CARE HOME ADULTS 18-65
Victoria House Residential Home Victoria House 30 - 31 Victoria Embankment Darlington Durham DL1 5JR Lead Inspector
Jean Pegg Unannounced Inspection 12th October 2005 10:00 Victoria House Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 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 Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 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 Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Victoria House Residential Home Address Victoria House 30 - 31 Victoria Embankment Darlington Durham DL1 5JR 01325 244960 01325 244961 admandaatkins@castlebeck.com 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) Castlebeck Care (Teesdale) Limited Ms Amanda Atkins Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Victoria House Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th June 2005 Brief Description of the Service: Victoria House is owned by Castlebeck Care (Teesdale Limited) Group. The home is registered to provide residential accommodation for seven service users with a learning disability aged between eighteen and sixty five years. Externally the home appears as two terraced houses but inside alterations have taken place that connect the two houses so that they operate as one home allowing service users access to both properties. The home is located in a residential area that is within walking distance of the town centre and all local transport links etc. The accommodation provided includes single bedroom accommodation, each with wash hand basin. Service users have access to two lounges, two kitchen diners, three toilets, one shower and one bathroom. There is also staff sleeping accommodation. Outside there are small paved gardens to the front of the house and a yard area at the back of the house. Victoria House Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Wednesday October 12 and lasted for four hours. This inspection covered all of the remaining key standards not covered in the June inspection. Once again all of the service users were seen and spoken to during the time spent there and once again everyone was warm, friendly and cooperative. The inspection went well with no issues identified for improvement. One service user made a point of saying that they were “very happy here” What the service does well: What has improved since the last inspection?
The last inspection recommended that the manager should consult service users to find out how they could be more involved in making decisions within the home. The manager was able to show how this had improved and service users were able to say how they had been involved in recent decisions about decorating in the home. Victoria House Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 Page 6 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 Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 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 Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 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): None None of these standards were assessed. EVIDENCE: Victoria House Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 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): None. None of these standards were assessed. EVIDENCE: Victoria House Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 Page 10 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): None None of these standards were assessed. EVIDENCE: Victoria House Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 Page 11 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 Care plans describe the level of personal support agreed with each service user so that all parties know what should be happening. Service user’s health needs are monitored and any problems are referred onto people who can help. Clear procedures are in place to help service users remain independent and self medicate safely. EVIDENCE: One service user’s file was looked at in detail. The file showed that detailed plans were in place to advise staff as to the agreed way to support the service user with their personal care. All plans were agreed with and signed by the key worker and service user. Arrangements for bathing, meals, going to bed etc are flexible and agreed with individual service users. Service users confirmed this. Contact details for specialist health care practitioners are listed in service user files and these files are regularly reviewed by key workers. Victoria House Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 Page 12 Service user health care needs are regularly assessed and reviewed by staff. One service user spoke about a recent trip to the hospital regarding a health issue. There was evidence on file to support the conclusion that service users health needs are monitored and access to other health professionals is facilitated. Service users are registered with a local GP whose surgery is within walking distance of the home. All service users self medicate and the way staff assist service users to self medicate was observed. The home has good documentation in place including risk assessments, written information about medication and side effects, up to date information about what medication is for and permissions for the giving of homely remedies. The observation of this process showed that staff and service users knew the procedures to follow to make sure that the correct medication was taken. When asked, one service user was able to say what the tablet they had taken was called, what the dosage was and what it was for. Records confirmed that the service user was correct. Documentation showing the receipt and disposal of medication was seen. All documents were found to be in order. Victoria House Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 Page 13 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): None None of these standards were assessed. EVIDENCE: Victoria House Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 Page 14 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 The home remains comfortable and well maintained. EVIDENCE: Since the last inspection one of the lounges has been redecorated and new carpets laid. The shower room and bathroom have also been redecorated and a new kitchen has been fitted. Victoria House Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 Page 15 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 takes appropriate steps to make sure that the staff they recruit are suitable for working in the home. Staff are offered training in areas that will help them meet service user needs EVIDENCE: The file of a recently appointed member of staff was checked and documents were found to be in order. The home carries out all of the checks needed to protect service users from being cared for by staff who are unsuitable. A new member of staff spoken to described how they had been helped to settle in at the home. All comments made were very positive. The home has access to a comprehensive training programme. The manager provided a copy of the training plan produced for the home which has been forwarded to head office. This plan shows completed and planned training for staff. A range of different topics are included for example health and safety training, management training and client specific training and training that leads to formal qualifications. Victoria House Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 Page 16 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 &42 The home is properly managed for the benefit of the people who live and work there. The home carries out a number of different activities to monitor the quality of the care provided to service users. Service users are involved in these monitoring activities. The home carries out health and safety checks so that people who live and work there are protected and safe. EVIDENCE: The registered manager has qualifications in nursing and management. It is clear from the inspection that the home is properly managed for example the records and documents shown, the appearance of the building and people who live and work there and the comments made by the people who live and work there. Victoria House Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 Page 17 The home has a range of different tools that are used to monitor the quality of care including internal and external audit tools. The home received an excellent external audit report in June 2005 showing compliance with ISO9001. The home also carries out Periodic Service Reviews (PSR) which audit a range of different things like care plans, accidents, files, the environment etc. A service user satisfaction survey was carried out in June 2005, the questions were very much focussed on the service user and what they thought about life in the home. There was evidence of service users having been more involved in decision making within the home. Those spoken to confirmed the involvement they had had in choosing the new decoration fabrics and colours for the home as well as choosing the new kitchen that had been recently fitted. Policies and procedures are reviewed regularly. Service users were able to recognise the inspector from the poster displayed on the notice board and all seemed to be aware of the reason for inspections etc. Records showing safety checks and maintenance checks were examined. Risk assessments were also seen. All documents were found to be in date and in order. Victoria House Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 x CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Victoria House Residential Home Score 3 3 4 X Standard No 37 38 39 40 41 42 43 Score 4 X 4 X X 3 x DS0000000817.V255860.R01.S.doc Version 5.0 Page 19 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Victoria House Residential Home DS0000000817.V255860.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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