Care Home: Victoria Court

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• The Lodge Nursing Home
• Bracken House
• Sunnycroft
• Field Farm House
• Edgeview Nursing Home
• Church Terrace Nursing & Residential Home
• The Forbury

What the care home does well What has improved since the last inspection? Recruitment documents are now accessible and available for inspection. Risk assessments have been completed for hazardous substance in use at the home. Parts of the premises have been redecorated and the fabric replaced. What the care home could do better: CARE HOME ADULTS 18-65 Victoria Court Memory Lane Wednesfield Wolverhampton West Midlands WV10 0QP Lead Inspector Joy Hoelzel Key Unannounced Inspection 24th February 2009 10:00 Victoria Court DS0000072801.V374308.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 Court DS0000072801.V374308.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 Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Court Address Memory Lane Wednesfield Wolverhampton West Midlands WV10 0QP 01902 307 009 01902 305 694 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) Midland Heart Limited Mr Richard William Price Care Home 16 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (16) of places Victoria Court DS0000072801.V374308.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 with Nursing - Code N; To service users of either gender whose primary care needs on admission to the home are within the following category: - Mental Disorder - Code: MD 16 The maximum number of service users to be accommodated is 16. Persons can be admitted under sections of the Mental Health Act 1983 & Mental Health Act 2007 as outlined in the statement of purpose. This is the first inspection of the service with the new providers. 2. 3. Date of last inspection Brief Description of the Service: Victoria Court is a purpose built home registered to provide accommodation and nursing care for up to 16 adults. The home is registered for people with mental health problems and provides rehabilitation and continuing care services. It is one of a group of homes owned by Midland Heart Ltd. The home is located in Wednesfield, close to shops, local amenities and a good public transport network is nearby. The building is single storey and is divided into three living units, each consisting of single occupancy bedrooms, kitchen/dining area, lounge, bathroom and toilet. Information of the home and the provision of the service are available in the statement of purpose and service user guide, both documents have recently been revised and are readily available. The service user guide includes details of the weekly fee of £454:00 and what is included in the fees. Commission for Social Care Inspection reports for this service are available from the provider or can be obtained from www.csci.org.uk Victoria Court DS0000072801.V374308.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 3 stars. This means the people who use this service experience excellent quality outcomes. This is the first inspection of the service following the change of the provider to Midland Heart Ltd. The home did not know that we would be visiting on this occasion. A look around the home took place, which included a number of bedrooms as well as communal areas. The care documents of a number of people using the service were viewed including care plans, daily records and risk assessments. Other documents seen included medication records, service records, some policies and procedures and staffing records. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the home for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for providers to share with the CSCI areas that they believe they are doing well. It is a legal requirement that the AQAA is completed and returned to the commission within a given timescale. The manager completed this document and returned to us. Comments from the AQAA are included within this inspection report. We asked for our Have Your Say, surveys, to be distributed to people living in, working in and visiting the home. Four were completed and returned from staff, with three returned from relatives. The responses and comments are included in this report. What the service does well: Information on the service is readily available and includes all aspects of the home and what it offers. This ensures that people have sufficient information to help them with deciding whether the home is suitable for their needs. People are fully involved in the planning of their care and are supported by the staff to make decisions and choices about their lives. The home is well maintained, comfortable and safe. People are protected by the homes robust recruitment procedures and people are supported by a well-trained and competent staff team. Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 6 People told us • As a relative of a person in the home, care is provided as is expected. • Good structures are in place to support the needs of people. • I am very satisfied with all aspects of the home. 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 Court DS0000072801.V374308.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 Court DS0000072801.V374308.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): Quality in this outcome area is excellent. People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information on the service and what it offers is available in a statement of purpose and service user guide. The documents contain the details of what the service offers and how much it costs to live there. This information ensures that people can decide whether the care home can meet their support and accommodation needs. The manager explained that referrals are made for admission to the home through a single referral forum. People who express an interest in moving in are visited by two members of staff and are invited to spend time at the home. Various assessments are completed to ensure the suitability of the service for the individual. The manager stated that people usually have to wait a period of time before moving in and are placed on a waiting list. Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 9 The case file of the person who recently moved into the home was looked at to see if information had been sought regarding this persons needs prior to moving in. Information had been gathered from various sources including the previous health care setting and a pre admission assessment was completed by the service. One person discussed the admission procedure and confirmed their full involvement with the process. They also stated that they visited the home on several occasions before they actually moved in. The home does not provide an intermediate care service. Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is excellent. The home has a plan of care that the person has been involved in making. People are able to make decisions about their life, with support if they need it. This is because the staff promote their rights and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person has a written plan of care that is based on the assessments of their care needs. Three plans were selected to be looked at in depth with people being at the home for varying lengths of time. The plans evidenced that the person, and/or their representative, is fully involved in the care planning and review process. The plans are very comprehensive, up to date and well organised. Each plan contained assessments for maintaining a persons safety and when a risk is identified it is linked with a corresponding support plan. For example Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 11 one person has a very specific health care need that requires daily monitoring. The plan details the agreed support they require to ensure that they remain well. Another plan recorded that on occasions a person may experience episodes of distress due to a specific condition. A support plan has been developed giving details of the possible triggers, the care needed and the action to be taken by staff to alleviate and reduce the distress for this person. Each plan included the assessments and support plans for developing and maintaining optimum independence, this being in preparation for the person moving from the unit in time. One person spoke of the plans to move to sheltered housing and stated that this was something they were looking forward to. The AQAA completed by the manager documents • All customers have individual care and support plans and risk assessments. Service users discuss their plans with staff and sign up to care documents. All staff also read and sign up to care documentation. • Staff support customers in making decisions and choices regarding diet, day activities, future plans, leisure activities and move on accommodation. A relative completed our survey and commented that in their opinion Victoria Court • Promotes independence, • Encourages people to care for themselves, good routines, good structures are in place. Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff supports their personal development. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the morning of the inspection a small group of people met to discuss healthy eating and nutrition. As all people at the home self cater this is a regular topic for discussion. People shop, prepare and cook their meals each day with appropriate help and support from the staff. One person stated that they were most satisfied with this arrangement as they could have what they want when they want it. Most people at the home require some degree of support with financing and budgeting. This is agreed and recorded in the support plan. Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 13 Information recorded in the AQAA identifies that • Most service users require assistance with shopping, meal planning, and healthy eating. These needs are reflected in care plans and are evaluated. Nutrition assessments are also carried out. And acknowledges that they could • Improve nutritional and health screening. Staff made comment in our survey that they feel they and the service • Promotes independence, builds confidence and self-esteem, promotes healthy living in a meaningful way. People can attend the local drop in centres if they wish and to use the other community facilities. One person was planning to go to an outreach centre during the afternoon, staff stated that this was a regular activity and that this person enjoyed it. Some people were out grocery shopping, some were preparing for hospital visits whilst other people stayed at the home either attending to household tasks or relaxing. People are able to choose their preferred activity for the day but equally have an agreed timetable of weekly events as part of their rehabilitation programme. All people have a key to the main front door and to their own room. Staff do not enter bedrooms with out the permission of the inhabitant. Their right to privacy is respected. Written arrangements are in place in cases of emergencies where access is required to ensure the safety of the person. Friends and relatives can visit the home at times suitable to the person. The statement of purpose and service user guide offers detail of the visiting arrangements. Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is excellent. Staff ensure that care is person led, personal support is flexible, consistent, and is able to meet the changing needs of the residents. Staff respect people’s preferences and have good knowledge about individual needs when offering support and guidance. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Most people at the home are self-caring, the amount of assistance with personal support they require is discussed and recorded in the support plans. Usual daily routines are very flexible and dependent on personal preferences. The AQAA records that • Customers are free to get up and go to bed as they please though some structured activity is encouraged. People have a named key worker to ensure a consistent approach with their personal support needs. Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 15 Most people are registered with a general practitioner at a local health centre and are encouraged and supported to use this facility for any problems, advice and health screening. People are supported and encouraged to manage their own medical conditions whenever possible. One person told us that they now had their own piece of equipment for monitoring a specific condition. This is something that they had never had before although the condition is long standing. An assessment is completed when a person wishes to handle and administer his or her own medications. A record is kept on file of the assessment together with any support they may or may not require. Medication is administered to some people by the registered nurses using a monitored dose system with additional boxes and bottles of medicines. The procedures were looked at, staff explained the processes and all evidence points to good arrangements being in place for the safe administration of medications. Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. If people have concerns with their care, they know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People told us that they would have no hesitation but to speak with the manager or their key worker if they had any concerns or complaints about the service. All were of the opinion that their concerns would be taken seriously and that the problem would be sorted. A complaints and concerns log is maintained and audited regularly by the manager. We, the commission, have not received any concerns regarding the service. Referrals are made to the safeguarding adults multi agency team when there are allegations or suspicions of abuse. The manager and staff are fully involved with the investigations and the referrals made recently have reached satisfactory conclusions. The manager confirmed that all staff have received training in protection of vulnerable adults and the safeguarding people. Staff spoken with described in a knowledgeable and informed way, the action they would take if they had any suspicions of wrong doings. Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 17 The home offers a facility for customers to deposit personal monies for safekeeping if they wish, records relating to this have been maintained and fully receipted. The manager discussed the daily working procedures to ensure the safety of the cash and the accuracy of the accounting. Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Victoria Court is a single storey purpose built dwelling, providing accommodation in three units for up to sixteen people. Each unit is selfcontained with communal and private facilities. Redecoration and the refurbishment of the premises continue, the manager has identified specific areas for improvement during the next year. People spoken with expressed a satisfaction with the accommodation. They said that their bedrooms are warm, the beds comfortable and that they can personalise their own rooms with pictures, ornaments and electrical items such as televisions and stereos, as seen during a brief tour of the home. Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 19 For security purposes, CCTV is sited at the entrance to the home, the monitor being in the staff office. The manager confirmed that there are no cameras sited in the actual building. This ensures the safety of people without imposing on daily life. Each unit has its own separate laundry facilities all are equipped with domestic type appliances. People are encouraged and supported to deal with their own washing and ironing each week as part of their rehabilitation programme. Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is excellent. People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A duty rota is maintained on a weekly basis to identify the members of staff in the home at any one time. During the morning of the inspection the registered manager confirmed that fifteen people were in residence being supported by a staff team consisting of a registered nurse and two support workers. Two student workers were also on the premises. People living at the home expressed a general satisfaction with the staff and the support that was provided. General observations and discussion with people confirmed that staffing numbers and the skill mix is satisfactory to meet the care and support needs of the people living at the home. Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 21 Two staff files were selected for inspection, both files were well organised and contained the information required to safeguard the people living at Victoria Court. Training in the mandatory and specialist topics continue to be arranged for staff. The personnel files looked at contained certificates of recent training in subjects such as moving and handling, infection control and fire safety awareness. The manager explained that all staff have received training in the protection of vulnerable adults, with plans for training in the Mental Capacity Act and the deprivation of liberty safeguards. Staff spoken with confirmed that the training was sufficient and relevant to the service. The AQAA offers information by stating • Five of the seven care staff (support workers) currently have National Vocational Qualification level 2 or 3. • All staff receive induction and a comprehensive range of mandatory training. • Victoria Court has a training plan, team training matrixes and individual staff training records. Staff Training is discussed and recorded in supervision sessions, appraisal meetings and staff meetings. Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is excellent. People have confidence in the care home because it is run and managed appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Richard Price is the registered manager of the service and has been at Victoria Court for a considerable period of time. Mr Price has a wealth of knowledge with managing a social care home and providing the support networks for the care and support offered to people with mental ill health. People offered positive comments of the management style • Fair and consistent. • Manager is willing to listen and give support. Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 23 • Manager is proactive and urges staff to keep up to date on mandatory training and training to enhance skills to give better care and address the needs of the individuals. The service has developed a quality assurance and monitoring system that makes certain the home is operating as it states it does and meets its stated aims and objectives. Satisfaction surveys are distributed to people living and visiting the home, action is taken on any suggestions for improving the service. The manager and senior staff complete regular audits to ensure that the systems employed at the home are robust. Staff and customer meetings are arranged at monthly intervals giving people the opportunity to discuss relevant issues. Records, documents and certificates are available for inspection to ensure that the weekly, monthly and annual health and safety checks are being carried out. Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 24 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 3 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 x 4 X 4 X X 3 x Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 25 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 Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. Extracts may not be used or reproduced without the express permission of CSCI Victoria Court DS0000072801.V374308.R01.S.doc Version 5.2 Page 27 - 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. 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