Inspection on 12/09/07 for The Victoria Lodge

This inspection was carried out on 12th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Victoria Lodge 29/09/08

The Victoria Lodge 04/02/08

The Victoria Lodge 27/02/07

The Victoria Lodge 30/01/06

The Victoria Lodge 13/09/05

The Victoria Lodge 07/10/04

The Victoria Lodge 06/05/04

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 Lodge 48-50 Shakespeare Road Worthing West Sussex BN11 4AS Lead Inspector Ms A Campbell-Currie Unannounced Inspection 12th September 2007 10:00 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 Lodge DS0000058057.V344298.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 Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Victoria Lodge Address 48-50 Shakespeare Road Worthing West Sussex BN11 4AS 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 201006 Victoria Care Elite Limited Mrs Elaine Marie Walker Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th February 2007 Brief Description of the Service: The Victoria Lodge is registered to provide accommodation and care for twenty-three residents over the age of 65. It is owned by Victoria Care Elite Ltd and is one of a number of homes that the group have in the Worthing area. It is situated near to the centre of town, close to shops and the railway station. The bedrooms are situated on three floors with access provided by a passenger lift. Due to the layout of the home wheelchair users cannot be accommodated. Mr P Burtenshaw is the responsible individual for the company and Mrs Elaine Walker manages the service. The charges range between £450 and £650 weekly. The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Unannounced Inspection and site visit were carried out following the unannounced inspection in February when a number of matters needed to be put right urgently to protect the health, safety and well being of people living in the home. The deputy manager came in to assist with the inspection and the manager was available by telephone. The providers were away. The staff on duty were also very helpful and all the information and paperwork needed was available. There were twenty people living in the home at the time. Before the inspection the manager completed an Annual Quality Assurance Assessment form (AQAA) about the home; this information was used in the inspection planning. Mr Burtenshaw had sent a letter in response to a request for an Improvement Plan to show how people would be kept safe; this was also taken into account. Before the inspection a survey was carried out to find out what people think about the home. Survey forms were received from nine people living in the home, four relatives, three GPs and a care manager. During the day a tour of the grounds and building was made with the deputy manager. Eight people living in the home were spoken with and three members of staff including the chef. Seventeen requirements were made following the inspection in February and an Improvement Plan was requested. Four of the seventeen requirements have been fully met and five additional requirements have been made following this visit. The outcome for people living in the home has been assessed in relation to thirty-two of the thirty-eight National Minimum Standards for the care of older people, including those considered to be key standards to ensure the welfare of people living in the home. Eighteen requirements have been made; thirteen requirements remain outstanding from the previous inspection and any further failure to comply with these requirements will result in the Commission taking enforcement action. Judgements were made from evidence gathered during the inspection, which included a site visit to the service and takes into account the views and experiences of people using the service, as well as evidence gathered from a range of sources since the last inspection of the home. What the service does well: The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 6 The commitment of the staff spoken with and the care provided by the managers and staff was very impressive. The people who returned surveys were positive about the care provided; all nine people said that staff listen and act on what they say. Some of the comments made were: “Excellent home”, “staff very kind and polite”, “staff always kind and efficient”, “I have been happy since I have been here”, “I can’t speak highly enough about the staff at Victoria Lodge, from the top to the bottom” and “this is a wonderful home with such a happy atmosphere and the staff do everything they can to make residents happy”. The areas of the home that have been redecorated with new carpet are bright and welcoming. The dining room is a pleasant place for people to take their meals. What has improved since the last inspection? What they could do better: The Statement of Purpose has not been updated to include the new policy of admitting people who are under sixty-five years of age. The Statement of Purpose does not include information about how people’s needs would be met and an assurance that staff have had the training to make sure they understand the particular needs of people admitted to the home. A requirement has been made regarding this matter. It was not clear that people had been involved with their assessment before they came to the home and no confirmation in writing that their needs could be met. The case records showed that one person had care needs that are not included in the category of Registration for the home and there was no indication that staff had received any specific training to meet the person’s needs. A requirement has been made regarding this matter. The contracts seen had been signed by service users but did not include the room number or fees to be paid. A requirement has been made regarding this matter. A number of policies need to be reviewed and updated including the admission policy, medication, infection control regarding the procedure with soiled The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 7 laundry, recruitment and fire safety. A second requirement has been made regarding this matter. Newly appointed staff must have the necessary checks returned before they begin work. A second requirement has been made regarding this matter. There must be an urgent programme to put right the health and safety risks presented in the building and the grounds. Second requirements have been made about each matter that presents a risk to people living in the home. All staff need to attend the mandatory training sessions as required to ensure that they know how to protect the health, safety and welfare of people. A requirement has been made regarding this matter. The quality assurance process in the home should include a frequent audit of the premises to ensure that people are kept safe. A second requirement has been made about this matter. Staff should receive individual appraisals annually and individual supervision at least six times a year, to ensure that they have the knowledge and skills to provide the care needed and so that they feel fully supported in their work. A second requirement has been made about this matter. 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. The Victoria Lodge DS0000058057.V344298.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 Lodge DS0000058057.V344298.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): 1, 2 and 3. Standard 6 does not apply. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The information provided to prospective service users does not include all the information that they require. Service users are provided with a contract that does not include all the terms and conditions of their stay. People have most of their needs assessed before they move into the home. EVIDENCE: People are provided with a Statement of Purpose and Service User Guide. Six of the nine people who returned surveys indicated that they had received sufficient information about the home. The Statement of Purpose does not reflect the recent change in admission policy to show that the needs of people under sixty-five years of age could be provided for. The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 10 Five people who returned surveys indicated that they had received a contract. Copies of contracts that had been signed by service users were seen on file; these did not include the cost of their accommodation or the room that they would be occupying. There was evidence to show that an assessment of need had been carried out before people moved to the home. One person had been admitted to the home although it was unclear that the home would be able to meet this person’s primary care needs that fall outside the category of Registration. One person said that he had been visited in hospital before he moved. The assessment forms that were seen did not show whether or not people had been involved in their assessment and there was no space to show who had carried out the assessment. The information on the forms seen were not detailed and did not include any reference to spiritual, sexuality or cultural needs, although this was included in the care plans seen. The Victoria Lodge DS0000058057.V344298.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): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ health, personal and social care needs are set out in an individual plan of care. Health and personal care needs are met. People are not fully protected by the home’s policies regarding medication. People are treated with respect and their right to privacy respected. EVIDENCE: Eight of the nine people who returned surveys indicated that they usually or always receive the care and support they need; one person said they sometimes do. The people spoken with said that they receive the care that they need and the staff are always kind and helpful. One person said that with the help he had from staff after leaving hospital he can now get about more independently. Samples of care plans and other documents showed that The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 12 people have an individual plan of care that includes detailed risk assessments in all aspects of their daily life. The deputy manager said that the staff take time to get to know people before the care plan is drawn up. There was evidence to show that care plans are reviewed and changes of need identified. Staff spoken with said they understand the needs of people living in the home. One person said that she was given all the guidance she needed to provide good care when she first started work. It was clear from case records, the surveys that were returned and discussion that people receive the health care that they need. Three GPs responded to a survey sent out and all expressed satisfaction with the home; one said that it is a “well run home”. There was evidence on case files to show that people see their GP when they need to and those spoken with confirmed this. The manager said that there is a good relationship with the local health care staff. One person is responsible for holding and administering their own medication; a consent form had been signed and lockable facility provided. There was no risk assessment to show that it would be safe for this person to hold his or her own medication. The administration practice has been reviewed since the last inspection and a lockable box has been provided to ensure that medication is kept locked during medication rounds. This means that the medication record can been signed as soon as the person has taken their medication. The medication policies have not been updated since the last inspection and do not provide guidance in respect of errors or the new procedure for administering medication in the home. The policies should be reviewed against the Royal Pharmaceutical Society Guidelines. Staff are given guidance and support about the way to provide personal care as part of their induction; staff spoken with were confident about this issue. People were being treated with care, sensitivity and respect during the day. People spoken with said the staff are kind and provide care in the way they prefer. Comments included: “Staff are very kind and helpful”; “staff always kind and efficient” and a relative said, “the matron and staff are always accessible and are always very kind and attentive.” The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 13 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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with the lifestyle experience in the home that suits them and are supported to maintain contact with their family and friends. People are supported to exercise choice in their lives and are provided with a wholesome and balanced diet in pleasing surroundings. EVIDENCE: Service users interests and hobbies were noted in the assessments and care plans. There is a programme of activities that are usually provided by the care staff. In the afternoon of the inspection a woman came to the home to provide a music and movement session. Activities were advertised on the notice board. Staff said that two people each day have the opportunity to go out for a short time and they make sure that everyone has a turn. The outings are sometimes short, as the staff are needed for other duties in the home. A fete was held recently and musical entertainment is provided from time to time. Four people who returned surveys said that there are usually or always activities arranged. The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 14 Several people were reading their newspaper during the morning. A member of staff said that she would like to have time to read with people who have a visual impairment. People are supported to maintain contact with their family and friends. One person said her visitors are made very welcome in the home. Three of the four relatives who returned surveys said that they are kept informed about their relative’s welfare. People said they are able to exercise some choice in their daily lives; one person said he is used to getting up very early and staff have been flexible in providing his breakfast early. People have been able to bring some of their possessions to the home. People are provided with a nutritious and varied diet. Those spoken with said that they could choose whatever they wish if they do not like the main meal and that the chef is very accommodating. The daily menu is displayed in the hallway. The dining room is pleasantly set out and lunchtime was a relaxed occasion. People said they were satisfied with the meals provided. The manager said that people’s wishes had been included in the menu planning. The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 15 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): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their relatives and friends are confident that their complaints will be listened to and acted upon. The recruitment process is not sufficiently robust to fully protect service users from possible abuse. EVIDENCE: There is a complaints policy that is provided to all service users. All those who responded to the survey indicated that they know how to make a complaint; this was confirmed by relatives and people spoken with were confident that their concerns would be listened to and acted upon. There is a system for recording complaints; two have been recorded in the past twelve months. The Commission has not received any concerns or complaints. There is a policy that provides guidance in safeguarding adults. All staff have attended training in recognising the signs of elder abuse as part of their induction. It was not clear that all staff have attended updated training sessions in the past year. The two staff spoken with and the deputy manager were clear about their responsibilities in the event of a concern that abuse may have occurred. A recently appointed member of staff began work a month before the necessary Criminal Records Bureau (CRB) check had been received. The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 16 If the necessary checks are not carried out before a member of staff begins work service users could be put at risk. The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 17 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): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Parts of the home are fresh and clean and provide a pleasant environment for service users. Some maintenance issues have been addressed in order to protect service users. There are a number of maintenance requirements that still need to be addressed to ensure that people are living in a safe, well maintained home. EVIDENCE: Eleven requirements were made in relation to the home and grounds at the last inspection. A tour of the premises showed that while some changes have been made; there are a number of issues outstanding that could present a risk to the health and safety of service users and staff. There is no clear programme for ensuring that these requirements are addressed. The manager The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 18 and deputy reported that there have been ongoing difficulties in getting support from a member of staff also responsible for maintenance in four other homes in the group. The building continues to need some attention externally and repairs that have been made to some area of the guttering and ceilings in two rooms have not resolved the problem. The garden was well cared for and several service users were walking or sitting outside. Old furniture has been moved from the path but is now stored in a corner of the garden; there are other items in the garden that could cause a risk to service users. This includes an old green house that has not yet been made safe. Staff use the building in the grounds for some laundry duties; it is in a poor state of repair, untidy and dirty. The deputy manager was advised to ensure that the room is kept locked so that service users are not put at risk, although there is a risk to the health and welfare of staff. The electrical wiring in the house has been checked by a qualified electrical and the safety certificate was seen. Door closures have now been fitted to the majority of doors to ensure that people who like to have their doors open are protected in the event of a fire. The deputy manager said that the remaining doors are due to have closures fitted. The majority of radiators have had guards fitted. The radiators in two bathrooms and the rooms of one service user are not protected to prevent the risk of burning. The water from a number of hot water outlets was very hot to the touch and one person said she had to be careful when running the water to wash. Water temperatures are monitored and recorded; these records showed that a number of hot water outlets are at a temperature at least ten degrees above the recommended level to ensure that people are not scalded. The building was well-lit and communal areas and bedrooms were well decorated. Locks have been fitted to communal bathrooms and toilets to ensure privacy; staff in the event of an emergency could open these. The communal bathrooms are small and in need of refurbishment. Staff commented that the bath hoists are old and not easy to use. There has been no assessment of the building and grounds carried out by an occupational therapist as required following the last inspection. Some areas of the home do not have hand rails to assist service users to get around and only some en-suite toilets had grab rails; it was not clear that any assessments had been carried out to ensure that people had grab rails in en-suite toilets if they need them. There are several call systems in use in the home. Some rooms have a system that can only be switched off in the room; the majority of rooms do not have this system. Most people have a system that can only be used from the bed, so if they fall while getting up from their chair they have no means of calling The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 19 for help. There is no system in the communal areas or garden; although staff said there is always someone close at hand in these areas. People said that they are happy with their bedrooms and that they are able to bring possessions to help them feel more at home. Every room has at least two electric sockets. It was noted at the previous inspection that a number of people have several appliances and there is a reliance on the use of extension leads; these present a risk of trips and falls. One service user said she is very worried about falling over in her room. The light fitting and a socket were not secure in this person’s room; the deputy said that this would be addressed as a matter of urgency. Window restrictors have been fitted to most windows; the deputy manager said that some people have refused to have restrictors fitted especially those on the top floor because it is very hot. The advice of the environmental health officer must be sought on this issue as service users could be at risk of falling. Some windows were difficult to open for ventilation and one room had a torn net curtain over the window. Some people have been provided with new mattresses; others seen were covered and clean. The home was clean and bright; housekeeping staff are employed to maintain the level of cleanliness. Eight of the people who returned surveys said the home is usually or always fresh and clean. The care staff are responsible for laundry duties. The manager has not consulted the health protection, community infection control nurse or the environmental health officer in respect of improving the current handling, storage and washing of laundry to prevent cross infection. A manager from another home in the group has assessed the laundry facilities; the manager of The Victoria Lodge has not yet received the results of the assessment. New flooring has been fitted and a new procedure for moving soiled laundry in baskets has been introduced. There are no hand washing facilities in the laundry and no ventilation in the staff toilet that is used by staff doing the laundry for hand washing. It was noted that clean clothes were being sorted and folded in the lounge and left on tables in the lounge while staff carried on with other duties. A lock has been fitted to the cupboard used for storing dangerous chemicals; this was open and accessible to service users. The deputy manager was advised to ensure that the cupboard is kept locked while not in use for the protection of service users. The infection control policy has been reviewed and re-written; it does not include guidance about the managing soiled laundry and use of the laundry facilities. The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 20 The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 21 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): 27,28,29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users’ needs are met by the numbers of staff on duty. The home’s recruitment procedure does not fully protect service users. Staff are not fully trained to meet the needs of people living in the home. EVIDENCE: People who responded to the surveys said that staff listen and act on what they say. One person said there are sometimes too few staff on duty. Samples of the staff rotas were seen and showed that there are four staff on duty in the morning and three in the afternoon; there are two waking staff on duty at night. Call bells were being responded to without delay and staff said they had time to attend to people’s needs, this showed that there were sufficient staff on duty to meet the needs of people living in the home. Seven of the eighteen care staff have achieved the National Vocational Qualification (NVQ) at level two or above. No staff are currently on the NVQ programme; the deputy manager said this is due to individual circumstances and people are encouraged to achieve an NVQ award to increase their knowledge and understanding. The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 22 The recruitment records for a member of staff recruited since the last inspection were seen; this person was also spoken with. There was no evidence to show that a POVAfirst check had been carried out before the person began work to ensure people living in the home would be protected. There was no evidence to show that any policy guidance had been given in order to protect service users in these circumstances. A Criminal Records Bureau (CRB) check had been received the month after the person began work. Written references were on file and an induction programme had been completed. There was no evidence that an interview had been carried out or an equal opportunities approach had been taken to employment. The recruitment policy was read and did not give clear guidance about interviews and did not mention the need to carry out CRB and Protection of Vulnerable Adult (POVA) checks before people begin in post. There is an induction and training programme in mandatory topics; staff spoken with said that they are encouraged to attend training. Certificates of attendance were seen on some staff records. It was not clear from the records kept that all staff have attended mandatory training as required including health and safety, safeguarding adults, moving and handling and fire training. There was no evidence to show that staff have been given training in any additional or specialist areas of care including meeting the needs of one person admitted since the last inspection. The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 23 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): 31, 33, 35, 36, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The health, safety and welfare of service users and staff are not promoted or protected. EVIDENCE: The manager has six years experience in managing a care home and has achieved the Registered Manager’s Award. The staff and service users spoken with all said that she is very accessible and addresses any concerns quickly. A care manager who returned a survey said: “Victoria Lodge is a very well run home with a good home manager in place”; a relative commented that the The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 24 manager is always accessible. A GP who returned a survey also said the home is well run. Seventeen Requirements were made following the last inspection as the safety and welfare of people living in the home was not being protected. While some improvements have been made since the last inspection in February, there are a number of outstanding issues that continue to affect the health and safety of service users. These include environmental and recruitment issues that have been noted (see Standard 19-26 and Standard 29). The home sends out a questionnaire each year to people living in the home in order to seek their views. This information has been collated and comments noted however the results have not been published and there was no evidence to show that people’s views had been acted upon. The deputy manager said that people’s views and comments have been taken into account and those spoken to said they could raise any concerns. Resident’s meetings are held and minutes kept showing that people have an opportunity to put forward their concerns and ideas. There is no annual development plan for the home and although risk assessments had been carried out for some areas of the home there was no evidence to show that there had been a plan of improvement or audit of the premises to meet the requirements made within the timescales given. There was no evidence to show that policies and procedures are reviewed and updated as required as part of a quality monitoring process. The procedures for supporting service users to manage their money were seen. Records and receipts are kept so that service users finances are protected. Staff spoken with said they feel well supported. Some staff had received supervision on certain training topics and some group supervision takes place six monthly at staff meetings. There is no system in place to ensure that staff receive individual supervision six times a year. Not all staff have had an annual appraisal. The health and safety of service users is not protected because there has been a limited response to the requirements made at the last inspection. An up to date electrical certificate was seen and the majority of doors have closures to protect people in the event of a fire. The fire records were seen and were up to date however not all staff have attended the mandatory fire training to ensure they know what to do in the event of a fire. The fire policy has not been updated to include the new legislation for Fire Regulation and Risk Assessment (2006). It was not clear that all staff have attended training in health and safety and moving and handling as required. The matters that could put service users at The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 25 risk and need to be addressed as a matter of urgency include: ensuring that all radiator surfaces are kept at a temperature that would not cause a burn; hot water temperatures to be kept at the recommended level; an alternative is to be found to the use of extension leads with trailing wires that could cause a fall; advice to be sought from the environmental health officer regarding window closures; the greenhouse in the garden to be made safe; door closures to be fitted to the remaining doors. The accident book was seen and incidents had been appropriately recorded. The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 26 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 2 2 1 X X N/A 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 1 1 2 2 2 2 2 2 1 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 2 1 The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Reg 4 (1) (c) 2 OP3 Reg 14 (1) Regulation Requirement People must be provided with an up to date Statement of Purpose to show that the home is able to meet their needs. People must only be admitted to the home if an assessment of need shows that they are within the category of Registration and that staff are suitably trained to meet their needs. People must be provided with a contract of the terms and conditions of their stay that includes the room to be occupied and the fees to be paid. The external grounds must be safe for the use of service users: the green house must be made safe; items that present a danger must be removed. This requirement is outstanding from the previous inspection. 5 OP19 Reg23 (2)(b) The home must be maintained in good order externally and internally. Windows must be maintained in a good state of DS0000058057.V344298.R01.S.doc Timescale for action 30/11/07 30/09/07 3 OP2 Reg 5 (c) 30/09/07 4 OP19 Reg 23 (2)(o) 30/09/07 31/10/07 The Victoria Lodge Version 5.2 Page 28 repair so that they can be opened for ventilation. Penetrating damp caused by poor repair to the roof or guttering must be addressed. This requirement is outstanding from the previous inspection. 6 OP19 Reg 23 (2)(n) The guidance of the 30/09/07 Environmental Health Officer is to be sought regarding the fitting or window restrictors. This requirement is outstanding from the previous inspection. 7 OP22 Reg 23 (2)(n) The home must have an assessment undertaken by an occupational therapist and adaptations, including grab rails made to ensure that service users have safe access to all areas. This requirement is outstanding from the previous inspection. 8 OP22 Reg 23 (2)(n) The call bell system must be within reach of the service users and only switched off at source. This requirement is outstanding from the previous inspection. 9 OP24 Reg 13 (4)(a) 10 OP24 Reg 16 (2)(c) The use of extension leads with long flex in service users’ rooms is to be reviewed to prevent the risk of trips and falls. To protect the privacy and dignity of service users bedroom doors must be fitted with suitable locks that could be opened by staff in an DS0000058057.V344298.R01.S.doc 30/09/07 31/10/07 30/09/07 30/09/07 The Victoria Lodge Version 5.2 Page 29 emergency. This requirement is outstanding from the previous inspection. 11 OP25 Reg 13 (4) Service users must be protected from the risk of burns by ensuring that all radiators or heaters have low surface temperatures. This requirement is outstanding from the previous inspection. 12 OP25 Reg 13 (4) 13 OP29 Reg 19 Service users must be protected from the risk of scalds by ensuring that all hot water outlets are kept at 43 degrees or below. No care staff should commence work without a CRB check unless a satisfactory POVA first check has been obtained. The required guidelines should be followed to protect service users until a full CRB check has been received. This requirement is outstanding from the previous inspection. 14 OP30 Reg 12 and 18 (c)(i) All staff must be provided with the updated training necessary for their job including health and safety, moving and handling, adult abuse and fire safety. This requirement is outstanding from the previous inspection. 15 OP33 Reg 24 The manager must implement a quality assurance system that measures the standards of the service against the requirements of the Care Home Regulations. DS0000058057.V344298.R01.S.doc 30/09/07 31/10/07 12/09/07 31/10/07 30/09/07 The Victoria Lodge Version 5.2 Page 30 This requirement is outstanding from the previous inspection. 16 OP33 Reg 10 and 12 Policies and procedures must be reviewed and updated with changing legislation and good practice advice from the Department of Health and other relevant professional bodies. This requirement is outstanding from the previous inspection. 17 OP36 Reg 18 (2) The manager must ensure that staff receive appropriate supervision. This requirement is outstanding from the previous inspection. 18 OP38 Reg 23 (4) Door closures must be fitted to all doors so that people who choose to have them open are protected from the risk of fire. This requirement is outstanding from the inspection carried out on 28/02/06. 30/09/07 31/10/07 31/10/07 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 The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 31 The Victoria Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 32 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 Lodge DS0000058057.V344298.R01.S.doc Version 5.2 Page 33 - 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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