CARE HOME ADULTS 18-65 Victoria Lodge 59 Victoria Drive Bognor Regis West Sussex PO21 2TQ
Lead Inspector Gaynor Moorey Announced 10 May 2005 V220459 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 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 Stationary 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 Lodge Version 1.10 Page 3 SERVICE INFORMATION
Name of service Victoria Lodge Address 59 Victoria Drive, Bognor Regis, West Sussex, PO21 2TQ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01491 579270 01491 579738 Victoria Lodge Ltd Miss Jade Weston Care Home 6 Category(ies) of LD Learning Disability 6 registration, with number of places Victoria Lodge Version 1.10 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for 6 adults with a learning disability. Date of last inspection 12/12/ 2004 Brief Description of the Service: Victoria Lodge is a care home for younger adults (18-65) who have a learning disabilities. The home is registered for six service users. The home has four residents at the present time. The home is in a residential area in Bognor Regis it is a large house with surrounding gardens. There is an annex to the house that is currenlty used as an activities room. The service has an ethos that is geared very much towards promoting independence and strives for its residents to lead full lives within the community. Victoria Lodge Version 1.10 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standard Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Victoria Lodge will be referred to as both ‘service users and residents’. The inspection was announced due to issues raised at the last inspection and the need for a detailed discussion with the manager. The actual inspection took place on the Tuesday 10th May 2005 between the hours of 10.30am to 5.00pm. Four residents were accommodated at the home on the day of the inspection. The inspection included a tour of the premises and it’s facilities, with all the residents being in at some point over the inspection. The service users were consulted before their bedrooms were seen by the Inspector. Approximately three of the service users were spoken to, one resident spent a longer period of time chatting to the inspector the length of contact with the service users is very much dependent on how the service user is feeling due to the complex need of the residents in the home. The manager, deputy manager and one member of staff were spoken to during the visit; whilst staff were also observed carrying out their duties. Records and documentation inspected included: residents files and the homes complaints book. A copy of the policies and procedures had already been sent to the Inspector as part of the inspection process. What the service does well:
The home has maintained a consistent staff team since last July this has allowed the service to develop and implement a comprehensive training programme that has given the team extra knowledge when working with the residents who have complex needs. The residents through conversations and questionnaires indicated that they felt happy and settled at the service and that the staff were kind and considerate. The home’s environment is now generally well maintained inside and out and is decorated to a consistent level with repairs being undertaken quickly by a local contractor. The home has a good system in place to deal with complaints and any possible incidents of adult protection, these systems are backed up by staff training. One service user said he felt that he could share his problems with the staff
Victoria Lodge Version 1.10 Page 6 and that they would listen and help him. Victoria Lodge now has an atmosphere that is homely, relaxed, and caring. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or
Victoria Lodge Version 1.10 Page 7 by contacting your local CSCI office. Victoria Lodge Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Victoria Lodge Version 1.10 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 standard(s) 1, 2, 3, 4, 5 The home provides good information for prospective service users and their representatives to make an informed decision about whether or not to move in. The service gathers together information on each potential resident and assesses the appropriateness of each person related to facilities and services at the home and how the possible new resident would fit in and relate to the service users already residing in the home. The service offers potential new residents a programme of introduction into the home to help their moving in period. However the service user contracts are not produced in an appropriate format meaning that resident are unable to understand guidelines set down for them whilst living at the home. EVIDENCE: Victoria Lodge have developed a satisfactory statement of purpose that outlines the layout of the premises, the homes philosophy of care, and the nature of the services offered to the residents. The home have also developed a service users guide which is available in two formats, one of which is Makaton. Residents files contained pre-admission information and assessments which had been completed by the referring Care Management Team. The service also
Victoria Lodge Version 1.10 Page 10 undertakes their own assessment on potential new people before confirming a placement. This process ensures that the home potentially can offer an appropriate service to each new person. Victoria Lodge has updated its training programme in order to meet the complex needs of those service users in place. Evidence was seen on file of the specialist services the home use to facilitate full care of the residents. The home has an introduction into the program that includes an initial visit to the home, meals and a overnight visit. One resident stated that he remembered having visits to the home before moving in and that the staff had been nice to him he also felt that some people were not right for the home because they made to much noise. The home does accept emergency placements this has caused problems previously for the home as the situation has caused unsettled feelings for the other residents due to the high impact of behaviour displayed by the people who have been placed in the home. Victoria Lodge now has a policy set around the emergency placements and people are always visited in their existing placement and the manager will undertake an assessment before agreeing to the person moving into the home. Victoria Lodge does have contracts in place for the residents. However these documents are not appropriate for the service users as they are too wordy and not set in an appropriate format. One service when spoken to said ‘he was unaware of any such thing’. The situation with the contracts needs to be reviewed so such documentation bears some relevance for the residents in the home. Victoria Lodge Version 1.10 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 standard(s) EVIDENCE: Victoria Lodge Version 1.10 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 standard(s) EVIDENCE: Victoria Lodge Version 1.10 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: Victoria Lodge Version 1.10 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 Arrangements for protecting service users are satisfactory keeping residents safe from risk of harm or abuse. Complaints are always taken seriously by the home and service users are confident that any concerns they may have are listened to and acted upon. EVIDENCE: The home has a detailed complaints procedure that is available in a service user ‘friendly’ format with both Makaton and symbols. The procedure is displayed on the office door in the service. No complaints about the homes operation have been received by the CSCI or the home in the past nine months. One service user spoken with said that staff working at the home, including the manager, were extremely approachable, and willing to listen to any concerns that he had. From the interaction observed between the service users and staff on duty at the time of this inspection it was apparent that they have good working relationships. The home has a comprehensive collection of procedures for responding to allegations or suspicion of abuse. Staff are trained in dealing with incidents or disclosures of abuse from the residents. A policy document is also available on dealing with aggression and service users care plans include specific guidance to help staff support service users whose behaviour may challenge the service from time to time. Victoria Lodge Version 1.10 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 30 The home is furnished and decorated to a good standard and is kept clean and tidy ensuring that the residents live in a homely, bright and well kept environment, which suits their lifestyles. The service has risk assessments in place to ensure the home is safe and to minimalize any risks to the service users. EVIDENCE: Victoria Lodge has historically had environmental problems a majority of the requirements from the last inspection referred to areas within the home. The service has made improvements to ensure the home now maintains the environment through a quick response to repairs and maintenance. The home was inspected by the Fire Department in January 2005 and was found to have satisfactory fire systems. The home has adequate communal areas including two lounges, a conservatory and activity room. The house is surrounded by a small garden and the service users are currently growing a variety of vegetables. The home uses local facilities for outside games. The home was found to be clean, tidy hygienic and free from any odours or smells.
Victoria Lodge Version 1.10 Page 16 All of the residents bedrooms were seen with their permission the rooms were seen to be very personalised. Some of the rooms are on the development plan to be re-decorated in the next six months. The rooms are furnished to a satisfactory standard. Service users who were spoken to stated that they were happy with their rooms and that they are consulted about décor. Victoria Lodge Version 1.10 Page 17 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35, 34, 36 The assessed needs of residents are met by the numbers and skills of care staff deployed at the home. The home maintains excellent records and supports and trains the staff to ensure that the residents have all of their needs met and to ensure that they are protected and safe. EVIDENCE: Within the home there has been a settled staff team since July 04. There is a mix of staff from various ethnic backgrounds. The team is mainly female and currently there are two male employees out of twelve staff. The manager has recently advertised in the local paper and is looking to employ more male staff if possible. This would be a positive for the residents as three of the four service users are male. The home has excellent staff records and through the recruitment procedures maintains two references and a CRB check on each member of staff. The home also undertakes to check staff through the POVA system. Staff receive both a job description and contract at the beginning of their employment. Part of the recruitment process is a three- month probationary period that can be extended to six months if needed. The system in place helps to ensure the safety of the residents. The records and the staff spoken to confirmed the system is in place and used for all new potential employees.
Victoria Lodge Version 1.10 Page 18 There is clear evidence of the training programme in place at the home the staff spoken to confirmed that regular basic training had been offered and undertaken. All the staff had undergone an induction programme this had been recorded and kept within the staff file. Currently only the manager has the NVQ3 qualification the company have not yet offered NVQ training to the general staff this has been an issue from previous reports. The manager is aware of the requirement for NVQ training and has said that within the next six months the company are going to implement NVQ training for all established staff. The staff spoken to stated that they felt fully supported by the manager and assistant manager. Supervision is given on an eight weekly basis there is evidence provided through a system where both the supervisor and supervisee both sign to confirm that sessions take place. Currently no appraisals have been completed these are set to happen over the course of May and June 05. The manager is not receiving the required amount of supervision this was confirmed within the records and from the manager. It is essential that supervision is provided to the manager so that she may feel supported with the running of the home. Victoria Lodge Version 1.10 Page 19 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 The home has a quality assurance system in place that involves consulting those involved with the service including the residents. The home has not undertaken a full programme of quality assurance so although the system is in place it has not yet been used to benefit the service users or help to assist in the development of the home. EVIDENCE: Within the home there is a quality assurance system in place that includes questionnaires appropriate for service users, families/carers, professionals and staff. A full assessment has not been undertaken. The home does not have a development plan in place. The implication of not having either undertaken a quality assurance survey or completed a development plan indicates that the home do not have service user, family/carer or professionals involved at the service ideas or input into planning improvements or future changes for the home. Victoria Lodge Version 1.10 Page 20 The policies and procedures for the home were last updated in 2003 the manager said that over the course of this year the guidance would all be updated and designed to be specifically appropriate for adults with learning disabilities. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 3 3 1 Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
Victoria Lodge Score x x x x x Standard No 24 25 26 27 28 29 30
STAFFING
Version 1.10 Score 3 3 3 x x x 3 Page 21 LIFESTYLES Standard No 11 12 13 14 15 16 17 Score x x x x x x x Standard No 31 32 33 34 35 36 Score x x x 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x x x Standard No 37 38 39 40 41 42 43 Score x x 2 x x x x Victoria Lodge Version 1.10 Page 22 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 St 5 Regulation 5 Requirement The home needs to develop service user contract that are appropriate for the residents and enable them to understand the document they are required to sign. The company need to ensure that NVQ training is offered to all established staff as part of their on-going development. The home needs to implement a new development plan and undertake an quality assurance survey for all those living and involved in the service. ( outstanding from the previous inspection). Timescale for action 31st July 2005 2. ST35 18 31st July 2005 31st July 2005 3. ST39 24 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. Refer to Standard ST36 ST36 Good Practice Recommendations The manager needs to ensure that the staff all undergo an appraissal over the next four months. The company need to ensure that the manager is receiving regular supervision sessions.
Version 1.10 Page 23 Victoria Lodge Victoria Lodge Version 1.10 Page 24 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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