Inspection on 05/09/06 for Victoria House

This inspection was carried out on 5th September 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 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Victoria House 28/02/06

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 Sarah Urding Unannounced Inspection 5th September 2006 08:30 Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 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.V311391.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 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.V311391.R01.S.doc Version 5.2 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 Position Vacant Care Home 24 Category(ies) of Physical disability (24) registration, with number of places Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To retain three named service users over the age of 65 years. Date of last inspection 28th February 2006 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 wellmaintained 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 residents 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. The current scale of charges are £559.84 - £1104.76 per week. Additional charges include hairdressing, chiropody, music therapy, aromatherapy and transport (excluding health care appointments). Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection and the visit to the home was unannounced, taking place over a period of two days. Fifteen hours were spent at the site visit. Questionnaires were sent out prior to the site visit to a range of people who have an experience of the service. The inspector received comments back from one GP; ten care managers and seven members of staff. This information as well as information received from the manager provides a focus for inspection and will be reflected in this report. On arrival at the home the building was looked around and a number of records and policies were inspected. The manager, assistant manager and four members of staff were spoken to. Eleven residents and two visitors to the home were also spoken to. What the service does well: The home ensures that a thorough assessment is carried out prior to residents living in the home. This information is gathered together in detailed and clear care plans for residents. This means that staff are well informed about how best to assist residents in daily living. Staff in the home have a good understanding of the importance of enabling residents to live their own lives and make their own decisions. Residents can choose the way that they live their lives and the flexible routine of the home contributes to this. The home feels very much like the residents own home and people are able to choose and maintain their own relationships. Some of the residents and visitors spoken to confirmed this and say that the home is a welcoming place. Personal healthcare and support is well met on an individual basis. One visitor to the home was particularly positive about the levels of care and assistance provided by staff to her daughter. Residents understand how to complain and feel that staff listen to what they want. Residents also say that they feel safe when staff are assisting them with personal care. Staff understand how to protect vulnerable adults from harm and were knowledgeable about how to report poor practice appropriately. This means that residents are protected form harm. The home is well decorated and suitable for its purpose. The home is clean and hygienic. Staff practice in a safe way to reduce the risk of cross infection. Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 Page 6 The home is well managed and residents are consulted with as to the running of the home. Residents are able to contribute and change things for the better. What has improved since the last inspection? What they could do better: Residents feel that they would be better able to contribute to the running of the home if they were invited to attend staff meetings. Residents should be given more opportunity by the home to be engaged in employment if they wish. A more regular programme of group activities should be developed for those residents not taking part in individual activities on a daily basis. It is important that the home informs residents of events in the home in a suitable way. The existing notice board is not user friendly and does not look interesting. One resident also says that she does not always know which staff are on duty. Ways to inform residents of this should be explored. Some of the staff and residents say that the minced and liquidised food is not well presented. Some residents say that the food is difficult to swallow because it lacks enough moisture. The company must get this right and provide training to staff in this area. Residents’ medication must be administered as prescribed. There was evidence to suggest that one resident had not been given their medication on one occasion. The record for this stated that the medication had been given when this was not the case. Records must be accurately kept to demonstrate that residents’ needs are met. Staffing problems in the home need to be addressed. Both residents and staff indicated that there were not always enough staff to meet all the needs of residents. On one occasion recently the home only had two members of staff on duty at one time. This is not acceptable and must be addressed to ensure that people can be safely assisted and cared for. The recruitment of one member of staff was not safe enough to ensure that the risks to residents were minimised. The home must follow regulation when recruiting staff so that people are protected. Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 Page 7 Staff are generally trained well to carry out their roles effectively. However some specialist training is required so that staff fully understand how to assist and care for people with cerebral palsy. The water system requires checking for the risk of Legionella to ensure that this is safe for residents. This was a requirement made at the last inspection and has not yet been met by the home. A copy of the certificate must be sent to CSCI on completion so that the home can evidence it is practising safely. 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.V311391.R01.S.doc Version 5.2 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.V311391.R01.S.doc Version 5.2 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): 2 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is able to meet the needs of residents’ owing to a thorough assessment on admission. EVIDENCE: All new residents receive a full needs assessment prior to being admitted to the home. Assessments are undertaken by experienced members of staff and involve the individual and their family or representative where appropriate. Where the assessment has been undertaken through care management arrangements, the service requests a copy of the summary of assessment and a copy of the care plan. This means that the home ensures that residents needs can be met before agreeing to admit them. Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 Page 10 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 and 9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Resident’s individual needs and choices are promoted through detailed care planning and an understanding of the importance of residents’ involvement. EVIDENCE: The service has a strong belief that it is essential to involve residents in the planning of care that affects their lifestyle and quality of life. Staff understand the importance of residents being supported to take control of their own lives and encourage them to exercise their rights and make decisions and choices. Care plans are very well presented and detailed in content. Service users are given a pack containing their care plan, the statement of purpose, service user guide, contract and a charter of rights. The care plan is presented in a format that residents can understand. Information is also available on a cassette if this is the preferred form of communication for residents. A key worker system enables staff to establish relationships with residents and work on a one to one basis. Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 Page 11 The plan is regularly reviewed involving the resident and their families where agreed. The residents living in the home have a diverse range of communication styles. Staff are aware of how to communicate with residents on an individual basis and induction training involves learning these skills. Residents say that they feel listened to and able to make their own choices about how to live their lives. Where residents are unable to make decisions because of risk or circumstance this is recorded and only limited after discussion in a multi disciplinary arena. One resident says that he fears that his finances are being taken over by the home. In discussion with the manager this is an on going issue that has been discussed with the resident at his last review. The issues and subsequent decisions made have been discussed fully and recorded in the resident’s care plan. The manager is aware that the resident is unhappy with the situation and had planned to address this matter again at a forthcoming review. The home has been dealing with this issue entirely appropriately to date. The manager has agreed to send a copy of the review minutes to CSCI. The home ensures that residents can access independent advocacy and selfadvocacy groups. One resident is a trustee within the company and is particularly positive about the home enabling her to make decisions about her own life. She says that she gets what she wants because staff do listen to her. Each plan includes a comprehensive risk assessment, which takes account of the specialist needs of people who use the service. The manager is aware of the need to balance risk with people’s aspirations for independence and choice. This means that residents are able to retain control over their lives. Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Good facilities are provided for residents to experience individual activities, relationships, community and religious involvement of their choosing where rights and responsibilities are respected but lack of nutritional training for staff results in dietary intake for residents being compromised. EVIDENCE: Staff are aware of the need to support residents to develop their skills, including social, emotional, communication and independent living skills. However this process could be improved. In talking with one resident she says that some residents are very lonely because staff are not able to spend the time with them that they need. This was a concern during my visit as residents have a diverse range of communication styles where interactions are time consuming due to the nature of some people’s disabilities. This along with the recent staffing difficulties places doubt on whether staff are able to give people the time that they need to communicate fully. One resident says Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 Page 13 that she would like some of the residents to be involved in staff meetings so that they can get their points of view across to staff. It is recommended that this take place. The deployment of staff will be addressed further in the staffing section of this report. Residents, however, are consulted with or listened to regarding the choice of daily activity. A variety of individual programmes are provided which include access to motorbike workshops, literary classes and arts and craft sessions. The recommendation made at the last inspection for ovens to be provided so that residents develop a full range of cooking skills has not yet been met by the home. The manager says that the home has plans to provide ovens in the near future. In discussion with the manager she spoke of the lack of resources in the area for education for people with physical disabilities. The courses run at the local college are for people with a learning disability and are not geared to facilitate the learning of the majority of residents in the home. The home attempts to fill this gap by providing a variety of learning opportunities for residents where certificates of achievement are given on completion of courses. Courses run in the last year include “Where we are”, “Body Works” and “The Viking Story”. This process could be further developed to look at employment opportunities for residents, where appropriate, in the local area as none of the residents are currently employed. Residents feel that they are part of the community and the home actively encourages this. Some of the residents are currently involved in a project in the community and one resident is a member of the Victoria Dock residents group. Good levels of support are provided for residents to take part in community activities and the home has links with the Hull Ability Club, Do something Different Club, Hull Lions and The Rotary Club. There are usually activities that take place within the home on a regular basis for residents to enjoy. A programme of activities is in place, which includes cooking skills, arts and crafts etc. Many of the activities for people are individualised which is good practice. On the first day of my visit to the home there were no activities taking place within the home. This could be improved upon by establishing regular opportunities for people to partake in group activities when not involved in their individual activities. The process of notifying people of events and activities lacks imagination and information is not provided in attractive or appropriate formats for some residents to understand. It is recommended this be addressed. Staff also say that because of recent staffing issues they do not spend as much one to one time with residents as they would like. This will be looked at within the “Staffing” section of this report. Residents are able to establish and maintain relationships of their choosing. One resident and member of her family visiting the home are particularly Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 Page 14 positive about this and say that the home is very flexible and accommodating. Guests can stay the night if they wish. There is a real sense that the home is the resident’s home and staff promote this ethos in their practice. All of the residents spoken to say that they can come and go as they please. Routines are flexible and their rights are respected by staff. Staff were observed to call residents by their preferred form of address and some residents say that they are able to choose the levels of participation in the home. The menus presented to me in the pre-inspection material are well balanced and varied. Choice is provided at every meal. However, many of the staff indicated in questionnaires sent out prior to inspection that they are not happy with the standard of presentation of many of the meals. Special diets are catered for but staff indicated that minced food “looks like dog food” and that liquidised food is not the correct consistency. One of the residents confirmed this and says that she finds some meals difficult to swallow, as there is not enough moisture in them. In discussion with the cook it is clear that the company has not provided the correct levels of training regarding nutritional intake for those residents on special diets. This must be addressed. Staff also raised concerns about the diet of one resident where it specifies in his care plan that food must be minced. The resident however refuses to eat most of the minced food and prefers it to be cut in to small pieces. The staff have respected the residents wishes and are providing diced food. Whilst it is understandable that staff want to respect the resident’s wishes, this practice could place him at risk. The current situation must be reviewed immediately. I also observed some poor practice during mealtimes for those residents who require assistance with feeding. Staff were observed to feed two residents at one time when assistance must be provided on a one to one basis. Staff also indicated that a lot of food is fried and that healthy eating is not promoted as well as it should be. The home however does have a Healthy Heartbeat Award. There are some elements of good practice in terms of educating people about healthy eating, however, in light of these comments this should be further progressed. Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The approach to residents’ personal support and health care is individualised and results in needs being well met. However there is a shortfall in the recording of the administration of medication, which highlights inconsistent practice. EVIDENCE: Residents’ personal files include details of any personal, emotional and physical health needs. Where necessary specific individual plans are in place, for example, moving and handling, posture and diet. GP’s and health practitioners confirmed in questionnaires that they have no concerns about how the home operates in this area. Residents’ appearance reflects their individual personalities and daily notes reflect that service users choose their routines. Staff and residents confirm that individuals are supported with their health and personal care needs. However, some staff expressed concerns in their questionnaires that personal care is not always fully met by all staff. For Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 Page 16 example, assistance with shaving, toileting and showering. In exploring these issues further during the site visit staff spoken to confirmed that they have raised issues in the past regarding this. They feel that on the whole the issues raised have been dealt with appropriately. However, one resident says that staff sometimes take a long time to come when assistance is required. She feels that this is due to not enough staff being on duty. This issue will be raised in the “Staffing” section of this report. One visitor to the home says that the equipment is maintained to a high standard. This includes the cleanliness of wheelchairs. The medication system is generally well managed and monitored. Records indicate that shortfalls in the system are highlighted by senior staff. There are no residents at the present time responsible for administering their own medication and the home takes on this role on their behalf. Residents’ records reflect that any queries regarding medication are followed up. Medication is appropriately stored and records are maintained. Four residents medication and corresponding records were assessed. Three records were accurately managed. However, the record for one resident indicated that a tablet had been administered when it remained in the blister pack. Staff must ensure that accurate records are kept and use the correct entry system to specify why medication is not given. Medication must not be signed as administered when it is not. Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for complaints and protection are handled well. EVIDENCE: The home has a clear complaints procedure in place. Residents spoken to say that they feel confident to raise issues of concern if they arise. The relationships between staff and residents were observed to be open and inclusive. This is encouraging and evidences that residents concerns will be dealt with appropriately. Complaints are recorded in a complaints log and addressed by the manager. There have been two complaints since the last visit to the home. These are currently being addressed. A resident raised a concern with me during the inspection. This was passed on to the manager with the resident’s permission. The resident requested that the concern be addressed by someone external to the home. The company has this provision in place and the manager agreed to progress this for the resident. Details of how the complaint has been addressed by the home should be sent to CSCI for information. The home has an appropriate policy in place for the protection of vulnerable adults. Staff spoken to are clear about reporting procedures should a resident make an allegation and around the indicators of abuse. Residents spoken to say that they feel safe when being looked after by staff. Staff receive training in this area as part of the induction process. Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 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 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users live in a safe, clean and comfortable environment, which is well maintained. EVIDENCE: The building was looked around and found to be clean, well maintained, hygienic and suitable for its purpose. Residents live in comfortable surroundings. The home is well decorated throughout but the lack of a plan outlining the regular upkeep of the building is not in place. Without this I cannot be confident that standards will be maintained. A plan of intended works with timescales should be produced and sent to CSCI for information. This will demonstrate the home’s commitment to maintaining and improving environmental standards for residents. The requirements of the fire and environmental health departments are being met by the home. Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 Page 19 During the visit a shelf in one resident’s room was found to be unsafe. There was a large television on the shelf, which had caused the shelf to buckle under the weight and lean forward. The manager was asked to address this issue immediately as it presented as a risk to the resident and staff. Appropriate action was taken prior to my departure. Specialist equipment and training are in place for the moving and handling of residents. Residents say that they feel safe when being assisted by staff. Policies for the control of infection are in place and followed in practice. The home has a laundry, which is suitable to meet the needs of residents. Residents are satisfied with the laundry service that the home provides and domestic appliances are provided for those residents who wish to use them. Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 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): 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are supported by well trained staff but staffing shortfalls at the present time mean that consistent practice is compromised. Lack of consistent rigour in the recruitment process places residents at risk of being looked after by unsuitable staff. EVIDENCE: Staff are well inducted to meet the needs of residents in the home. There is a positive ethos within the home and staff display a sound understanding of the importance of enabling and including residents in decision making about their lives. Staff are engaged in a programme of NVQ level 2 qualifications but the home does not currently meet the recommended level of 50 . Four staff are currently engaged in this qualification and on successful completion the home will meet this standard. The home is generally appropriately staffed to meet the needs of residents. However in recent months there have been shortfalls in staff. Agency staff have been used on occasions and the home is currently recruiting to provide permanent staff. During the weekend before my visit to the home it was noted that there were only two staff on duty. This is unacceptable as the needs of Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 Page 21 residents are compromised. The manager was unaware that this was the case and says she will look in to this, as agency staff would have been provided. It is my belief that this was an isolated incident but nevertheless must not occur. Some residents say that at times staff take time to respond to their calls and that staff cannot spend as much time with them as they would like. Staff commented on this also. One resident says, “Some staff just come and get the residents up and do nothing else with them”. The lack of group activities on a day to day basis may also be indicative of a staffing issue. Also as mentioned previously in this report the communication needs of residents may not be consistently met due to the length of time it takes for some residents to communicate and the difficulties that staff have in the need to balance the personal care role with one to one time. The deployment of staff should be reviewed in light of this information. One resident says that she does not know the staff that are on duty at night. This was discussed with the manager who indicated that the condition of the resident could lead to short term memory impairment. However it would be good practice if the home developed a system for informing residents of which staff were on duty at a given time. The recruitment of staff is generally sound and ensures that the risks of employing unsafe people to work with residents are minimised. However, it was found that the recruitment of one member of staff did not adhere to regulation. Although a POVA first and CRB check had been carried out prior to the person starting work, only one written reference had been sought. Regulation states that two written references must be provided. This inconsistency does not fully protect residents and must be addressed. Staff receive regular training to undertake the work they perform. This includes training in equality and diversity. However this could be further improved. As mentioned previously in this report there has not been appropriate nutritional training for the cook. Some of the residents in the home have cerebral palsy and there is currently no training about this condition. This is recommended. Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 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): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents live in a well managed home that is inclusive but the recent change in manager has been unsettling for some residents and staff. EVIDENCE: The registered manager for the home has recently left the company and a new manager has been in place for six weeks. The manager is not yet registered with CSCI but an application is in process. The manager is an experienced practitioner and has been employed by the company for eleven years. She has been in a managerial role for four years. The manager has recently achieved an NVQ level 4 in care and plans to start The Registered managers Award in September. The manager feels supported in her role by the company and has a clear job description. The length of time in post has not yet enabled the manager to make effective change within the home. The manager says that Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 Page 23 she has spent the short time auditing standards of care and highlighting areas for improvement but has not yet had the opportunity for their implementation. It is clear form talking to staff and residents that the change has been unsettling for some whilst for others this is viewed as entirely positive. This is to be expected with any change in management and the manager is looking forward to establishing herself in the role. There was one accident involving a resident that required notification to CSCI under regulation. This had not occurred and must be consistently carried out. 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 manager and staff it is clear that the home’s ethos is to promote participation and inclusion for the residents. Some comments made by the residents were; “I always get what I want because the staff listen to me”, “we are involved in making decisions about how the home is run”. There is written evidence to confirm that residents are consulted on a regular basis. Surveys are completed throughout the year and an annual report is produced explaining the outcome of the surveys and any relevant action to be taken. The home has a fire policy and a 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 a nurse call system fitted to ensure that all residents are able to request assistance. The water system has not yet been tested for Legionella but an appointment has been made for this to take place shortly. On completion a copy of the certificate must be sent to CSCI to evidence that health and safety requirements are being met in this area. The home undertakes its own portable appliance testing as two members of staff have undergone appropriate training. Residents and relatives spoke highly about the staff and manager throughout the visit and say that the environment is kept very clean and safe. Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 2 12 2 13 3 14 2 15 4 16 4 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 Page 25 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 YA17 Regulation 12, 18 Requirement Timescale for action 31/10/06 2. YA17 3. YA17 4. YA20 5. 6. YA33 YA34 7. YA42 Training must be provided for staff regarding nutritional intake for those residents requiring special diets. 12, 15 The dietary requirements of one resident must be followed or the change formally reviewed and recorded in his care plan. 12, 13 Residents must receive appropriate assistance at mealtimes. Assistance with feeding must take place on a one to one basis. 12,13,16,17 Medication must be administered as prescribed or the reasons for nonadministration clearly recorded. 12, 18 The home must be appropriately staffed at all times. 12, 19 Staff must be recruited safely. Two written references must be in place prior to staff starting work. 17,23 The water system requires checking for the risk of Legionella. A copy of the certificate must be sent to CSCI on completion. Previous timescale of 28/03/06 was not met DS0000000908.V311391.R01.S.doc 30/09/06 30/09/06 30/09/06 30/09/06 12/09/06 30/09/06 Victoria House Version 5.2 Page 26 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. 4. 5. 6. 7. 8. 9. 10. Refer to Standard YA11 YA11 YA12 YA14 YA22 YA24 YA32 YA33 YA33 YA35 Good Practice Recommendations Residents should be given the opportunity to attend staff meetings An oven should be fitted in one of the rehabilitation kitchens to enable residents to partake fully in cooking skills. Residents should be accessed to employment opportunities. A regular programme of group activities should be established. Information about events and activities should be conveyed to residents in appropriate formats. Details of how the referred complaint is addressed for one resident should be sent to CSCI. A maintenance plan for the ongoing re-decoration of the home should be developed and sent to CSCI for information. 50 of care staff should be qualified to NVQ level 2. The deployment of staff should be reviewed to enable staff to spend more quality time with residents. Information should be provided to residents in appropriate formats about which staff are on duty at a given time. Training should be provided to staff about cerebral palsy. Victoria House DS0000000908.V311391.R01.S.doc Version 5.2 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.V311391.R01.S.doc Version 5.2 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. 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