10 When this is possible the person would visit and meet the other residents, staff and manager, one staff member described how they would “welcome the person and show them the room that was vacant, introduce them to the other residents and just make sure that they feel comfortable”. Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 11 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 & 9 The residents are very well cared for, but this would be enhanced by risk assessments being more specific and greater consistency being achieved. Care plans are informative, descriptive and clear about what care tasks need to be undertaken. EVIDENCE: Three residents’ files were looked at during the inspection and on the whole were in very good order. For each person a detailed community care assessment, care plan, reviews and daily notes were in place. Not all of the reviews seen were up to date and there is potential risk to residents that their needs may have changed or increased and staff are unaware of this. Risk assessments had been developed for various areas including mobility, the risk of falling, eating and drinking, showering, dressing and sleeping, one of the resident’s file did not contain a risk assessment for the use of bed rails nor was there a multi-agency agreement that this was the best course of action to ensure the safety of the resident. Staff stated that another resident misuses alcohol and non-prescribed medication continuously, but there was no risk Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 12 assessment or evidence in place about how to reduce or manage these risks. A more holistic risk assessment approach would enhance and aid the residents’ moving to greater levels of independence. Staff talked about having access to relevant training including epilepsy, protection of vulnerable adults, catheter care and general care practice issues. It wasn’t clear either from speaking to the assistant manager or staff that more specialist training is offered that would be appropriate to the residents’ needs including Parkinsons, Huntingtons, mental health awareness, learning and other physical disability training, this would enhance the skills base and knowledge for the staff team and ensure that best practice was followed. However, staff did confirm that the manager encourages learning and fully supports the staff on a day-to-day basis. Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 13 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): 11 & 17 Residents are fully supported and enabled to take part in appropriate leisure activities, hobbies or opportunities for personal development, ensuring that they feel part of the community. The menu is varied, nutritious and wholesome and residents are fully satisfied with the food offered to them. EVIDENCE: Throughout the day the residents spoke highly of the home and staff confirming that dignity was maintained at all times, by staff listening and talking to them nicely. Staff were observed interacting with the residents and this was carried out sensitively and respect was shown to the residents. Residents also confirmed that any relationships they have are supported by staff, family or friends are welcome to visit at any reasonable time. Two of the residents live as a couple and share a room, they also have a lounge/kitchen that they have sole use of. From speaking to the two residents it was clear that they feel supported in maintaining as much independence as possible, both confirmed that it was their choice to stay in the home and they felt secure here, but also enjoy going out and about and do so on a daily basis. They Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 14 stated, “we like living here because we are safe, but we also like going out together and we walk lots”. The home has two rehabilitation kitchens, one upstairs and one downstairs, these have recently being refitted. Several of the residents confirmed that they enjoy cooking and use the kitchens quite a lot. One resident did state that he would like, “an oven to do some cooking”. Given that the majority of the residents are young people and others may be admitted on a rehabilitative basis, residents should have access to and be able to take part in appropriate daily living skills programme which would include cooking, this would be difficult to achieve by using a hob only. From speaking a relative it was confirmed that overall the home offers very good support, he commented; “the staff are manager are good, there is always someone around and my son gets to go to the places that he enjoys and he seems to be very happy here”. The home offers a varied, nutritious and healthy menu. Some comments from residents and relatives included, “I love the food”, “it is very good and there is always a choice”, “the food always looks very nice and everyone seems to be satisfied”. Lunch was observed and consisted of either scampi and chips or shepherds pie, peas and chips, followed by a variety of desserts. Lunch is the lighter meal, the main meal being served at teatime and on the day was going to be chicken breast and fresh vegetables, there was an alternative if required. The home has achieved the Heartbeat Award for offering a healthy and nutritious diet and all of the catering staff have undertaken the food hygiene training. There is a picture menu for those with communication difficulties. The menu for that day is displayed in the dining room, but staff confirmed that residents are consulted the day before as to what their preference would be and discussions are held in residents meetings about the choice on the menu. Overall it is evident that the residents are offered a very good diet and choice of food, but care is taken with regards to any special dietary needs and those who require assistance were offered this is a respectful way. Victoria House DS0000000908.V263709.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): 20 & 21 The home has a medication policy and procedure, but records do not always confirm that this is adhered to and therefore could pose a risk to the health and safety of the residents. Death and dying is handled in a sensitive and caring manner. EVIDENCE: The home has a medication policy and procedure in place, the medication records were examined and on the whole found to be in good order. From the records checked one resident’s medication stock did not correlate with what was recorded on the Medication Administration Record and therefore it wasn’t possible to ascertain whether or not that particular medication had been administered correctly. All staff who administer medication have undertaken the accredited training and when two staff were spoken to could describe what was good practice. There has been a recent pharmacist visit and no requirements were made at that time. The home has had 2 deaths since the last inspection both of which were unexpected. From speaking to two staff members it was confirmed that staff receive support and time following an event such as that and also additional support is offered to the residents. Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The home has a complaints procedure, which meets the needs of residents who feel their views are listened to. A vulnerable adults procedure and policy is available and staff are formally supervised and trained in order to protect residents from abuse. There are other policies in place to further protect the residents in relation to finances, risk assessments and staff training. The one area that requires development is training in relation to dealing with aggression or physical intervention. EVIDENCE: The home has a clear complaints procedure, information is given to the residents about how they can complain and who to. From speaking to the residents it was clear that they knew about the procedure and one confirmed that he had used this on a regular basis, “I have complained when I haven’t been happy with something, Richard sorts it out straight away”. The home has a multi-agency protection of vulnerable adults procedure and staff confirmed that they were aware of this, they also demonstrated during interview a sound knowledge of the procedure. Financial procedures are in place to ensure that the residents’ monies are handled safely. Risk assessments also ensure that residents’ are both able to take risks and have any risk managed appropriately. Although risk assessments are in place for a variety of events there were none covering alcohol and medication misuse. The organisation has a physical intervention policy, but from speaking to the assistant manager and the manager over the phone it was clear that the home does not carry out any physical intervention, the policy requires amendment to omit this part. None of the staff have received any training in relation to managing aggression and therefore could have difficulty in dealing with any Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 17 difficult or aggressive behaviour. The manager stated that some training has been arranged for March 06 in relation to dealing with aggression. Victoria House DS0000000908.V263709.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): 24 & 30 Residents live in a safe, well-maintained environment. Some adjustments to doors and exits would promote indepence. On the whole the home is clean, tidy and homely, one bedroom had urine on the en-suite floor posing a slip hazard and risk. EVIDENCE: A tour of the premises was undertaken and overall the home is well maintained, it is a large building spreading over two floors. The home has a maintenance plan and handyperson who undertakes any work that needs doing. On the day of the inspection the handyperson was carrying out repairs to a resident’s bedroom sink. The communal areas were clean, tidy and hygienic, but unfortunately the domestic hadn’t cleaned the bedrooms at that time (12.35 pm) and one room had urine over the floor in the en-suite shower room, posing a slip hazard and risk of cross infection. The assistant manager explained that currently the home had only one domestic who worked afternoons, the vacancy has been filled, but the person cannot commence work until the POVA 1st or CRB has been returned. Care staff do assist residents in and out of bedrooms and will need to be vigilant and report any spillages or risks to management. Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 19 Since the last inspection all radiators have now been covered by guards ensuring that surfaces are low temperature and do not pose a risk of burning. Communal and individual rooms are decorated to a good standard, from communicating with the residents it was clear that they have input into the colour scheme within their room, all of the bedrooms contained personal items including computers, tv’s, books, pictures and teddy bears. Several residents confirmed that they were very happy with their room and that there wasn’t anything else they require. One said, “my room is great, I have a lovely view”. A lot of the rooms and the lounge overlook the river and there is a large balcony and gardens for the residents’ to enjoy. Infection control training is offered to all staff as part of their induction. The home has policies in relation to safe working practices. Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 20 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): 34 & 35 The home’s recruitment and selection procedure does not fully protect the residents. Staff receive good induction and foundation training, more specialised areas are not covered and this would enhance the knowledge of staff and could offer a more holistic, person centred approach. EVIDENCE: The home has a clear recruitment and selection policy and procedure, from inspecting three staff files it was found that some documentation was not in place including proof of identity. All files contained a CRB check, two references and a medical declaration. A discussion occurred with the assistant manager with regard to a new employee commencing work as a domestic on 6.3.06, this person has an existing CRB and the home thought it would be acceptable for this post. It was explained that CRB checks are not portable and prior to anyone commencing employment or induction a full CRB or POVA 1st must be received, (POVA 1st is on an individual basis and subject to agreement with the CSCI). The staff files also contained personal details including a photograph, statement of terms and conditions of employment and general correspondence, training certificates were also held in individual staff files. Unfortunately, supervision records are not kept with the individual staff files and were unavailable for inspection. On the whole the training offered by the Disabilities Trust is good, the induction and foundation meets the Skills for Care specification and the Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 21 majority of files looked at confirmed that mandatory training is kept up to date. There was no evidence to confirm that more specialised training is undertaken for example, learning disability, mental health and other physical disabilities – Huntingtons, Parkinsons etc. This would enhance the good basic care offered currently to residents and enable staff to deal with a variety of conditions/issues more effectively. Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 22 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): 38, 39 & 42 The home’s quality assurance programme is comprehensive and qualitymonitoring systems are based on seeking the views of all stakeholders, this merely needs collating and an annual report produced and shared with residents and other stakeholders. Residents’ health and safety is not always safeguarded as maintenance is not always up to date. EVIDENCE: The home has developed a quality assurance system that involves residents, carers, family, staff and other professionals giving their views about the home. From speaking to the assistant manager it was clear that the home’s ethos is to promote participation and inclusion for the residents. Some comments made by the residents were; “I get to have my say and the staff listen”, “we have meetings and can express ourselves there”. There is written evidence to confirm that residents are consulted on a regular basis. Surveys are completed throughout the year and written evidence was seen, but there was no evidence to suggest that an annual report had been produced explaining Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 23 the outcome of the surveys and any relevant action required arising from those questionnaires, the report must be shared with the residents and other stakeholders and a copy forwarded to the CSCI. Overall the home offers a safe environment to the residents, some paperwork and maintenance has lapsed and requires attention. The home has a fire policy, fire risk assessment that has been updated recently. The fire alarm has been tested and regular weekly tests on equipment are undertaken, fire drills are carried out on a monthly basis. The home has had a new nurse call system fitted to ensure that all residents are able to request assistance. The home offers both induction and foundation training that meets the Skills for Care specification. Other more specialist training is not currently undertaken covering areas in relation to learning disability, mental health awareness or physical disabilities such as Parkinsons, Huntingtons. All of the hoists and passenger lift had been serviced on a regular basis, evidence was in place to confirm this. The water system had not been tested for Legionella, although the handyperson does record the temperature of the water outlets and this was within a safe range. The home undertakes its own portable appliance testing as two members of staff have undergone appropriate training and the tester is calibrated annually. From discussion with the assistant manager it was felt that the electrical wiring and gas boiler/gas appliances had been maintained, but no evidence could be found to confirm this. She was going to contact the appropriate contractors and request copies, these will need forwarding to the CSCI as evidence. Several residents that they felt safe in the home and some comments included; “we feel safe here, the staff look after us”, “it’s not safe out there, but it is here”. Residents and relatives spoke highly about the staff and manager throughout the visit, “Richard is very good, he spends a lot of time with me” and “all of the staff are approachable, if I have any queries about my son’s care I can ask any of them and Richard the manager’s door is always open”. Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 24 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 1 2 3 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 2 12 X 13 X 14 X 15 X 16 X 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 3 X X 2 X X 2 X Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 25 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 Standard YA1 Timescale for action Standards The service provider must apply 28/05/06 Act 2000 for a variation of registration in respect to persons subject to learning disabilities and those over the age of 65. The statement of purpose and service user guide must be updated to clearly state how those additional needs would be met, staff training, staff hours etc. (Previous timescale not met – 01/09/05) 12,13,14 Risk assessments must cover 28/05/06 all areas relating to the residents safety including the use of bed rails, alcohol misuse/dependency and medication misuse (non prescribed). 12,13,16,17 The registered person must 28/05/06 ensure that the medication procedure is adhered to, regular monitoring of the recording to ensure these are accurate. 12,13,16,17 See standard 9. 28/05/06 12,13,17,18 All staff must undertake appropriate training in relation to dealing with aggression or physical intervention. DS0000000908.V263709.R01.S.doc Regulation Requirement 2 YA9 3 YA20 4 5 YA23 YA23 28/05/06 Victoria House Version 5.1 Page 26 6 YA30 7 8 YA34 YA35 9 YA39 10 YA42 12,13,16,23 The home must be clean and hygienic, systems and monitoring in place to ensure this occurs. 17,19 All staff files must contain proof of identity. 17,18,19 Staff to undertake more specialised training in relation to physical and learning disabilities and mental health awareness. 17,24 The quality assurance system requires expansion to include an annual report that is shared with residents, a copy of which needs to be forwarded to the CSCI. 17,23 The water system requires checking for the risk of Legionella. Copies of the Landlord’s Gas Safety and Electrical Wiring certificates to be forwarded to CSCI. 28/05/06 28/05/06 28/05/06 28/05/06 28/03/06 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 3 Refer to Standard YA6 YA11 YA24 Good Practice Recommendations Residents care plans should be reviewed at least every 6 months. An oven to be fitted in one of the rehabilitation kitchens to enable residents to partake fully in cooking skills. The doors within the home should be assessed to ensure that they are capable of being used independently by the resident. Victoria House DS0000000908.V263709.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000000908.V263709.R01.S.doc Version 5.1 Page 28 - 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!