Inspection on 27/03/07 for The Victoria Grand

This inspection was carried out on 27th March 2007.

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

The Victoria Grand 12/01/06

The Victoria Grand 27/09/05

The Victoria Grand 27/09/04

The Victoria Grand 19/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE The Victoria Grand 22 Mill Road Worthing West Sussex BN11 4LF Lead Inspector Mr Richard Slimm Unannounced Inspection 27th March 2007 09:00 X10015.doc Version 1.40 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 The Victoria Grand DS0000058062.V333270.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 Older People. 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. The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Victoria Grand Address 22 Mill Road Worthing West Sussex BN11 4LF 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) 01903 248048 Victoria Care Elite Limited Mrs Julie Courtnadge Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: The Victoria Grand is one of a number of homes in the Worthing area owned by Victoria Care Elite Ltd. The home is a large detached Victorian building within it’s own grounds. It is situated on the corner of a busy road close to shops and other facilities, including Worthing seafront. The home is situated on three floors with a passenger lift serving all but three rooms that have a few stairs down to access the mezzanine floor. There is a main lounge overlooking the garden and fishpond, and a smaller, quiet, conservatory, lounge to the eastern side. The home has 20 single bedrooms, 11 with en suites, and 3 shared bedrooms, and is registered to accommodate 26 older persons. Mrs Julie Courtnadge manages the service. The scale of charges varies from - £450.00 to £650.00 per week dependent on the type of bedroom occupied. The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site inspection visit to the home took place between the hours of 10.00 and 16.00 hrs on the 27th March 2007. This site visit was the culmination of pre-field work inspection activities including – • • • • • • • A review of the history of the service since the last inspection Gathering information from a variety of professional sources, including The Commission’s database Pre-inspection information provided by the home prior to the last site visit in October 2006 Previous inspection reports Contacts with and feedback from service users and relatives and advocates of service users outside of the home Linking with CSCI staff who have knowledge of or had visited the service This was a key inspection, being part of a new inspection programme, called “Inspecting For Better Lives “ (IBL) which measures the service against the core and/or key national minimum standards, and focuses on quality outcomes of people using the service, and any issues of safety and/or risk. One regulation inspector carried out the visit, Richard Slimm. While in the home the inspector was able to meet 90 of the residents currently accommodated, carrying out case tracking with a number of service users all of whom were able to confirm that their care needs were met. Additional paper work where necessary was reviewed, a tour of the premises took place, and the registered manager; staff members, and residents were interviewed. Verbal feedback was given to the registered manager at the end of the visit. What the service does well: The home’s staff team provide care and support to residents of varying ability in a kind, respectful, cheerful and sensitive manner. The owners are nearby and run a number of care related services in the locality. The registered manager is on site monitoring services regularly, and there is also an on call at other times, in case of emergencies. The home also has senior care staff. There are a total of 20 carers, and the home also employs a full-time cook. Domestic workers are also employed. Fifty percent of staff have achieved the national NVQ training benchmark set by government. The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 6 The manager and staff have developed good relations with external professionals to the direct benefit of outcomes for service users. Feedback from residents, all of who were able to contribute to the inspection process was positive. More vulnerable and frail residents were found to be comfortable and well looked after. A sample of relatives interviewed felt the home was one of the better home’s in the area, and that the staff were excellent and there was a low turnover of staff members benefiting residents. 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 The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2 and 3 were assessed – Each service user has a written contract called a “General conditions of contract. “ The wording of this document does not fully promote all of the standards or support some rights of residents. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standard 6 was not assessed, as this home does not offer intermediate care services. The following evidence was obtained in respect of standard 2 Contract – • The contract fails to identify the specific bedroom to be occupied DS0000058062.V333270.R01.S.doc Version 5.2 Page 10 The Victoria Grand • • • • • • • • • Aspects of the contract are contrary to best practice as described in the recent Office of Fair Trading Report 2006 into contracts in older persons care homes The contract uses the dated term matron to describe the registered manager, when the home is not registered to provide nursing services, and later states no nursing care is provided Fees are set four weekly yet notice periods from customers to the company exceed four weeks for some residents Full fees to be charged when residents in hospital and not eating meals or using the support of staff and other services additional to the room space being rented Residents are being refused the right to maintain their independence in the area of self-medication. This must be based on assessment and the wishes of the resident and the views of the prescribing doctor. Residents are being refused their rights to choose to keep and / or drink alcohol without the approval of a doctor, or agreement of the manager. This should be based on assessment and the views and needs of the resident. The contract states that residents are only free to journey out with the approval of the manager. This should be based on assessment of risk and the views of the resident. The contract reserves the right for the company to make additional charges where the service is above the standards. Another condition appeared to be potentially unreasonable in the context of the vulnerability of potential service users, with the company reserving the right to charge interest on late fees at 5 above the company bankers published base rate. The following evidence was obtained in respect of standard 3 Needs assessment – • • • • • From a case tracking exercise of a sample of service users who gave their permission it was evident that all residents are assessed prior to admission to the home Assessment information included personal profiles about the person’s life and history before admission Key information was also obtained as part of the assessment process and included key people such as next of kin; friends; advocates; GP; nurse etc Assessment paid attention to issues of risk as well as needs and wishes Residents interviewed were aware of their personal records and had been involved in their assessments The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, and 10 were assessed – The service user’s health, personal and social care needs are set out in an individual plan of care, which although informative, could capture further information during monthly reviews. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. The contract currently fails to fully acknowledge the rights of residents in this aspect of daily living. Service users feel they are treated with respect and their right to privacy is upheld. This is with the exception of the tangible lack of provision of adequate privacy locks to rooms where privacy is to be expected. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 12 EVIDENCE: The following evidence was obtained in respect of standard 7 service users Care Plan – • • • Each resident had a plan of care set out within a standard document and based on the outcome of the care assessment of the resident concerned Daily notes and chronologies are maintained in a “cardex system”. The quality of information being kept was variable and provided some evidence that staff may benefit from further training in this area Reviews are carried out on a monthly basis and recorded in the plan document. Once more the quality of information varied, but in general relevant information was being captured with regard to daily care needs of residents Care plans and records identified residents health care needs and ensured that prompt action is taken to meet these needs with the support of local community health care teams, including GP’s district nurses and other specialists when needed Residents interviewed said they were happy with the quality of support the received at their home • • The following evidence was obtained in respect of standard 8 Health Care – • • • Residents confirmed that they could see their GP on request A district nurse was evident visiting a patient at the home at the time of this visit Care plans and records identified residents health care needs and ensured that prompt action is taken to meet these needs with the support of local community health care teams, including GP’s district nurses and other specialists when needed Staff confirmed there were good relations with visiting health care professionals • The following evidence was obtained in respect of standard 9 Medication – • • • The home’s contract currently fails to fully promote residents rights to self-medicate if appropriate In reality practice in the home did enable residents’ assessed as able to maintain their own medicines to do so, and more frail residents medications were found to be managed by the home safely Residents spoken to said they were happy with the arrangements made for the management of their medications, and more able residents were supported to remain independent The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 13 • • • • • • • The home uses a monitored dosage system with medicine administration records (MAR) sheets used to record and keep an audit trail of medicines administered Medicines were being stored safely, with the exception of some eye drops that had been left outside of the drug trolley, this was dealt with when pointed out The home has a separate metal standard controlled drug cabinet that is secured to the wall At the time of the visit the controlled drug book was left in view in a communal hall and needed to be stored in the drug cupboard to protect issues of confidentiality for service users. This matter was addressed immediately when pointed out to the manager Staff members involved in any aspect of medication administration are trained to do so Staff induction is based on Skill for Care industrial occupational standards and includes familiarisation with the home policies and procedures concerning medication and drugs administration Other staff training is provided in regard to safe medication practices The following evidence was obtained in respect of standard 10 Privacy and Dignity – • • • • • • • • • A large number of residents have their own telephones in their private bedrooms Residents interviewed said they felt staff respected their privacy and dignity Staff were observed to knock on bedroom doors before entering No private bedrooms had been provided with privacy lock facilities. This was not an issue for existing residents spoken to by the inspector Residents had been asked to sign disclaimers for the provision of privacy locks to their personal bedrooms by the provider One communal toilet and bathroom had not been provided with a privacy lock, consequently the occupant could not lock the door if they wished Arrangements are in place to ensure that residents who share bedrooms do so having exercised informed choice The manager was aware of the need to promote the provision of privacy locks for new residents in line with Standard 24.5, as a tangible facility to give residents choice, control and to promote independence Residents’ told the inspector they had requested a blind to be fitted to the dining area in August 2006. One of the owner’s had visited the day before the site visit to measure the window for a blind The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 were assessed Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family / friends / representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. This is contrary to some of the poor wording of the current contract. Service users receive a wholesome appealing balanced diet in pleasing Surroundings at times convenient to them. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 15 EVIDENCE: The following evidence was obtained in respect of standard 12 Social Contact and Activities – • • • Residents interviewed said they were happy with arrangements made at the home in respect to their lifestyles One resident has said she would like more trips out in the mini-bus, perhaps weekly trips as opposed to the current fortnightly trips It was evident that some residents would like to see more entertainment and activity going on in the home, but many are quite happy with things as they are, preferring to make their own arrangements, and taking part in those activities the home provides that include; mini-bus outings; shopping trips; quizzes; games and keep fit Relatives spoken to said they felt there could be more stimulation for residents The home provides a mini-bus and trips out on a two weekly planned basis The home has put on activities, but inspector was advised these were not well attended. This may indicate the need to consult more with residents before putting on activities to ensure they are in line with the needs and wishes of the whole resident group Residents were free to come and go as they pleased based on their needs and abilities. More able residents confirmed that they went out for daily walks around the neighbourhood. More dependent residents are supported to go out on trips in the mini-bus, or families are encouraged to take them out The manager explained that residents are consulted on a regular basis, both formally and informally. Residents interviewed also confirmed that the manager and the staff check with them that everything is ok, and that they had been given surveys in the past about the home, as well as regular meetings • • • • • • The following evidence was obtained in respect of standard 13 Community Contact – • • • • Residents confirmed they received their guests when and where they wished Relatives confirmed they could visit at any reasonable time and did not need to pre-plan this with the home The home has a clear visiting policy Residents are free to choose who they see The following evidence was obtained in respect of standard 14 Autonomy and Choice – The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 16 • • • • • • • Practice in this area was contrary to the wording of the current contract for the home Residents confirmed that they were able to make choices about their daily lives in an adult and age appropriate manner In practice there was no evidence of restrictive practices at the home, and the resident group where able to challenge such practices The home has declared they have no involvement in dealing with residents personal or financial affairs, preferring to leave this to residents and/or their families/advocates Residents were found to be aware of their personal records and had been involved in developing their own plans of care and support Residents are consulted by the home The degree to which the organisation takes action based on the specific requests of the resident group was unclear. Residents stated they had asked for a blind to be provided to the south-facing window in the dining room. They had been asking for this since August 2006 and the manager had passed this request to the owners, who had visited to measure the window the day before the inspection visit. There was some evidence that the type, frequency and quality of activity provided at the home was not fully based on the wishes, or indeed a thorough and specific consultation with the current resident group The following evidence was obtained in respect of standard 15 Meals and Mealtimes – • Residents confirmed that the quality of the food was very good, comment included “the chef is excellent”; “I really look forward to my meals here”; “the food’s so good I’m having to watch what I eat because of putting on too much weight”. Food menus offered a full varied and nutritious diet The chef confirmed he is provided with the resources needed to keep the residents happy Residents have choice and control over the food they eat, and where they eat The inspector was given the opportunity to join residents at lunch, which is the main meal of the day. All residents praised the food saying this was one of the highlights of their day. Such comments as “the food is always good”, “there’s always plenty of food and it’s always well presented”. The meal included a choice of two main courses and several highly attractive desserts Staff were discreetly attentive to residents support needs throughout the lunch serving period • • • • • The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed – Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. EVIDENCE: The following evidence was obtained in respect of standard 16 Complaints – • • • • • • There had been no complaints recorded in the last 12 months Residents are all given a complaints procedure in the companies welcome pack for the home. This now needs updating as the Worthing Office of the CSCI has now closed Residents knew who to speak to if they had any concerns Residents said the manager is very approachable and would deal with any problems A relative also confirmed the staff and the manager are approachable and has never been made to feel uncomfortable when asking for specific issues to be addressed in respect of his loved one’s needs The company has introduced a quality assurance system that monitors complaints and/or comments about the service DS0000058062.V333270.R01.S.doc Version 5.2 Page 18 The Victoria Grand The following evidence was obtained in respect of standard 18 Protection – • • • • • • • There had been no reported protection of vulnerable adults (POVA) case at the home The manager was aware of her responsibilities with regard to POVA The home has a copy of the local social services policy and procedure with regard to POVA Staff interviewed were able to demonstrate an awareness of what may constitute abuse of adults and/or older persons Staff confirmed they had been trained in POVA Residents confirmed that they felt safe living at the home In respect of one staff member full POVA and CRB checks had not been carried out (See section six Staffing) The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 and 26 were assessed Service users live in a safe, well-maintained environment. With the exception of some external décor that was below standard. Service users live in safe, comfortable bedrooms with their own possessions around them. However, doors to service users’ private accommodation, and other rooms such as a communal WC and bathroom, are not all fitted with locks suited to service users’ capabilities and accessible to staff in emergencies. This potentially infringes on the rights, dignity, security, choice and privacy of residents. The home is clean, pleasant and hygienic. With the exception of the laundry area which is in need of investment, deep cleaning, and action to help minimise health and safety risks in respect of the tripping hazard to the door threshold, and poor floor/wall coverings. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 20 EVIDENCE: The following evidence was obtained in respect of standard 19 Environment – • The internal aspect of the home where service users have access, such as communal areas and personal / private bedrooms were all decorated and maintained to a good standard, providing a valuing environment to residents The external aspect of the building was in need of investment, redecoration and maintenance, flaking paintwork and wood rot was evident in some areas. The manager advised the inspector that this work will carried out this year, and will include work to maintain a metal fire escape in need of significant upkeep The kitchen area is run as a busy, professional kitchen, so service users do not routinely have access to the kitchen, but this did not pose any problems for the residents accommodated, who advised the inspector that staff members are always available to provide for any of their needs in this area of daily living. • • The following evidence was obtained in respect of standard 24 Individual Accommodation / Furniture and Fittings – • Privacy door locks are not provided to doors where privacy is to be expected – it was noted that all private bedroom doors to private rooms and at least one communal WC/bathroom had not been provided with suitable privacy door locks for residents to use if they wished. Residents had been asking for a sun blind to their dining room since the late summer 2006 There is no alarm call point provided to the dining area Residents had been supported and encouraged to personalise their own space and were consulted about the décor and upkeep of other areas that are shared in their home Current Service user’s had been asked to sign disclaimers so that the company did not have to provide privacy locks in line with the standards. While this was not an issue for current residents spoken to, new residents admitted to the home from 1/5/07 will need to be provided with a lock to their individual bedrooms as standard. Care plans and risk assessments did not identify reasons why residents had not been provided with suitable locking arrangements to their private space, and there were no reasons evident at the time of the visit that residents could not have been provided with this fundamental facility. • • • • The following evidence was obtained in respect of standard 26 Services / Hygiene and control of infection – The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 21 • • • • The laundry area was poorly cleaned due to poor design and in need of investment to provide an area that staff can use safely and keep properly cleaned in order to avoid risk of cross infection. Occasionally service users are accommodated with conditions that need to be carefully managed. The area needs a floor and wall surfaces that are impermeable. Current lino floor coverings and un-tiled walls are not acceptable, or effective. The door to the laundry has a hazardous threshold that could present a tripping hazard to persons using the area. Other areas of the home were being kept clean and there were no offensive odours throughout the home at the time of the visit. The home employs separate domestic workers who work hard to keep the home fresh and well presented for residents Staff members are provided with appropriate resources, such as disposable gloves, aprons and cleaning materials to do their jobs safely Residents’ confirmed that their home is always kept clean and tidy by the dedicated domestic staff The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 were assessed The numbers and skill mix of staff meets Service users needs. Service users are in safe hands at all times. Service users are not fully supported and protected by the home’s recruitment policy and practices. The organization was not carrying out the necessary staff checks to all staff employed and working at the home. Staff members are trained and competent to do their jobs. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. EVIDENCE: The following evidence was obtained in respect of standard 27 Staff Complement – • Staffing levels were sufficient to meet the needs of residents, with four care staff on duty on arrival unannounced to the home, with the manager, domestic, Kitchen assistant and chef in addition. The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 23 • • • • Residents confirmed that staff are very attentive and if they have to call for staff assistance via the alarm call they do not have to wait long before staff arrive The staff team are well established, well trained and receive good induction into working at the home in line with Skills For Care standards There is a low turnover of staff at this home Staff training has included – POVA; Infection Control; Health & Safety Awareness; Life Support; Safe Handling of Medicines; Nutrition, Health and Food Hygiene; Manual Handling and Moving; Health and Safety Risk Assessment; Dementia; First Aid, with 14 staff holding a First Aid certificate and Fire Training. The following evidence was obtained in respect of standard 28 Staff Qualifications – • One staff member interviewed was qualified to a degree level. Another was studying to obtain a degree. Fifty of care staff have been supported to get their NVQ level 2 qualifications that meets the government benchmark for the care sectors. There was evidence of a commitment to the ongoing training and development of staff working at the home • The following evidence was obtained in respect of standard 29 Staff Recruitment – • • • A sample of staff records were inspected, including the most recently employed person One record showed the organisation had not carried out the necessary employment checks to ensure the safety of residents. No new CRB or POVA 1st check had been carried out as required Other staff had been checked appropriately in both POVA 1st and CRB The following evidence was obtained in respect of standard 30 Staff Training – • • • Care staff receive induction that uses the industries occupational standards and follows standards produced by Skills for Care, and provides a good standard of familiarisation for new staff joining the team The home has a training programme Staff interviewed said they were well trained and received good induction, and regular supervision The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 were assessed – Service users live in a home, which is managed by the manager and run by an organization that have been registered and deemed competent and fit to run the home. The home fails to provide residents with privacy locks to promote their best interests. The contract between the company and service users is in need of review. The views and wishes of service users need to be further listened to and acted on by the company. Other areas of service were found to promote residents best interests (see above). The provider needs to review the contract in order to ensure that the service users’ financial interests are fully promoted and safeguarded. The home has declared that they do not get involved in handling or have any other involvement in residents’ personal, financial affairs. Residents’ who may need support in this area would have families involved. The home’s assessment systems do identify legal safeguards already in place, such as guardianship, and or power of attorney. The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 25 The health, safety and welfare of service users could be further promoted and protected by extending the alarm call system to all rooms in the home, in line with the standards. The health and safety of staff could be further promoted in respect of a tripping hazard to the entry door of the laundry area. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. EVIDENCE: The following evidence was obtained in respect of standard 31 Day to Day Operations – • • • • • The registered manager has many years experience working with older persons, and has achieved the NVQ level 4 in management qualification The registered manager is committed to ensuring that the best possible services are provided to residents and that residents are fully consulted about the sort of services provided The home provides a staff structure including senior care staff to whom the manager can safely delegate duties and tasks, as well as having an on-call emergency arrangement in place Residents confirmed the manager was approachable and does a very good job Staff members interviewed confirmed that they felt valued and supported by the manager of the home who provides them with regular meetings, supervision and annual appraisals The following evidence was obtained in respect of standard 33 Quality Assurance – • • • The manager arranges to hold regular meetings with both staff and residents about the running of the home The company have an annual development plan and are also pro-active about upkeep and maintenance, with extensive decoration and maintenance planned to the external aspects of the home this year The company have put in place a quality assurance system to support the work of the manager and to promote resident involvement in ongoing developments and the overall improvement of the service provided Feedback is actively sought from service users in a variety of ways including, meetings, surveys and informally • The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 26 • • Residents confirmed they were consulted, though some were impatient that the organisation had taken so long to provide the blind requested for the dining room in August 2006 There is a need to review some documentation as identified above in line with current best practice The following evidence was obtained in respect of standard 35 Service Users’ Money – • • • • The home have declared that they are not involved in any aspect of dealing with service users’ personal or financial affairs Residents interviewed said they managed their own affairs with the support of their relatives, or other advocates external to the home The home is aware of legal arrangements for more vulnerable residents under such arrangements as court of protection Records indicated that arrangements would be made for residents with support needs such as court of protection, either with families or externally to the home The following evidence was obtained in respect of standard 38 Safe Working Practices – • A fire officer last inspected the home on the 31/3/07. Fire equipment was tested on the 6/9/06. The last fire drill took place 20/11/06, and included a fire lecture for staff. The fire alarm is tested on Fridays. Residents confirmed this practice took place The environmental health officer last inspected the home on the 12/5/06 Tests are routinely arranged with appropriate contractors to ensure all systems in the home are maintained safely and to manufacturers recommendations There is a contract for the disposal of soiled waste and sharps The emergency alarm call system was last serviced on the 15/12/06, the alarm call system does not extend to the dining room The home has clear policies and procedures in respect of the maintenance of health and safety related topics at the home The laundry area needed deep cleaning, and needs investment in order to ensure the area is easily cleanable with impermeable surfaces to floors and walls, and tripping risks to the entrance door need to be addressed • • • • • • The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 28 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. 1 Standard OP2 Regulation 5/ schedule 4 Requirement Timescale for action 01/05/07 2` OP24 3 OP26 OP38 4 OP29 The registered person must review the current contract and terms and conditions document in line with the promotion of the rights of service users, the standards and best practice. 12/13 & The registered persons must 01/05/07 23 provide suitably designed privacy door locks to all rooms in the home where privacy is to be expected. 13/16 The registered person must 01/05/07 provide the commission with a clear plan outlining how they intend to develop the laundry area so as to provide a safe area with impermeable floor and wall coverings – and to address the issue of the tripping hazard identified at the time of the site visit. 19/schedu The registered persons must 28/03/07 le 2 carry out Criminal Records Bureau checks including POVA 1st checks on all staff who have access to vulnerable adults. The single staff member without current and up to date checks must not work at the home until DS0000058062.V333270.R01.S.doc Version 5.2 The Victoria Grand Page 29 such checks are carried out and are returned. 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 OP16 Good Practice Recommendations It is recommended that the registered persons update the complaints procedures address for the CSCI as the West Sussex office has now closed, and the Southampton office is now the alternative addresses. The provider may wish to liaise with the home’s link inspector with regard to this matter It is recommended that the registered persons provide a call / alarm call system for residents in the dining area of the home. 2 OP22 The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 The Victoria Grand DS0000058062.V333270.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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