Care Home: Victoria House

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What the care home does well The home ensures that a thorough assessment is carried out prior to people moving into the home. This information is gathered together in detailed and clear care plans. This means that staff are well informed about how best to assist people in daily living. Staff in the home have a good understanding of the importance of enabling people to live their own lives and make their own decisions. People can choose the way that they live their lives and the flexible routine of the home contributes to this; however the people who live at the home told that this can sometimes be limited due to staff routines and roles. The home feels very much like the peoples own home and they are able to choose and maintain their own relationships. Personal healthcare and support is well met on an individual basis. People understand how to complain and feel that staff listen to what they want. People also say that they feel safe when staff are assisting them with personal care. Staff understand how to protect vulnerable adults from harm and were knowledgeable about how to report poor practice appropriately. This means that people are protected from harm. The home is well decorated and suitable for its purpose. The home is clean and hygienic. Staff practice in a safe way to reduce the risk of cross infection. The home is well managed and people are consulted with as to the running of the home. People are able to contribute and change things for the better. What has improved since the last inspection? The home has improved the food which is provided for the people who live there. This now makes sure that people receive good quality food and plenty of choice. The home now makes sure that medication is now administered properly and that people health is not put at risk. The home now makes sure that all the proper recruitment checks are made before someone starts working at the home; this makes sure the people who live at the home are safe and protected from harm. What the care home could do better: The home need to make sure there are enough staff on duty and that they are deployed effectively to meet the needs of the people who live at the home. The home should make sure that needs of the people who live there are met in way of their choosing. CARE HOME ADULTS 18-65 Victoria House Maldon Drive Victoria Dock Hull East Yorkshire HU9 1QA Lead Inspector George Skinn Key Unannounced Inspection 19th August 2008 09:30 Victoria House DS0000000908.V369247.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 House DS0000000908.V369247.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 House DS0000000908.V369247.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria House Address Maldon Drive Victoria Dock Hull East Yorkshire HU9 1QA 01482 213010 01482 216310 clare.smith@thedtgroup.org www.birt.co.uk The Disabilities Trust 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) Miss Clare Michelle Smith Care Home 24 Category(ies) of Physical disability (24) registration, with number of places Victoria House DS0000000908.V369247.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: Physical disability - Code PD The maximum number of service users who can be accommodated is: 24 5th September 2006 2. Date of last inspection Brief Description of the Service: Victoria House is situated on a large housing development on the banks of the river Humber, just to the east of Kingston Upon Hull. The purpose built home opened in 1993 offers permanent accommodation to a maximum of 24 residents with a physical disability. The home is owned by the Disabilities Trust, which is a national organisation. All of the bedrooms are single occupancy with en-suite toilet and shower, and have views across the well-maintained garden and the river Humber. There is a large dining room on the ground floor, with a small sitting area and a large lounge on the first floor, again offering views of the river. There are two assisted bathrooms and two rehabilitation kitchens where residents can prepare their own snacks and breakfasts. All bathrooms and en-suite bedrooms are appropriately designed and equipped. There is a sensory room on the upper floor, which is regularly used. A passenger lift, external ramps, wide corridors and doorways, and automatic doors to the entrance enables residents access to all parts of the building. Local facilities on the fast developing and expanding housing development include a community centre, public house, chemist and a primary school. Residents have access to local transport into the town centre and the home has its own mini bus transport, which is run by a transport committee made up of residents. There is a large car park to the front of the home where visitor’s cars and the home’s mini buses park. The current scale of charges is £512.68 - £1167.65 per week. Additional charges include hairdressing, chiropody, music therapy, aromatherapy and transport (excluding health care appointments). Victoria House DS0000000908.V369247.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 that the people who use this service experience good quality outcomes. The key inspection has used information from different sources to provide evidence. These sources include: • • • • Reviewing information that has been received about the home since the last inspection. Information provided by the registered person on an Annual Quality Assurance Assessment (AQAA) Comment cards returned from people who live at the home, relatives and staff A visit to the home carried out by one inspector. A site visit was carried out which lasted 7 hours. We spoke with the people who live at the home, their relatives and staff. Records relating to the people who live at the home, staff and the management activities of the home were inspected. During the visit care practices were observed, where appropriate, and time was also spent watching the general activity within the home We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: The home ensures that a thorough assessment is carried out prior to people moving into the home. This information is gathered together in detailed and clear care plans. This means that staff are well informed about how best to assist people in daily living. Staff in the home have a good understanding of the importance of enabling people to live their own lives and make their own decisions. People can choose the way that they live their lives and the flexible routine of the home contributes to this; however the people who live at the home told that this can sometimes be limited due to staff routines and roles. The home feels very much like the peoples own home and they are able to choose and maintain their own relationships. Victoria House DS0000000908.V369247.R01.S.doc Version 5.2 Page 6 Personal healthcare and support is well met on an individual basis. People understand how to complain and feel that staff listen to what they want. People also say that they feel safe when staff are assisting them with personal care. Staff understand how to protect vulnerable adults from harm and were knowledgeable about how to report poor practice appropriately. This means that people are protected from harm. The home is well decorated and suitable for its purpose. The home is clean and hygienic. Staff practice in a safe way to reduce the risk of cross infection. The home is well managed and people are consulted with as to the running of the home. People are able to contribute and change things for the better. 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 House DS0000000908.V369247.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 House DS0000000908.V369247.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 this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. 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. EVIDENCE: All new people who intend to use the service receive a full needs assessment prior to being admitted to the home. Assessments are undertaken by experienced members of staff and involve the person and their family or representative where appropriate. Where the assessment has been undertaken through care management arrangements, the service requests a copy of a summary of the assessment and a copy of the care plan. This means that the home ensures peoples needs can be met before agreeing to admit them. The Service User Guide is now available in large print or on audio for those people who require this. Victoria House DS0000000908.V369247.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 this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. EVIDENCE: The service continues to have a strong belief that it is essential to involve the people who live at the home in the planning of care that affects their lifestyle and quality of life. Staff understand the importance of people being supported to take control of their own lives and encourage them to exercise their rights and make decisions and choices. Care plans continue to be very well presented and detailed in content. People who live at the home are given a pack containing their care plan, the Victoria House DS0000000908.V369247.R01.S.doc Version 5.2 Page 10 Statement of Purpose, Service User Guide, contract and a charter of rights. The plans continues to be regularly reviewed involving the people who live at the home and their families where agreed. The care plan is in a format that people can understand. Information is also available on a cassette and in large print if the person’s needs dictate this. A well-established key worker system continues to enable staff to establish positive relationships with people and work on a one to one basis. However some people told us that the staff’s roles and responsibilities sometimes means that there is limited time for them to undertake some one to one activities and support them in leading their chosen life styles. The people who live at the home have a diverse range of communication styles. Staff are aware of how to communicate with people on an individual basis and induction training involves learning these skills. People continue to tell us that they feel listened to and are enabled to make their own choices about how to live their lives. Where people are unable to make decisions because of risk or circumstance this is recorded and only limited after discussion in a multi disciplinary arena. The home continues to ensure that people can access independent advocacy and self-advocacy groups. One person is a trustee within the company and is particularly positive about the home enabling her to make decisions about her own life. She says that she gets what she wants because staff listen to her. Each plan includes a comprehensive risk assessment, which takes account of the specialist needs of people who use the service. The homes staff are aware of the need to balance risk with people’s aspirations for independence and choice. This means that people are able to retain control over their lives. Following a recent safeguarding adults investigation the home have changed policies and procedures for handling people’s finances these are now more transparent. Information provided on the AQAA indicates that the people who live at the home are now more involved with their personal finances and where appropriate are receiving tuition in this area to help gain the necessary skills. Staff are receiving more training this area to be able to support people. This will ensure that people rights are safeguarded. Victoria House DS0000000908.V369247.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 this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender including gender identity and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home could do more to support people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, wellpresented meals and snacks, at a time and place to suit them. EVIDENCE: Staff continue to be aware of the importance of supporting people to develop their skills, including social, emotional, communication and independent living Victoria House DS0000000908.V369247.R01.S.doc Version 5.2 Page 12 skills. However, some people told us that they felt the staff had very limited time to be able to achieve this. People told us that they felt the staff’s roles and responsibilities took them away from providing them with the quality time they needed. This was discussed at length with the manager and she is to undertake a full review of the staff’s working practises and responsibilities and how this affects the quality of the one to one time spent with people who live at the home. People continue to be listened to regarding choice of daily activity. A meeting was taking place while we were at the home and the people who live there were being consulted about future activities. A variety of individual programmes continue to be provided including access to motorbike workshops, literary classes and arts and craft sessions. At the last inspection it was recommended that ovens be provided so that people can develop a full range of cooking skills. The AQAA sent in prior to the site visit indicated these had been requested as part of next years budget. Historically opportunities for people with physical disability to participate in any educational resources outside of the home have been lacking in the local community and local colleges, this remains the case. Consequently educational activities have been provided in house. The home continues to fill this gap by providing a variety of learning opportunities for people where certificates of achievement are given on completion of courses. People told us that they feel they are part of the local community and the home actively encourages this. Good levels of support are provided for people to take part in community activities and the home has links with the Hull Ability Club, Do something Different Club, Hull Lions and The Rotary Club. The home has recently won an award for the presentation of their gardens in a local competition. The AQAA indicated that the recruitment process now looks at the staff member’s ability to drive, as this is big factor in people’s ability to access outside activities. There continues to be activities taking place within the home on a regular basis for people to participate in if they wish; these includes cooking skills, arts and crafts etc. Staff told us that they do not spend as much one to one time with residents as they would like. As mentioned above the manager is to address this in the review. People continue to be enabled to maintain relationships of their choosing; two of the people who live at the home have been a longstanding relationship and this encouraged by the staff and they are supported well. There continues to be real sense that the home is the people home and staff promote this ethos in their practice. Victoria House DS0000000908.V369247.R01.S.doc Version 5.2 Page 13 All of the people who live at the home spoken to say that they can come and go as they please within the home, however they did express concerns about lack of staff time to pursue individuals interests. Routines are flexible and people’s rights are respected by staff. Since the last inspection the home have focussed on the meals provided. We saw that these were varied and the cook told us that he always offers a choice at every mealtime. The people we spoke with told us that the meals were very good and there was always a varied choice. The cook has received plenty of training since the last inspection and the home was awarded an A by the Local Authority Environmental Health Department for the cleanliness of the kitchen. At the last inspection it was noted that some staff were assisting two people to eat simultaneously. We saw that staff were sensitive when helping people eat and this was done discreetly. The staff ate with the people who live at the home so as to make their meal a more social occasion and to encourage good table etiquette. Victoria House DS0000000908.V369247.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): 18, 19 & 20 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. EVIDENCE: We looked at sample of care plans and files which belonged to the people who live at the home: these included details about personal, emotional and physical health needs. Where necessary specific individual plans continue to be in place, for example, moving and handling, posture and diet. These were regularly updated and we saw that people have access to these. People we spoke with during the site visit confirmed they were able to see health care professionals when they needed to and had access to specialist health care when required. We saw that people’s health is monitored closely and the home act appropriately to seek medical attention when required. Victoria House DS0000000908.V369247.R01.S.doc Version 5.2 Page 15 We saw that the medication system is well managed and monitored. We saw that the there was a clear audit trail of any medication received into the building. We saw that staff had received the necessary training, with regard to the administration of medication, to ensure the safety of the people who live at the home. Victoria House DS0000000908.V369247.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): 22 & 23 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. If people have concerns with their care they, or people close to them, 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. EVIDENCE: The home continues to have a clear complaints procedure in place. People spoken with say that they feel confident to raise issues of concern if they arise. Complaints continue to be recorded in a complaints log and this details if the complainant was satisfied with the outcome of any investigations undertaken by the home. The AQAA received prior to the inspection indicated that the home have received 1 complaint since the last inspection. The home has an appropriate policy in place for the protection of vulnerable adults. Staff spoken to are clear about reporting procedures should anyone make an allegation; they were also clear about the indicators of abuse. People spoken with told us that they feel safe when being looked after by staff. Staff receive training in this area as part of the induction process. The home has been subject to 1 safeguarding adults’ investigation since the last inspection. We saw that the manager had handled the allegations appropriately and the local authority had undertaken an investigation. The matter is now being investigated by the police; the home has made major Victoria House DS0000000908.V369247.R01.S.doc Version 5.2 Page 17 changes to the finical procedures since the investigation. These now better protect the persons rights. Victoria House DS0000000908.V369247.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): 24 & 30 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. EVIDENCE: During the site visit we saw that the building continues to be well maintained and clean. The bedrooms of those people who live at the home are personalised and spacious to enable ease of movement. The AQAA received indicated that the home has commenced a programme to: Place tracking hoists in each bedroom, refurbish bathrooms, make the gardens more wheelchair accessible, the smoking room has gone and the space will be used to create another room, new curtains to be provided in everyone’s room and throughout the building, patio furniture on the balcony, new communal TV’s and stereos/radios, new flooring in the lounge. Victoria House DS0000000908.V369247.R01.S.doc Version 5.2 Page 19 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 this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have safe and appropriate support but there may not be 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. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers, but their roles and workload may not allow this to happen as regularly as it should. EVIDENCE: Staff continue to receive sound induction to meet the needs of the people who live at the home. There continues to be a positive ethos within the home and staff display a sound understanding of the importance of enabling and including people in decision making about their lives. We looked at the recruitment and selection procedures and found these to be robust. All staff have the appropriate checks done before the commencement of their employment. We saw that all staff have 2 references and the home undertake a Criminal records Bureau (CRB) check. Staff spoken with confirmed that they had under gone check before working at the home. The people who Victoria House DS0000000908.V369247.R01.S.doc Version 5.2 Page 20 live at the home are given the opportunity to comment about the conduct of a member of staff at the end of their 3 month probationary period. This is used as part of the recruitment process. We saw that staff received training which was relevant to their role and helped them to care for the people who lived at the home. Staff were qualified to NVQ level 2 and some were doing NVQ level 3. Staff spoken with told us that they received good training and there were plenty of opportunities. During the site visit people told us that they felt there were not enough staff on duty to meet their needs and that sometimes staff did not have enough time to care for them or support them to undertake activities. We spoke with the manager and looked at rotas in operation at the home. We found that there was a shortfall of staffing hours and the manager provided us with written documents as to how staffing levels were calculated according to individual need. The home have agreed to increase the staffing levels and review staff’s roles and responsibilities and how this may impact on the quality of the one to one time spent with the people who live at the home; and to make changes as required. The people who live at the home need to be involved with this process and any outcomes need to be reported to the CSCI. Victoria House DS0000000908.V369247.R01.S.doc Version 5.2 Page 21 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 this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. EVIDENCE: The manager is registered with the CSCI and has the relevant qualifications and experience for this role. People who live at the home told us that she approachable and they have confidence in her. Staff told us that she is supportive and provides them with good leadership. From speaking to the manager and staff it is clear that the home’s ethos is to promote participation and inclusion for the people who live at the home. Victoria House DS0000000908.V369247.R01.S.doc Version 5.2 Page 22 The home continues to have a well has developed quality assurance system that involves the people who live at the home, carers, family, staff and other professionals giving their views about the home. Surveys are completed throughout the year and an annual report is produced explaining the outcome of the surveys and any relevant action to be taken. The home has a fire policy and a fire risk assessment and the fire alarm is tested weekly. Tests on equipment are undertaken and fire drills are carried out on a monthly basis. The home has a nurse call system fitted to ensure that all the people who live at the home are able to request assistance. All the equipment in the home is tested at the appropriate intervals and all maintenance certificates are up to date. The AQAA which was returned by the home prior to the site visit was well completed and told us about areas for improvement. Victoria House DS0000000908.V369247.R01.S.doc Version 5.2 Page 23 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 3 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 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 3 X 3 X X 3 X Victoria House DS0000000908.V369247.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. 1 Refer to Standard YA18 Good Practice Recommendations The home should make sure that the home meet the needs of the people who live there in a way that they prefer and this Is not dependent on staff number or work load The home should make sure that the needs of the people who live there are met by the staff who are on duty The home should send copies of regulation 26 visits within which should be evidence of discussion about the deployment of staff. 2 3 YA35 YA38 Victoria House DS0000000908.V369247.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region 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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