CARE HOME ADULTS 18-65
Victoria Lodge 36 Emerald Street Saltburn-by-Sea TS12 1ED Lead Inspector
Val Daly Unannounced 4 May 2005 9:30 am 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 B51-B01 S60 Victoria Lodge V223654 280405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Victoria Lodge Address 36 Emerald Street Saltburn-by-Sea TS12 1ED 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) 01287 624337 Mr D Kerrison & Mrs S Kerrison Mrs Judith Laverick Care Home 14 Category(ies) of MD - Mental Disorder (8) registration, with number MD(E) - Mental Disorder over 65 (6) of places Victoria Lodge B51-B01 S60 Victoria Lodge V223654 280405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None 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 six single and four double bedrooms. Victoria Lodge B51-B01 S60 Victoria Lodge V223654 280405 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 10 a.m. and lasted for four hours. Five residents one care staff, one domestic staff, the cook and the manager were spoken to during the inspection. Numerous records including care plans, policies/procedures and staff records were examined. What the service does well: What has improved since the last inspection?
The manager and staff have continued to strive to meet the individual needs and wishes of the residents who live in the home. Victoria Lodge B51-B01 S60 Victoria Lodge V223654 280405 Stage 4.doc Version 1.30 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 Lodge B51-B01 S60 Victoria Lodge V223654 280405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Victoria Lodge B51-B01 S60 Victoria Lodge V223654 280405 Stage 4.doc Version 1.30 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 standard(s) 2, 3 & 4 Resident’s needs are assessed prior to admission ensuring they can be met by the home. Residents spend time in the home prior to admission. EVIDENCE: Three residents files were examined, each contained a full detailed assessment of needs. The assessments are carried out with the resident where possible. If they are not interested staff discuss care needs with the resident and then document that the resident did not wish to be involved. Other professional people are involved where necessary e.g. the General Practitioner. Residents are encouraged to visit the home prior to their admission. They meet and spend time with staff and other people who live in the home. Victoria Lodge B51-B01 S60 Victoria Lodge V223654 280405 Stage 4.doc Version 1.30 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 standard(s) 6, 7 &10 The home plans well for and is good at meeting the personal and social care needs of the people who live there. Confidentiality agreements are in place. EVIDENCE: Care plans are reviewed routinely with residents every six months. However if changes are necessary in between those times an extra review is held. From speaking to residents and reading care plans it is apparent that decisions about lifestyles and day to day choices are made by them. Staff give assistance when needed. Residents are aware that information about them remains confidential between themselves, staff in the home and other professionals where necessary. A confidentiality agreement is signed by the resident and staff in the home on admission. Victoria Lodge B51-B01 S60 Victoria Lodge V223654 280405 Stage 4.doc Version 1.30 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 standard(s) 12, 13, & 14 Appropriate activities are planned with the resident on an individual basis. Residents are given support and encouragement from the staff EVIDENCE: Residents are encouraged to take part in activities. Care plans examined showed the individual interests and how staff encouraged residents to aspire to them. One resident talked proudly about his allotment and the vegetables he was growing. Another resident was in the process of making a scale model of a ship made initially from cardboard. He was also keen to discuss his other projects, such as a model of the titanic. Residents are encouraged to take part in the local community, one gentleman visits the local pub most evenings, many go to the local shops and visit family and friends. At the time of the inspection a voluntary visitor was in the home who goes every week to read to a resident. This came about from church involvement, the resident is very knowledgeable about topical items and the visitor reads items of interest from the newspapers to him. One resident prefers to be at home and has jobs around the dining room and kitchen. Victoria Lodge B51-B01 S60 Victoria Lodge V223654 280405 Stage 4.doc Version 1.30 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 standard(s) 20 The home has robust policies and procedures for medication. EVIDENCE: The home has policies and procedures for the receipt, recording, storage, handling, administration and administration of medication in place. A record is maintained of current medication for each resident. In the three care plans examined residents had given their consent to receive medication. At the time of the inspection there were no residents managing there own medication. Staff responsible for the administration of medication had received training in the safe handling of medicines. Victoria Lodge B51-B01 S60 Victoria Lodge V223654 280405 Stage 4.doc Version 1.30 Page 12 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) 23 Service users are protected, the home has policies and procedures in place and staff receive regular training. EVIDENCE: Staff training files were examined which showed that training in ‘No Secrets’, the protection of vulnerable adults had been completed. There were detailed policies and procedures to follow in the case of alleged abuse and the manager had also written a summary of the training, which included the important points. Information about adult protection is available to residents. Victoria Lodge B51-B01 S60 Victoria Lodge V223654 280405 Stage 4.doc Version 1.30 Page 13 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 & 30 The environment is attractive homely and comfortable for the people who live there. All areas were safe, well maintained and extremely clean. EVIDENCE: All areas of the home were comfortable, safe and well maintained. Some redecoration is required on the second floor, however the manager said that this will be carried out over the next few months. Resident’s bedrooms are individually decorated and furnished to suit their needs and wishes. Three of the residents spoken to were in their rooms, watching television or videos or working on individual projects. The home was extremely clean without any odours. Victoria Lodge B51-B01 S60 Victoria Lodge V223654 280405 Stage 4.doc Version 1.30 Page 14 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) 34, 35 & 36 There are clear leadership skills demonstrated by the manager and staff are adequately supervised. Recruitment policies and procedures are robust. EVIDENCE: The home has recruitment policies and procedures in place. Three staff files examined showed that the home’s policies are being followed and all the required documentation was in place. Staff training files were examined which showed training had been carried out in First Aid, COSHH, Food Hygiene, Data Protection, ‘No Secrets’ and Fire Training. An update for Moving and Handling had been booked for June 2005. At the time of the inspection more than 50 of care staff had achieved NVQ level 2 or above. The home has a formal supervision system in place with staff receiving supervision every eight weeks. The manager is available to carry out extra supervision sessions if needed. Victoria Lodge B51-B01 S60 Victoria Lodge V223654 280405 Stage 4.doc Version 1.30 Page 15 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) 38 & 42 The manager gives strong leadership and staff work as a team. Residents are protected by the health and safety policies and procedures. EVIDENCE: The manager has been in post for a number of years. Staff and residents felt they were able to approach the manager with any problems and everyone worked together as a team. Meetings for residents and staff are held on a regular basis where people have the opportunity to raise any issues. The home has Health and Safety policies in place and training for staff. Risk assessments are also in place for equipment and activities carried out. Victoria Lodge B51-B01 S60 Victoria Lodge V223654 280405 Stage 4.doc Version 1.30 Page 16 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 3 3 3 x Standard No 22 23
ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 x x 3
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 x x x x 4 Standard No 11 12 13 14 15 16 17 x 4 4 4 x x x Standard No 31 32 33 34 35 36 Score x x x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Victoria Lodge Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x 3 x x x 3 x B51-B01 S60 Victoria Lodge V223654 280405 Stage 4.doc Version 1.30 Page 17 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 Regulation None 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. 1. Refer to Standard 24 Good Practice Recommendations Some redecoration is needed on the second floor. Victoria Lodge B51-B01 S60 Victoria Lodge V223654 280405 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection Unit B, Advance St Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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