Inspection on 15/11/05 for Victoria Lodge

This inspection was carried out on 15th November 2005.

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 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 16/10/08

Victoria Lodge 17/04/08

Victoria Lodge 30/07/07

Victoria Lodge 13/09/06

Victoria Lodge 10/05/05

Victoria Lodge 13/12/04

Victoria Lodge 14/06/04

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

CARE HOME ADULTS 18-65 Victoria Lodge 59 Victoria Drive Bognor Regis West Sussex PO21 2TQ Lead Inspector Ms G Moorey Unannounced Inspection 15th November 2005 9:00 Victoria Lodge DS0000040980.V254753.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 Lodge DS0000040980.V254753.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 Lodge DS0000040980.V254753.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Victoria Lodge Address 59 Victoria Drive Bognor Regis West Sussex PO21 2TQ 01491 579270 01491 579738 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) Victoria Lodge Ltd Miss Jade Michelle Elizabeth Weston Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Victoria Lodge DS0000040980.V254753.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th May 2005 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 DS0000040980.V254753.R01.S.doc Version 5.0 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 unannounced and took place on the Tuesday 15th November 2005 between the hours of 9.00am to 1.30pm. Five residents were accommodated at the home on the day of the inspection and one person was on an overnight stay with a view to moving into the home in the near future. The inspection included a tour of the premises and it’s facilities, a majority of the service users were spoken to apart from two people who were at college for the day. The service users were consulted before their bedrooms were seen by the Inspector. Approximately four of the service users were spoken to and the person on the over night stay. 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, medication records, menu’s and the homes complaints book. The new policies and procedures file was also viewed. The manager of the home is pregnant and the service needs to put into action a plan to cover the maternity leave whilst she is away. What the service does well: The home has continued to build upon the positive changes. The service has up-graded its documents and systems and has consistently offered stable placements for those that have been at the home since it opened and for those that have arrived in the last year. On the day of the inspection the general atmosphere in the home was good and the home had a new service user who was on an overnight stay. The staff and service users seemed to share good professional relationships and were enabling the potential new resident to settle-in without to much disturbance to the other residents. Victoria Lodge DS0000040980.V254753.R01.S.doc Version 5.0 Page 6 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. Victoria Lodge DS0000040980.V254753.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 Lodge DS0000040980.V254753.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): 5 The contracts for each of the service users are produced in written word/Makaton and fed back to each service user in the most appropriate manner according to their communication need so that the residents can have some understanding of the guidelines set down for them whilst living at the home. EVIDENCE: The home has now produced a contract for each of the service users these are produced in an appropriate format and fed back to the service users, their families and social worker at their statutory review and signed by all present. This ensures that the home are explaining in a open manner in front of the service user and those involved with them the routines and guidelines for the home. Victoria Lodge DS0000040980.V254753.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): 6, 7, 9, 10 There are clear and comprehensive care plans within the service ensuring that staff are able to understand the complex needs and offer consistent care to the residents within the home. The systems for service user consultation are good with a variety of evidence that indicates that service users’ views are both sought and acted upon. The home has a comprehensive set of risk assessments and management strategies in place to ensure staff know how to support the service users to maintain and develop their independent living skills, while so practicable, minimising the risks associated with them engaging in activities and daily life. EVIDENCE: The home has implemented a new format for their care plans which is a comprehensive document that includes such areas as health plans, mental health, managing emotions, communication skills, daily living skills, self care skills, relationship and sexual needs, community presence and participation, employment and education etc. These are set alongside the overview of immediate goals and aspirations and weekly planners. Victoria Lodge DS0000040980.V254753.R01.S.doc Version 5.0 Page 10 During the inspection it was evident that the care plans and weekly planners were being used and followed. Each of the service users have an assigned key-worker who will undertake to look specifically at the needs of individual residents and have input in to the reviews and report writing process. The service users are consulted whenever necessary on their care plans and when planning activities for the home. This can be subject to interpretation as some of the service users have very complex needs and decisions and understanding can be difficult. Currently the service does not have an advocacy service but the home is involved with the community team and each of the service users has some family contact. The home has in place a full compliment of risk assessment that includes behaviour management, aspects of problematic issues that could arise due to the complex needs experienced by some service users, activities outside of the home and all areas within the home. Most recently the home have produced risk assessments for the manager’s pregnancy whilst she is still working at the service. The risk assessments are kept within the care plans and own individual file. The home has a Confidentiality Policy that is in line with the Data Protection Act 1998. The policy is fully comprehensive. The staff are trained in understanding confidentiality this is part of the induction process. Staff sign to say they have read and understood the policy. Information is only passed to professionals and families on a need to know basis. The policy is available to read and is passed on verbally. Service users records are kept in the office. Victoria Lodge DS0000040980.V254753.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16, 17 The service users’ at the home are offered numerous opportunities to engage in age appropriate activities and education with a strong emphasis on using community based resources. This enables the residents to live a more independent everyday life within the local community. The home has a clear ethos of encouraging contact with family and friends. All of the service users enjoy contact with family and friends that encourages and reinforces memories and identity. Through careful care planning the service users have clear daily routines and activities that include life skills. General life in the house has boundaries and guidance in order to offer the service users respect, rights and dignity. Meals appear to be nutritionally well balanced, and clearly based on the service users food and preferences. EVIDENCE: The service has in place comprehensive care plan that relate to the weekly planners. The weekly planners look at a five- day working plan in the week and the weekend being less structured with more choice of activities. Victoria Lodge DS0000040980.V254753.R01.S.doc Version 5.0 Page 12 The five -day plans consist of college, community activities, living skills and general time spent at the home. Three of the service users are currently at college undertaking various courses. Time spent in college varies for each person as each resident has very individual needs and abilities. One service user has been identified to start a day centre in the near future. Currently none of the service users work as they have complex care needs and at the moment would not be able to deal with a working environment. The home undertakes various activities with the service such as swimming, cinema, going out for meal, playing pool at the pub and shopping. The service users will chose at the weekends what they would like to do. The service has recently been given a new van which is larger than the old one which has enabled everyone to travel in a comfortable manner which meets their specific care needs. The service users have various levels of contact with their families. The home facilitates contact for each person. Two service users have local family and visit home on a regular weekly basis. Where appropriate service users are encouraged to seek outside relationships and the home would help to facilitate this with the necessary boundaries. One service user attends church every Sunday and this supported by staff at the home and his family. All services users are supported spiritual and culturally. Each person is registered to vote when they are placed at the home. All of the service users have Independent Life Skills built into their weekly planners which covers various area such as washing, cleaning, cooking and personal hygiene. Each service user has comprehensive care plan and risk assessments to indicate what is appropriate for each person this does include such issues and preferred name, independence levels and coping abilities. Each service user is able to make the decision of their bedtime and how much time is spent alone in their room. However this can be depended on the risk assessment in place. The home operates a four- week menu system offering a nutritional balanced diet, this is influenced by the preferences of the service users. The home does not have a cook and meals are prepared by staff and where appropriate residents’. All of the staff have undertaken food and hygiene training. Each person has their dietary needs assessed and all staff are made aware of any specific need each person may have. Mealtimes are undertaken in the dinning room and can vary as to who eats with each other this is very much dependent on how each service user is at the time of the meal. Victoria Lodge DS0000040980.V254753.R01.S.doc Version 5.0 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 the following standard(s): 18, 19, 20, 21 Personal support in the home is offered in such a way as to promote and protect service users’ privacy dignity and independence. The health needs of the service users are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication at this home is well managed promoting good health. EVIDENCE: Records at the home within the service users’ files indicated that each resident was having their personal care needs met and recordings of weight, diet, personal hygiene showed the regular basis on which checks were happening. Each service user has a clear plan and detailed description of how they preferred to receive any personal care needs. The residents each have very different levels of personal care from full support to general supervision. Each service user is registered with the local doctors practice, dental surgery and opticians. There is evidence within the files that residents attend and receive appointments where needed. However one service user is struggling to receive the appropriate treatment, as there have been problems with his Victoria Lodge DS0000040980.V254753.R01.S.doc Version 5.0 Page 14 parent allowing appointments and recommended tests to happen. The home needs to continue with the appointments and ensure support from the social worker involved. This issue needs resolution at the earliest possible time. There is evidence on file of the service users receiving any needed specialist services such as occupational therapy, chiropodist, and the community team input. Medication is stored in a metal lockable cabinet in the office. A comprehensive system is in place and medical administration records were being appropriately maintained by staff and accurately reflected medication stocks held in the home at the time of the visit. Staff are trained in the distribution of medicines through the home. The home has clear protocols and policies in place to guide staff in the issue of resident medication. A local pharmacist has checked the medicine system in the unit. The home has a clear protocol for the ageing and death of a service user and has asked service users, carers, families about their wishes in the case of their death. This information is collected at an appropriate time. In the event of a death within the home or a family member the home would consult with community team about bereavement services. Victoria Lodge DS0000040980.V254753.R01.S.doc Version 5.0 Page 15 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): EVIDENCE: Victoria Lodge DS0000040980.V254753.R01.S.doc Version 5.0 Page 16 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 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. EVIDENCE: The home presented as clean and tidy and has conquered the historical problems of maintenance and up keep to the property. The service has continued to make improvements to ensure the home now maintains the environment through a quick response to repairs and maintenance. The home has now employed a local maintenance man. The home has adequate communal areas including two lounges, a conservatory and activity room. The house in surrounded by a small garden which the service users help to upkeep. 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 DS0000040980.V254753.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36 The assessed needs of the residents are met by the numbers and skills of care staff deployed at the home. The home trains the staff to ensure the health and safety of the service users. However the home does need to extend this to take a more active role in NVQ training to enable staff when working with the residents. The home needs to implement an appraisal system in order to enhance the development of the staff in order for the staff to continue the improvement of knowledge and working practices when with the service users. EVIDENCE: The home employs twelve staff currently with two waking night staff. The staff team is made up of a majority of women. The rotas reflect working practice of 3 days on and 4 days off. The 3 days on are long 12 ½ hour shifts. The home is currently not using any agency staff and are awaiting two new staff to begin work. The home has now initiated NVQ training and one staff member is now signed up to begin the course. All of the other staff have signed up and are awaiting conformation. This does show some commitment to the training but not enough progress since the last inspection. The staff are paying half of the costs towards their courses. Victoria Lodge DS0000040980.V254753.R01.S.doc Version 5.0 Page 18 The manager needs to implement an appraisal system within the home where each member of staff receives a yearly review of their practice and development and objectives for the following year. The new area manager is going to start a supervision plan and sessions for the manager as currently this has still not happened. Victoria Lodge DS0000040980.V254753.R01.S.doc Version 5.0 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 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): 39, 40, 41, 42, 43 The home conducts itself in manner that ensures the security, health and safety of the service users in order to prevent the residents from harm. The home now undertakes a yearly Quality Assurance Survey in order to gain the view of all those living, working and having contact with the home in order to ascertain views to put towards the homes development of service. EVIDENCE: The home has now introduced a Quality Assurance system that has been designed with appropriate formats for the service users. The system was seen to have been used this year in a successfully. The new area manager has also introduced a new format for the home own monthly assessment report. This new document is comprehensive and highlights area that need to be addressed and the time scales for this. The home has recently received an updated version of the company policies and procedures. The manager has maintained and scaled down the appropriate Victoria Lodge DS0000040980.V254753.R01.S.doc Version 5.0 Page 20 guidance for the service, as the documents are generic to the Beacon Care Homes. The resident’s records are kept within the office, which is locked and generally not used, by the service users or any visitors to the home. The home has in place comprehensive health and safety records and guidance. The staff are given mandatory training around issues of health and safety including moving and handling, first aid and COSHH. The service hold fire records that highlight the routine checks and drills are undertaken at the home. Guidance on safety procedures is posted in strategic places around the home such as no- smoking, fire procedures and safety in the kitchen. The home is funded through the Beacon Care and has in place the required funding and insurance cover in order for the smooth running of the service and its maintenance. Victoria Lodge DS0000040980.V254753.R01.S.doc Version 5.0 Page 21 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 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 X 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Victoria Lodge Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score X X 3 3 3 3 3 DS0000040980.V254753.R01.S.doc Version 5.0 Page 22 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. 1. Standard NMS36 Regulation 18 Requirement The manager needs to ensure that the staff receive appraisals before the next inspection. Timescale for action 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard NMS35 Good Practice Recommendations The service needs to maintain its commitment to the NVQ training of staff. Victoria Lodge DS0000040980.V254753.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Worthing LO 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 © 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 Lodge DS0000040980.V254753.R01.S.doc Version 5.0 Page 24 - 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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