Inspection on 27/02/07 for The Victoria Lodge

This inspection was carried out on 27th February 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 12/09/07

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 Clare Hall Key Unannounced Inspection 27th February 2007 09.30 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.V327947.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.V327947.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.V327947.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2006 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 residents are situated on three floors with access provided by a passenger lift. Due to the layout of the home wheelchair users cannot be accommodated. Elaine Walker manages the service. The charges range between £400 and £650 weekly. The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced site visit to Victoria Lodge Residential Home took place on 27th February 2007 and was undertaken by one inspector over one day. Throughout the visit the Registered Manager was available and the staff assisted the inspector in general. The owner was present during feedback and given the opportunity to discuss the inspection process, findings and outcomes. All staff contributed to the findings both individually and in groups and were very supportive of the process. The judgements made in this report were based on information gathered preinspection from previous reports, the service history, Regulation 37 notices received and reports sent to the CSCI by the provider. Also considered were correspondence with the home, contact sheets, reports and feedback relayed to the commission. The managers assisted the audit process by handing out relevant comment cards pre inspection to service users other stake holders, health and social care professionals and staff. The management team completed the pre inspection evidence and this was used to inform the report. Most of the environment was audited and a tour of the premises undertaken. The inspector had the opportunity to sit in the main lounge and dining areas and observe the routines and care practices in the home. As a result of this audit process 18 requirements have been raised, one of which has been repeated from the previous visit. The home received an immediate requirement notice in respect of fire safety. What the service does well: On the whole the majority of service users were very happy with the service received and their surroundings and they feel supported by the staff employed. One relative when asked what the home does well said “everything.” Other services users commented: “ If all care homes were like Victoria Lodge, elderly people would be queuing up to enter with no fears at all.” The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 6 Another service user said, “We were very fortunate to find such a place and very much count our blessings, cannot praise too highly in all areas.” One service user wrote “The matron is always ready to listen to any concerns I might have.” Health and social care professionals said the home was providing good support for individuals living there. Staff said they felt supported and consulted by the management. What has improved since the last inspection? What they could do better: Although service users are well supported they are let down by the environment. The owners have not been updating the premises and some areas of the home have become neglected. Despite the potential occupancy the laundry facilities are limited and in a poor condition. The call bell system in place is old and dated and in need of replacement. Consultation with the health protection agency and community infection control nurse with regards to the infection control, laundry policies and procedures in the home is needed and has been raised. Other areas needing attention are the breaches in the roof or guttering which is causing the water damage to walls and ceilings, which have now become problematic with mildew and causing damage to the décor in some areas. Service users find it difficult to open the old sash and pull cord windows. These are in need of attention. Service users are not being provided with suitable fixtures and fittings to lock and unlock doors to their bedrooms, bathrooms and toilets. The building is in need of an assessment by an occupational therapist to ensure the fixtures, fittings and aids (grab rails) are suited to the needs of older persons. The flooring in areas of the home is old and worn in places and poses a significant trip hazard. The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 7 Some radiators around the home were found to have high surface temperatures, therefore posing a risk to service users. The manager must improve the recruitment procedures as staff have been employed without having the relevant checks undertaken, as a result the service users are not safeguarded. Medication procedures must be reviewed to ensure risk to service users is minimised. The homes policies and procedures are in need of updating and review and the manager needs to ensure staff receive the necessary training, induction and supervision to support them in their work. An immediate requirement was made in respect of the fire safety system, as designated fire doors were held open with wedges. A requirement had previously been made in respect of this. The level of concerns raised as a result of this process has indicated that the manager does not implement a good quality assurance process, which monitors the standard of the service provided. 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.V327947.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.V327947.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, 3, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users feel informed and said the home meets their needs and expectations. The service users are not always informed of the terms of their stay and do not always sign contracts regarding the fees they are to pay and the rooms to be occupied. EVIDENCE: Service users reported that they had received enough information about the home before moving in so they could decide if it was the right place for them. One comment made regarding the choice of home was “the best of the many I have seen.” One service user stated they had received an excellent recommendation. The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 10 Two service users reported that they couldn’t recall receiving a contract. Files audited did not indicate contracts had been provided and one had a contract but this had not been signed. Service users must know what the terms of stay are. They must be provided with contracts, which explain the fees to be paid, and the room to be occupied. In one survey a service user wrote, ”The brochure is well presented and we were made very welcome on our visit to view.” One care manager reported that the care services assessment and arrangements ensure that accurate information is gathered and that the right service is planned and given to individuals. Records supported that pre visits and assessments are undertaken to ensure that the home can meet the service users needs. Information about the home was seen in the rooms of service users. The Victoria Lodge DS0000058057.V327947.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, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their supporting health care professionals feel their needs are met by caring and supportive staff. The home could improve their medication policy and procedure. EVIDENCE: Service users said they received the medical support they needed. A number of service users said throughout the visit and in surveys that they received excellent care. One service user told the inspector that, “the matron or the deputy are always on hand with regards to medical matters”. Service users also commented, “A doctors visit is requested if required and district nurses call twice a week for dressings to ulcers on my legs.” The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 12 Three doctors reported that the home communicates clearly, works in partnership and that there is always a senior member of staff to confer with. They also said patients can be seen in private and staff demonstrate a clear understanding of the care needs of individuals. It was also commented that any specialist advice given is incorporated into the care plan and medication is handled appropriately. District nursing staff were observed consulting with staff and supporting care needs of individuals with healthcare needs. One resident was being supported with a specialist mattress, nursing bed and hoist. One care manager reported in her survey that the individual’s health care needs are properly monitored and attended to. She felt the care service supports individuals to administer their own medications or manage this correctly where this is not possible. Another care manager wrote, “Excellent care provided in all aspects of care needs.” and that, “there is no improvement required at this time.” One visiting district care worker reported that she always felt that the residents in this home were well cared for and had never had any concerns about their needs not being met. She explained the staff were approachable supportive and always very aware of the needs of their residents and would never hesitate to contact the district nursing team if their were issues. The care records held were detailed, well written and had been regularly reviewed. The home use the good care planning records, which clearly identify current needs and risk assessments in relation to nutrition, falls, mobility, mental health and social needs. During a discussion with the manager and observation of the administration of medicines it was identified that the way medications are carried around the home should be improved, as they are not administered from a trolley or locked box but from a tray. The manager was observed laying a tray of medications on the table then walking pots of medications through the dining and lounge areas. This process leaves medications accessible to anyone who may be passing by and does incorporate the safe practice of taking the administration records with the medication so the records can be signed as the medication is given. The homes medication policy and procedure lacked information in respect of medication errors and the manager has agreed to review it against the Royal Pharmaceutical Society guidelines. The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 13 Service users reported during discussions that staff respect their personal space their choices and treat them respectfully. This was confirmed when observing the interactions between residents and staff. Staff knocked on resident’s doors prior to entering and were observed consulting them on what they would like to eat and whether they would like to remain in their rooms or go downstairs. The Victoria Lodge DS0000058057.V327947.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The majority of service users are happy with the food provided, but the service would benefit from conducting a regular survey of service users satisfaction. Service users are happy with the level of activities provided. EVIDENCE: One service user stated, “very varied activities most weekday afternoons.” “Festivities at Christmas and New Year couldn’t be better,” and, “Visitors are welcome at all times.” Service users reported that if you feel well enough to attend there are activities arranged by the home that you can take part in. One service user said, “I lead a happy and contented life.” One lady said, “its difficult if you have worked all your life to keep busy but I do enjoy the musical quizzes and take part in those. When it comes to the summer I cant resist the garden and I hope they will let do some planting.” The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 15 Service users were observed reading newspapers and magazines and enjoying the television and radios. Before lunch the bar was opened and residents were seen enjoying pre-meal drinks. One lady visited explained how the home had allowed her to bring her dog. She had a room on the ground floor with it’s own back door so the dog could easily come and go. The manager also allowed her to bury the dog in the garden when she passed away. Residents were seen undertaking personal hobbies of needlework. There were notices around the home of forthcoming group events, quizzes and musical entertainment. The majority of service users who responded said they were very satisfied with the standard of meals at the home but three did say they felt their wishes to include their choices in the menu had not been acted upon and that there weren’t enough greens served. Despite some poor feedback some service users were very complimentary. One service user wrote, ”The meals are as good as any restaurant. Varied menu at all times. Fruit and sweeties always available in dishes in lounge.” The inspector observed a nicely presented meal of casserole and vegetables and a selection of three desserts offered on the day. On the day of the visit the vegetables provided were carrots and peas and these were the vegetables that service users felt were provided too often. The previous week’s menu was read and on each day there was a varied selection of vegetables provided. The home would benefit from incorporating the wishes of the service users into the planning of meals. The manager could deal with the poor comments received from service users in house. If there was a process for auditing the opinions of the residents, possibly anonymously. In the pre inspection information a copy of the menu was a hand written on A4 paper and during the site visit the menu was not up on display so service users could not tell what was on the menu that week. The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 16 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are aware of how to make a complaint but the staff are not fully aware of the local protection policy and how to report abusive practice. EVIDENCE: Service users responses indicated that they know who to speak to if they are not happy and that they are aware of how to make a complaint. When one service user was asked did they know who to speak to if they were not happy said, “my daughter or the matron, but it’s a happy home and everybody is so cheerful.” During a tour of the premises the homes brochure including the complaints procedure was noted in service users rooms and in the communal areas. The complaints procedure is out of date, having the name of another manager as the person to report a complaint to. It is in a pictorial format but more suited to persons with learning disabilities and needs review. During a group discussion with staff it was noted that the staff did not know who they should report abuse to despite having received protection of The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 17 vulnerable adults training in-house. The manager was asked to pass this feedback to the trainer. Service users stated that they had no concerns at this time regarding the conduct of the staff. All reported staff were sensitive kind and caring. No concerns or complaints have been received by the commission since the last inspection. The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 18 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, 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although there are parts of the home which provide a pleasant environment for the service users the providers have not been addressing the maintenance requirements of the home as a whole and ensuring it is safe, well maintained and updated. EVIDENCE: During a visit to the home and a tour of the premises with the manager it was apparent that there is great disparity between some areas of the home. There is a newer and older part to the building and the older part of the home is in need of some significant work. The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 19 The information provided pre visit by the organisation indicated that the staff toilet has been redecorated, room 20 has had a new carpet, the hallway and stairs have had a new carpet, and rooms 7,14,15 and 17 have been redecorated. The new dining facilities are nicely decorated, bright and clean and the rooms, which have been refurbished and redecorated, are also bright, clean and very welcoming. The kitchen has also been refitted and decorated. During the visit and tour of the premises the inspector was concerned regarding a number of issues in relation to structural building works rather than just the decor. The plumbing has been described a problematic and the electrical wiring dated. The home is currently having problems either with the guttering or the roof as there is water damage to the ceilings and walls in a number of areas. Staff said they have on going problems with windows, roof, plumbing and electrics and say that they also said the day-to-day maintenance is not being done due to lack of maintenance staff. As a result of sheer number of concerns which will be noted in this report the provider will be asked for an improvement plan to address all concerns raised. The provider will be asked how they intend to improve the service in relation to the areas identified, giving a clear indication of when and how the provider proposes to address the issues raised. During the inspection process concerns were received by the inspector regarding the temperature of the water, the problems in some areas of the home due to mildew, the poor state of the gardens, the poor state of some areas of the home in relation to the wallpaper, the poor quality of the bedding and flooring. It was very apparent that the lack of adequate maintenance staff, acknowledged by the provider, was having a direct impact on the state and standard of maintenance of the premises. It was confirmed that there has been only one maintenance personnel to all five of the provider’s homes. This has caused a long list of outstanding maintenance works. Staff also said there is no clear programme of routine maintenance and renewal of the fabric and decoration of the premises and that the home doesn’t have a gardener either so even this area has fallen into a poor state. The inspector toured the garden and found the garden in need of tidying up. The garden shed had a broken pane of glass, which would put service users at risk and there was an old chair being stored along the path. There were also The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 20 numerous pots filled with cigarette ends and cigarette butts floating in water and littering the paths. When touring the internal space the inspector was concerned at the number of doors that still lacked closures linked to the fire alarm and being wedged open. This concern was raised as a requirement in the previous report. The inspector had been informed by the manager that all the outstanding closures had been fitted, however this was not the case. The current practice places service users at significant risk should there be a fire. While touring the premises it was further noted that areas of bedrooms and bathrooms in some areas had significant water damage, mildew and damp areas to their walls and ceilings. Walls were cracked in places and wall paper hanging in others. Visitors report this has been,” ongoing for months and complained about but not addressed.” The inspector was also informed during the visit that service users had been without hot water for one month and that the home suffers with plumbing problems. On the day of the visit it was noted that a washing machine, toilet and sink were out of order. Further outstanding maintenance works were noted when a number of lights within the house were without working bulbs causing corridors to be dark. The maintenance book identified that staff repeatedly reported this issue and a number of lights were regularly reported as out of order. During the walk around the building the inspector visited service users in their rooms. Service users complained of handles off furniture and drawers and of windows, which are difficult to open. They also said some of the bed mattresses were stained. One commented that a mattress provided was in a very poor condition. It was further noted that some of the carpets through out the home were dirty, old worn and rucked up in places constituting a trip hazard. Also in some of the toilet and bathrooms the floor coverings were of poor quality and uneven, again a potential falls risk. The inspector undertook the tour with the manager. It was noted that a number of radiators are uncovered and one felt by the inspector and manager was hot to touch and directly next to a service users chair. Overall there were areas around the home in need of significant decorative improvement and repair. The rooms that had been redecorated, had been The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 21 maintained to a good standard but the standard was not consistent through out the building. There are external aspects of the building, which also require some redecoration. The windows are also in need of updating, improvement and in some areas cleaning as they are in a poor state. This makes it difficult for the service users to open them safely. Some lack restrictors. The tour also raised issues about the lack of updating the building has received since being registered. Throughout the building it was noted that there were service users bedrooms, bathrooms and toilets not fitted with locks suited to service users capabilities and accessible in an emergency by staff. Part of the homes has call bell system, which is old and dated. It does not provide adequate and easy access to it by service users and cannot be switched off at source. There is also a lack of emergency call bell facilities in toilets and bathrooms and the staff toilet downstairs has no window and no extractor fan. The environment has not been adequately assessed in respect of providing suitable mobility aids. There is a significant lack of grab rails and service users said they do struggle to get up and down the stairs in places. The home does not have lift access to all areas. Those areas not accessible by shaft lift do not have a chair lift on the stairs. Service users have to maintain their mobility to access all areas of the home. One en-suite door frame had a foam pad stuck to it because the access was so narrow that the service user kept injuring his arm when entering. A lack of updating was also noted in the excessive use of extension leads within service users rooms. Even in rooms where there were two double sockets they have been obscured by furniture and were inaccessible. In one room an extension lead was attached to another extension lead and then laid down to the socket. The building does not have a current electrical safety certificate and the manager said there is re wiring work and improvements outstanding Therefore the use of extension leads in this way is concerning. Some service users did have positive comments. One service user said, “We have a very nice cleaning lady. My room is kept fresh and very clean.” Another said, “The home is beautifully kept. Warm and cosy.” One service user visited in her room said, ”This is my second room and I think I have got the best room in the house. I am very happy here; I have no complaints and since I have been here all the staff have gone out of their way to help me”. The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 22 When visiting the laundry facilities on a number of occasions throughout the day it was noted that there is a lack of working space for the storage of clean and dirty laundry and there are no hand washing facilities. Dirty laundry was un-bagged and spread on the floor and wet clean washing laid un-bagged on top of the machine. The flooring was not impermeable and the linoleum covering the floor had a hole in it. It was also noted that here were also strong odours in one of the rooms. The staff explained they do not have industrial machines and they think this is why they are always breaking down. The washing machine was out of order on the day of the visit as well as the dishwasher and one toilet. All staff spoken to said the one thing about the home they would like to see improved was the maintenance and decoration. They also said they would like a gardener. They reported there was only one maintenance guy who was doing his best but he covered five homes. The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 23 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): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users state their needs are met by the staff employed. The process for inducting new staff and providing them with the necessary support in respect of training and supervision needs improvement. The current processes for recruitment are not robust and do not protect service users. EVIDENCE: Service users reported that the staff listen and act on what they say and that there are usually enough staff available to them. On the day of the visit there were eight empty beds and the staff on duty were meeting the needs of individuals in an unhurried manner. Staff were described in surveys as very good and caring. One survey response quoted, “the staff are always very cheerful and helpful.” Two staff that were employed last year were case tracked. Records and discussions held with the manager indicated that only one of the staff employed had finished their induction despite being employed over four The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 24 months. Records audited indicate that neither member of staff had undergone training in health and safety training or in infection control or abuse. Their files held certificates in food handling and manual handling training only. When viewing the recruitment records it was noted and discussed with the manager that neither staff had a renewed criminal record bureau check or POVA first check prior to their employment. Both staff had provided the home with an old criminal record bureau check relating to their previous employment some six months or so before. Staff spoken to in a group stated they had not been receiving regular one to one supervision but did have regular group staff meetings. Throughout the visit and during discussions with service users the staff were always referred to as good, kind, caring and attentive. When speaking to one service user she said, “ Everybody is so nice. I think it’s wonderful. The girls are lovely, including the cleaners.” “It literally is a home from home with the most caring staff. Very good, warm and cosy, a real family feeling.” The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 25 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 31,32,33,34,35,36,37,38 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: There were some very positive comments received regarding the manager and the care provision in the home. One care manager reported, “This is an excellent home operated by an excellent manager and staff.” Overall the majority of service users were very happy with the management of the home. One residents said, “The matron is marvellous, like a second mother.” and another service user said they would recommend this home to anybody. The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 26 A regularly visiting professional to the home reported in her questionnaire, “I have been attending the residents of Victoria lodge for the past 13 years. They talk to me on a one to one basis and are happy and comfortable. Management and staff are kind helpful and approachable. I consider residents very lucky to be in such a lovely home.” One doctor said that, “This is a very well organised home with excellent communication, matron always there and knows about all her clients.” Another two doctors giving feedback on the home commented that the management and staff take appropriate action when they can no longer manage the care needs of the service users and that they are satisfied with the overall care provided to the service users. Staff also reported that they felt the management of the home was excellent. They said they felt supported by the manager and felt she did a really good job. They also said the level of care and efficiency of the homes manager couldn’t be better and that they felt their opinions were sought and respected. However, the inspector has found concerns, which directly affect the health safety and well being of the service users and staff. These include poor maintenance, upkeep and updating of the premises, poor practices in relation to infection control, a lack of proactive audit of the standards within the service and poor recruitment practices. When the inspector observed some poor practices in relation to fire and infection control she audited the homes policies and procedures and guidance given to staff. It was noted that the homes policies and procedures were in need of review. The infection control procedures did not reflect the Department of Health Infection in Care Homes Guidance, 2006. The fire policy does not reflect that it has been reviewed and updated to include the new legislation for Fire Regulation and Risk assessment (2006). Other organisational policies lacked review. The inspector was concerned at the poor response made by the provider and manager to the outstanding maintenance works. Outstanding works listed in the maintenance book were loose steps, walls needing painting, damp around windows, windows which can’t be opened, a request for all light bulbs to be replaced, top floor with no light, a carpet rucking up presenting a trip hazard, windows needing cleaning, toilet problems, mildew and many other issues. The manager could not provide an up to date electrical wiring certificate as she explained they needed to undertake some further rewiring and there is a need for some earthing which also remains outstanding. The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 27 Outside in the garden is the garage, which houses the dried food stores. The two chest freezers in here were in need of defrosting as the ice was above the seal .The cook stated he didn’t monitor the temperatures of these. The staff lack adequate induction, supervision and training in some areas and are not provided with the information necessary to practice safely. The manager needs to improve the quality audits undertaken within the service especially in relation to standards around the environment and recruitment practices, as the findings of this visit indicate these have not been monitored adequately. Despite this the service users do feel consulted and well cared for. One reported, “Yes, they do ask me what I think about the home. I hear such horrible stories ….a lot depends on the staff and they have such good staff here that like the firm they work for. When they are compatible like that they all work together.” The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 28 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 3 3 3 3 3 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 1 1 2 2 2 3 2 1 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 1 X 3 1 3 1 The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 29 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 OP19 Regulation 23 (2)(b); Requirement The home must be maintained in good order externally and internally. The following matters must be addressed within the given timescale: The leaks causing water damage to the ceiling must be repaired and the damage made good; Windows must be maintained in a good state of repair and replaced where necessary. 2 OP19 23(2)(o) The external grounds must be safe for use by service users: Old furniture must be removed from the garden path to allow residents access; The greenhouse must be made safe and broken glass removed; 3 OP19 23(2)(p) All lights and lamps around the DS0000058057.V327947.R01.S.doc Timescale for action 20/04/07 20/04/07 30/03/07 Page 30 The Victoria Lodge Version 5.2 home must be maintained in working order. Windows must be able to be opened for ventilation, and fitted with restrictors to prevent service users from falling. 4 OP22 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 access to all areas. Call points must be within reach of the service users and must be responded to promptly by staff. Broken furniture must be repaired or replaced. All service users must be provided with a clean and good quality mattress on their bed. The call system in the rooms must be within reach of the service users and be able to be switched off only at source to ensure staff go to the resident when they call. All bedrooms must have at least two accessible double sockets. All carpets which are old worn and not laying flat must be made safe, clean and replaced where necessary. All old, worn, torn and stained linoleum must be replaced. Bedroom doors must be fitted with suitable locks, which can be opened in an emergency, to which service users have a key, unless the reason for not doing so is detailed in the care plan. The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 31 20/06/07 5 OP22 16(2) 20/04/07 6 OP24 16(2) c 20/05/07 Toilet and bathroom doors must have locks fitted which are suited to the abilities of service users and which can be opened by staff in an emergency. 7 OP25 13(4) The hot surface and uncovered radiators in the home must be covered to protect service users from burning. The current procedure for placing dirty and clean linen unbagged on the floor or on work surfaces must be stopped. The manager must consult the health protection, community infection control nurse and /or environmental health in respect of improving the current procedures regarding the handling, storage and washing of laundry to prevent cross infection and control the odours in the rooms of service users and ventilation system in the staff toilet, the flooring in the laundry and the facilities for hand washing. Criminal bureau checks must be undertaken with protection of vulnerable adults first checks prior to employing staff. Staff must be provided with the training necessary for their job role within a six-week induction period. Policies and procedures must be reviewed and updated with changing legislation and good practice advice from the Department of Health. The manager must implement a quality assurance system, which measure the standards of the service against the requirements of the care Home Regulations. The manager must ensure that DS0000058057.V327947.R01.S.doc 30/03/07 8 OP26 13 (3) 16 (2) 13(3) 16(2) j 30/03/07 9 OP26 20/04/07 10 OP29 19 30/03/07 11 OP30 12,18 30/03/07 12 OP33 10,12 30/05/07 13 OP33 24 30/05/07 14 OP36 18(2) 30/03/07 Page 32 The Victoria Lodge Version 5.2 15 OP38 12 16 OP38 13 17 OP38 13 staff receive regular supervision Staff must receive induction and foundation training in line with the skills for care council recommendations and training in infection control in conjunction with the recent guidance given by the Department of Health. The manager must put a suitable lock on the cupboard, which stores substances hazardous to health. The provider must ensure the homes electrical wiring is safe and forward a copy of the safety certificate demonstrating this to the commission within the time stated. 30/05/07 30/03/07 14/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations The manager should review the homes medication policy and procedure in lines with the recommendations made by the Royal Pharmaceutical society. The Victoria Lodge DS0000058057.V327947.R01.S.doc Version 5.2 Page 33 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.V327947.R01.S.doc Version 5.2 Page 34 - 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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