Inspection on 15/01/08 for Victoria Lodge

This inspection was carried out on 15th January 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Victoria Lodge 16/11/06

Victoria Lodge 03/11/05

Victoria Lodge 04/05/05

Victoria Lodge 15/12/04

Victoria Lodge 07/07/04

Similar services:

Ashlea Mews Residential Home

Eastwood

West Lodge

Arran House

Avenue Community Nursing Home

Cosin Lodge

Farmborough Court

Cragston Court

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

CARE HOME ADULTS 18-65 Victoria Lodge 36 Emerald Street Saltburn-by-Sea TS12 1ED Lead Inspector Val Daly Unannounced Inspection 15 January 2008 09:30 Victoria Lodge DS0000000060.V352943.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 Lodge DS0000000060.V352943.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 Lodge DS0000000060.V352943.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Lodge Address 36 Emerald Street Saltburn-by-Sea TS12 1ED 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) 01287 624337 Mr D Kerrison Mrs S Kerrison Ms Penelope Joan Markham Care Home 14 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (14) of places Victoria Lodge DS0000000060.V352943.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Mental disorder, excluding learning disability or dementia - Code MD, maximum number of places: 14 The maximum number of service users who can be accommodated is: 14 16th November 2006 2. Date of last inspection Brief Description of the Service: Victoria Lodge is registered as a care home under the Care Standards Act 2000 with the Commission for Social Care Inspection to provide care and accommodation for up to fourteen adults who have a mental disorder. The home is situated in a quiet street near the main shopping centre. It is within walking distance of the seafront and promenade facilities. The home is in a residential street and is indistinguishable from family homes in the area. Residents at the home are encouraged to live as independently as possible and to utilise the local amenities and community. The accommodation is on three floors and there are fourteen single bedrooms. The weekly fees for the home are from £380 to £385. Victoria Lodge DS0000000060.V352943.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was a key unannounced inspection and was completed by an inspector in one inspection day. As a key inspection, all of the key standards were examined. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use services, and that it does what the Care Standards regulations say it must. A number of records were looked at including resident’s assessments and plans of care, staff recruitment records, complaints and maintenance records along with the annual quality assurance assessment. Two residents two members of staff and the deputy manager, were engaged in discussion about living at Victoria Lodge. The manager had completed an Annual Quality Assurance Assessment prior to the inspection. The AQAA is the services self-assessment of they thinks they are meeting the National Minimum Standards. This information is received prior to the inspection and it is then used as part of the inspection process. On the day of the visit the manager was on sick leave and the deputy manager provided the information and documentation required. The Commission for Social Care Inspection sent a number of surveys to the home for people who use the service to complete. Four were completed and returned from people who use the service and relatives. Comments received can be read within the report. The Inspector was warmly welcomed by all. Feedback was well received and there was constructive discussion throughout. What the service does well: Victoria Lodge provides a clean, pleasant and well-maintained home for people to live. It provides the people who use the service with a comfortable and homely environment, offering a good standard of care. People who use the service are involved in a wide range of activities and hobbies depending on their particular likes and dislikes. Some people said they preferred to spend their time at home, in their own rooms or lounges, reading, listening to music, watching television, helping set the tables, tidying the conservatory. A new person said she liked being in the kitchen and the cook Victoria Lodge DS0000000060.V352943.R01.S.doc Version 5.2 Page 6 was hoping to encourage her to help bake some cakes. Outside activities include; include, theatre trips, car boot sales, library, shopping, attending church, visiting friends and relatives, going to the local pub. One person has a visitor from a local church who reads the local newspaper to him twice a week, which enables him to be in touch with local news. Another does some gardening at his allotment. One of the proprietors also takes people out in the better weather, going to Scaling Dam, Stokesley, Great Ayton, Sands End and Runswick Bay. 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Victoria Lodge DS0000000060.V352943.R01.S.doc Version 5.2 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 Lodge DS0000000060.V352943.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience excellent quality outcomes in this area. Each persons care needs are assessed prior to the move to the home, and periodically thereafter. This will help ensure that each person’s needs are met at the home and inappropriate admissions avoided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An assessment of the needs and wishes of prospective residents are carried out before admission to the home. Since the previous inspection the assessment documentation has been reviewed and developed further. Included is information regarding, personal details, a description, mental health history, medical history, the activities of daily living including plans and fears for the future, family and friends. The files of two people who use the service were examined and they both contained this information. Further assessments are carried out on a regular basis and in most cases the person is involved and signs to show their agreement. If a person does not wish to take part this is documented in their care plan. Victoria Lodge DS0000000060.V352943.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 People who use the service experience good quality outcomes in this area. People who use the service are supported to take risks within a risk management framework. This helps to ensure they remain safe and that their independence is promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the previous inspection, new care plan documentation had been introduced. There is information written for each area of daily living, which forms a comprehensive and detailed picture of the resident. However the documentation could be further developed to include a ‘plan of action’ where a need is identified. Two people spoken to during the inspection knew about their care plans and that they are involved in the reviews of the plan with their key worker if they wish to be and they sign to agree. There is also a summary written every month by the person’s key worker, which gives an overall picture of what has been happening in their daily lives. Information for the plan is gathered from the person, relatives where possible, social worker and health professionals. Each person has individual risk assessments in their plan depending on their needs and activities that they carry out. The risk assessment documentation Victoria Lodge DS0000000060.V352943.R01.S.doc Version 5.2 Page 10 had been improved upon, was detailed and included scoring to denote a high, medium or low risk. They are either reviewed annually or as the situation changes. Victoria Lodge DS0000000060.V352943.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People who use the service experience excellent quality outcomes in this area. Links with the community are very good and enrich people’s opportunities. The meals are good, offering both choice and variety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who use the service are involved in a wide range of activities and hobbies depending on their particular likes and dislikes. Discussion took place with two of the people in the dining are and others were spoken to during the tour of the home. Some people said they preferred to spend their time at home, in their own rooms or lounges, reading, listening to music, watching television, helping set the tables, tidying the conservatory. A new person said she liked being in the kitchen and the cook was hoping to encourage her to help bake some cakes. Outside activities include; include, theatre trips, car boot sales, library, shopping, attending church, visiting friends and relatives, going to the local pub. One person has a visitor from a local church who reads the local newspaper to him twice a week, which enables him to be in touch with local news. Another does some gardening at his allotment. One of the Victoria Lodge DS0000000060.V352943.R01.S.doc Version 5.2 Page 12 proprietors also takes residents out in the better weather, going to Scaling Dam, Stokesley, Great Ayton, Sands End and Runswick Bay. Relatives and friends visit at any time. Since the previous inspection the menus had been changed and now offered more choice. People who use the service have been involved in the changes, which were discussed at their meetings. People in the home are shown the menu a day in advance to choose their meals. There are more alternatives available along with any special diets. At lunchtime on the day of the inspection people were having either an omelette or sardines and the choices for tea were liver and onions or sausages and mash. All people spoken to said how much they enjoyed their meals and cook also made cakes and biscuits. Victoria Lodge DS0000000060.V352943.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience good quality outcomes in this area. People who use the service receive good support from staff to ensure that their personal, physical and emotional needs are met. The homes procedures for storing and administering medication are robust to safeguard people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information in the care plans showed that people who use the service receive personal support in the way that they need and wish. Staffs are always at hand to spend time with the people and they know them very well. Each person has their own General Practitioner and is also seen by their Psychiatrist three monthly. One of the proprietors is on hand to give residents a lift to health appointments. One person who uses the service goes to the chemist every week, collects and signs for his own medication in a ‘nomad system’. Staff in the home checks the previous weeks ‘nomad’ for compliance. The person has a locked facility in his room to keep medication safely. Victoria Lodge DS0000000060.V352943.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. The home has a complaints system, which people can use if they are unhappy, have a grievance or dispute. Staffs have received training in adult protection to safeguard the people who use the service from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A copy of the complaints procedure is on display in the home and is also in every person’s room. Some people who use the service have the procedure in picture format where they have difficulty reading and writing. People interviewed said staffs were always around to talk to if they had any problems. A comment in a persons survey was that ‘he would speak to a member of staff he felt comfortable with’. Another comment from a survey was that the staff’s cares well for people, if there is a problem they will do their best to resolve it as quickly as possible. There had not been any complaints made since the previous inspection. Examination of the staff training files showed that all staff had received training in Adult Protection. Two staff interviewed was able to describe the procedure to follow in the case of suspected abuse. Victoria Lodge DS0000000060.V352943.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use the service experience excellent quality outcomes in this area The environment is attractive homely and comfortable for the people who live there. All areas were safe, well maintained and extremely clean. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the previous inspection major refurbishment had been carried out throughout the home. In the kitchen the cooker had been replaced along with the freezer and fridge. There was also new flooring and an island had been put in which enabled the people who use the service to take part in food preparation if they wished. A new stair carpet was in place, which had been chosen by the residents along with the re decoration. All the bedrooms are now for single occupancy with the majority having en suite facilities. There are also more shower rooms, which two people said they preferred. People who use the service chose the colour scheme and carpets in their rooms, maintaining their individuality. All people spoken to during the inspection said how pleased they were with their rooms. A conservatory has been built at the rear of the home, for those people who wish to smoke and the proprietors Victoria Lodge DS0000000060.V352943.R01.S.doc Version 5.2 Page 16 have also installed a flat screen television. The office has been moved from the first floor to the ground floor. The home is very clean and without any odours. A comment in a resident survey was that ‘the home is spotless and clean’. Victoria Lodge DS0000000060.V352943.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People who use the service experience good quality outcomes in this area Staffs have a clear understanding of their roles. Recruitment policies and procedures are robust. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has recruitment policies and procedures in place. Two staff files examined showed that the home’s policies are being followed and all the required documentation was in place. Training for staff is ongoing. Since the previous inspection training has been delivered in Moving and Handling, Health and Safety, First Aid and Safe Handling of Medicines. However whilst staff know the residents well it would be beneficial if training in aspects of Mental Health was available. At the time of the inspection there were thirteen carers employed. Seven had achieved NVQ level 2 or above and a further three carers had commenced a course in NVQ 2. The duty rota showed that senior staff covers the home on every shift. Victoria Lodge DS0000000060.V352943.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People who use the service experience good quality outcomes in this area The home regularly reviews aspects of its performance through a programme of self-review and consultations, which include seeking the views of people who use the service and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection the manager had been in post since August 2007, however she had also had a lot of time off due to sickness and had decided to resign. The deputy manager has worked at the home for many years and was running the home with support from the proprietors. All staff work closely together to support the people who live there. Residents are involved in the running of the home and any proposed changes are discussed at resident meetings, which are well attended. Minutes are taken and a resident signs to agree them. Victoria Lodge DS0000000060.V352943.R01.S.doc Version 5.2 Page 19 The deputy manager carries out regular audits in areas such as medication, and care plans. Residents are given questionnaires to complete, which cover areas such as, the environment, staff attitude, food, complaints, activities and personal bedrooms. Relatives are also given questionnaires and comments received were; ‘staff friendly’, ‘lovely room, every care from staff’, ‘lovely place, staff are really nice’, friendly, warm and comfortable, a home from home’. Staff records showed that training in health and safety is received, and staff interviewed confirmed this. The home has health and safety policies and procedures in place. Victoria Lodge DS0000000060.V352943.R01.S.doc Version 5.2 Page 20 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 4 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 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 4 15 X 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 X 3 X X 3 X Victoria Lodge DS0000000060.V352943.R01.S.doc Version 5.2 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 Lodge DS0000000060.V352943.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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