Inspection on 04/02/08 for The Victoria Lodge

This inspection was carried out on 4th February 2008.

CSCI found this care home to be providing an Adequate service.

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 12/09/07

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 Annette Campbell-Currie Key Unannounced Inspection 4th February 2008 9:30 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.V357033.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.V357033.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 Ltd 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.V357033.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th September 2007 Brief Description of the Service: The Victoria Lodge is registered to provide accommodation and personal care for twenty-three residents in the category OP. It is owned by Victoria Care Elite Ltd. The home is situated near 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.V357033.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is One Star. This means that the people who use this service experience adequate quality outcomes. The site visit for this key unannounced inspection was carried out by Annette Campbell-Currie over five hours. The manager and staff assisted with the inspection and all the information and documents that were needed were available. There were sixteen people staying in the home at the time. Following the key unannounced inspection carried out in September eighteen requirements were made; thirteen of these were outstanding from the previous inspection. The provider was asked for an improvement plan to make sure that people in the home would be safe. The provider, Mr Burtenshaw had informed the Commission that the requirements had been addressed. This information was taken into account as part of the inspection planning. The manager had completed an Annual Quality Assurance Assessment form (AQAA) last July; this information has been used in the preparation of the two recent inspections. During the site visit five service users were spoken with also two visitors and three members of staff. The gardens, communal areas and the majority of bedrooms were seen. The case records of two people living in the home were read; health and safety risk assessments, medication records, key policies, staff training records and supervision plans were also seen. Information received from surveys circulated by the Commission to residents, relatives, GPs and a care manager in the past six months was also taken into account. 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 the key standards to ensure the welfare of people living in the home. Fourteen of the requirements made at the last inspection have been fully met and four remain outstanding; two additional requirements have been made and two recommendations for good practice. Mr Burtenshaw and Mrs Walker confirmed that action would be taken to make sure that the requirements will be met within the next two months. What the service does well: The managers and staff are committed to providing a good quality of life for the people living in the home by ensuring that requirements and recommendations are addressed. There has been a low turnover of staff so The Victoria Lodge DS0000058057.V357033.R01.S.doc Version 5.2 Page 6 people receive care from staff they know well. Staff said that they feel well supported and receive the training they need to do their job well. People who returned surveys in the past six months were very positive about the care they receive. People spoken with on the day also said that staff are kind and that they have the care that they need. One person said: “No complaints, everything is great and the staff are marvellous”. Two visitors to the home spoke very highly of the care their friend is receiving. The areas of the home that have been redecorated 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 is in need of further review and updating to show the age range and needs of people the home could accommodate. A further requirement has been made regarding this matter. All those living in the home should receive a contract of the terms and conditions of their stay that includes the room to be occupied and the fees to be paid. A further requirement has been made regarding this matter. While a training plan has been developed the manager should ensure that all staff receive updated training in all health and safety matters as soon as this becomes due. A further requirement has been made regarding this matter. The Victoria Lodge DS0000058057.V357033.R01.S.doc Version 5.2 Page 7 While a supervision plan has been developed the manager should ensure that all staff receive formal supervision appropriate for their role. A further requirement has been made regarding this matter. The recruitment policy should be reviewed and updated to include guidance about the checks to be carried out before a new member of staff begins in post. A requirement has been made regarding this matter. The provider should ensure that a written report is produced for each monthly unannounced visit to show that the quality of the service is being kept under review. A requirement has been made regarding this matter. A written maintenance and development plan should be provided to ensure that the improvements to the service are maintained and developed. A recommendation has been made regarding this matter. The advice of the fire officer should be sought in relation to the linen storage facility in order to ensure this meets fire regulations. A recommendation has been made regarding this matter. The manager should reconsider the way that medication is being administered, as the current method is not in line with the Royal Pharmaceutical Society guidance for good practice. 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.V357033.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.V357033.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users have some of the information that they need to make an informed choice about where to live. People have not yet been provided with contracts that detail the room to be occupied or the fees to be paid. People have their needs assessed before they move to the home to make sure that the home is a suitable place for them. EVIDENCE: People are provided with a Statement of Purpose and Service User Guide so that they have some information about the home before they make a decision to move there. The manager has updated the Statement of Purpose to show adults could be admitted to the home not just people who are over sixty-five. The manager was advised to ensure that the information provided in this document includes all the points in Schedule 1 of the Care Homes Regulations in particular “ the age range and sex of the service users for whom it is The Victoria Lodge DS0000058057.V357033.R01.S.doc Version 5.2 Page 10 intended that accommodation should be provided for” and “the range of needs that the care home is intended to meet”. The manager said that she is reviewing the range of activities and leisure pursuits to meet the needs of people under sixty-five. There is space on the new contract forms for the room number and the cost. One of the contracts seen had been signed by the person’s next of kin, however the fee to be paid had not been noted. Mr Burtenshaw said that people have not yet been provided with new contracts that include their room number and details of the fees to be paid, he said that he would arrange for this to be done. The manager said that either she or the deputy manager carry out the preassessments before it is decided whether or not the home could meet the needs of a prospective service user. They are both qualified and experienced to carry out the assessments. The form that is completed has been updated to include space for the date and time of the assessments, a place for the assessor and the service user to sign their agreement and to show that they have been involved in the process. The assessment for someone who had recently moved to the home was seen. The information was detailed and covered most aspects of the person’s needs and interests. The person’s spiritual needs had been noted however there was little space for noting particular needs relating to ethnicity or cultural wishes or requirements. This was discussed with the manager who agreed to make sure these elements are included. The people spoken with during the day said that they are receiving the care that they need. The Victoria Lodge DS0000058057.V357033.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. People’s health, personal and social care needs are set out in a care plan and their health and personal care needs are being met. People are protected by the home’s medication policy and practices. People are treated with respect and their right to privacy respected EVIDENCE: There is a process for care planning and review when people move into The Victoria Lodge. The documents used are comprehensive and include space for information about all aspects of the person’s life. There is a format for risk assessments in mobility, moving and handling, risk of falls, nutrition and behaviour. The sample of care plans seen showed that these had been completed in detail and guidance provided to staff about the way to provide care. The people spoken with said that they are receiving the care that they need. The staff spoken with were confident about providing care in the way people wish. It was evident that the care plans and risk assessments had been The Victoria Lodge DS0000058057.V357033.R01.S.doc Version 5.2 Page 12 reviewed and changes in need documented. People had signed to say that they had been involved in drawing up their care plan. Health care needs were noted in the case records that were seen and contact with health care professionals and GPs had been documented showing that health care needs are monitored and support is provided when required. The manager said there is a good relationship with local community nurses and this has allowed one person whose needs have increased to remain in the home where she is settled. Three GPs responded to surveys circulated in September and all expressed satisfaction with the home. One person is responsible for holding and administering their own medication; a consent form had been signed and lockable facilities provided. There were risk assessments to show that it is safe for this arrangement to continue and it was clear that this is reviewed monthly. The administration policy and practice has been under further review since the last inspection. Medication records are signed when medication is administered. Staff have now been provided with guidance about what to do in the event of a medication error. The current method of administering medication is not in line with the Royal Pharmaceutical Society guidance for good practice and the manager should reconsider how the staff are administering medication. The staff who administer medication have all attended training to make sure they have the knowledge and skills that they need. There is a new process being introduced for the induction of staff that ensures that staff understand how to provide personal care in the way people prefer. Staff spoken with were confident and experienced in providing personal care and receive the guidance that they need. During the day people were being treated with respect and sensitivity and their privacy was being respected. People were assisted to move about the home in a relaxed and unhurried way. People spoken with said the staff are very caring. The Victoria Lodge DS0000058057.V357033.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 they are supported to maintain contact with their family and friends. People are encouraged to exercise choice in their daily lives and are provided with a wholesome and balanced diet in pleasing surroundings. EVIDENCE: There is a programme of activities during the week, a quiz, a music quiz and art and craft take place on some afternoons. In the mornings people sit and read the newspaper or spend time in their rooms. People’s interests and hobbies were noted in their care plans. One person said that staff help her with her hobby and sometimes sit with her to keep her company. Some evening entertainment is provided in the home at times during the year. People are supported to maintain contact with their family and friends. The Statement of Purpose provides information about visits to the home. Two visitors spoken with said they are very impressed with the care their friend is receiving and that they were made very welcome in the home. They said that The Victoria Lodge DS0000058057.V357033.R01.S.doc Version 5.2 Page 14 the staff had been very friendly and helpful. Family members have said that they are kept informed about the welfare of their relative. One person is assisted by staff each day to visit a relative who lives in a nearby home. People are able to exercise some choice in their daily lives. People are supported to maintain the daily routine that they choose and can spend time in their rooms or in the communal areas. People are encouraged to bring personal possessions to the home. The menu for the day is displayed and people are asked for their choice of meal for the following day. The food is home cooked, nutritious and appetising. The chef is responsible for preparing the lunch and supper. Care staff now assist in the kitchen as there is no kitchen assistant. The manager said that all care staff who work in the kitchen have attended food hygiene training. People can choose an alternative meal at any time. The dining room is attractively set out and lunchtime was a relaxed and sociable occasion. There were nutritional assessments on the case records that were seen and everyone has their weight checked each month. The Victoria Lodge DS0000058057.V357033.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 good. This judgement has been made using available evidence including a visit to this service. People who live in the home and their relatives are confident that their complaints will be listened to and acted upon. There are policies and systems in place to protect people from abuse. EVIDENCE: There is a complaints policy that is provided to everyone living in the home and their relatives. People who have returned surveys said they know how to make a complaint and feel confident that their concerns would be listened to and acted upon. Complaints are recorded with the action taken to resolve the complaint. One complaint had been recorded since the previous inspection and the record showed that the complaint had been investigated and action had been taken. Residents meetings are held every six weeks and issues and concerns can be discussed. Minutes of these meetings are kept. The Commission has not received any complaints about the home. There is a policy that provides guidance about safeguarding vulnerable adults and the West Sussex policy and procedure for safeguarding vulnerable adults is followed. Staff receive training about preventing abuse as part of their induction. There is a programme of ongoing training to make sure staff are up to date. The home has a training DVD about preventing and reporting abuse that staff are encouraged to watch and discuss with the manager. Staff in the The Victoria Lodge DS0000058057.V357033.R01.S.doc Version 5.2 Page 16 home are clear about their responsibilities in the event of a concern that abuse may have occurred. The provider has confirmed that no staff would begin work until the necessary checks have been made with the Criminal Records Bureau. The Victoria Lodge DS0000058057.V357033.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 adequate. This judgement has been made using available evidence including a visit to this service. People live in a safe environment with pleasant communal areas. People have their own rooms that they can personalise. The bathrooms are in need of refurbishment. There is no written development and maintenance plan to ensure that people continue to live in pleasing surroundings. EVIDENCE: Ten requirements relating to the environment were made following the previous inspection of the home; these included requirements that had not been fully met from the inspection in February 2007. The provider was asked for an improvement plan to show how the requirements would be addressed. Mr Burtenshaw kept the Commission informed of progress as the improvements were made. A tour of the grounds and the rooms that were The Victoria Lodge DS0000058057.V357033.R01.S.doc Version 5.2 Page 18 seen at the previous inspection showed that the requirements have now been fully or partially met. The greenhouse has been cleared from the garden and steps marked with paint to prevent the risk of falls. The building in the grounds is now only used for storage and is kept locked when not in use. Repairs have been made to the roof and guttering so that there is no penetrating damp. Windows have been loosened so that they can be opened and window restrictors have been fitted for safety reasons. The external paintwork is shabby and some internal paintwork on window ledges is in need of work. The advice of the environmental health officer has been sought and an inspection was due in two days time. An occupational therapist has carried out an assessment of the premises. The advice regarding handrails has been followed. The occupational therapist has also made recommendations regarding the fitting of ramps and handrails outside the front door and the replacement of toilet seats that have not yet been followed. The call bell system has been reviewed so that all rooms including bathrooms and toilets have an accessible call bell that can only be switched off at source. This will ensure that people can call for help when they need to. The use of extension leads has been reviewed and people who need additional sockets have extension cables attached to the wall to prevent the risk of falls. All bedrooms now have locks so that privacy and dignity can be maintained. Radiators have been fitted with covers; one small radiator in a bathroom on the second floor is due to have a cover fitted in the next few days. Measures are in place to prevent someone falling against it. All hot water outlets have been fitted with valves to ensure the water is not over the recommended temperature to prevent the risk of scalds. All doors have been fitted with closures so that people who wish to have their doors open can do so as the door would automatically close in the event of a fire. There is a shower room on the ground floor that is also used for storage. There are two bathrooms on the first floor and one on the second floor. All the bathrooms are in need of updating with equipment that is fit for the needs of service users. Two of the bathrooms have wood panelling that could create a risk of infection and one bathroom is carpeted which presents a risk of cross infection. The laundry room is due to have a wash hand basin fitted. The room is in need of redecoration as paintwork on the walls and ceiling is peeling. The linen is now kept in an area near one of the fire exits at the front of the building. The manager was advised to seek the advice of the fire officer in case the storage presents a fire risk. A recommendation has been made with regard to this issue. The home was clean and hygienic; domestic staff are employed to maintain this standard. The Victoria Lodge DS0000058057.V357033.R01.S.doc Version 5.2 Page 19 There is one maintenance person and one gardener for the group of five homes. The manager said that any maintenance issues are noted and usually addressed quickly if it is a priority. There is no written development or maintenance plan for the building and grounds. It is clear that bedrooms are redecorated and carpeted before prospective residents move in and that some ongoing decoration of the building is being done. In order to ensure that the building does not fall into disrepair again and the internal decoration is kept to a good standard it is recommended that a written development plan should be drawn up. The Victoria Lodge DS0000058057.V357033.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. The needs of the people who are living in the home are being met by the numbers and skill mix of staff on duty. The home’s recruitment policy is due to be updated to ensure people living in the home are protected. The staff in the home are experienced and qualified to meet the needs of the people living there. Not all staff have attended training updates in mandatory topics. EVIDENCE: The staff team are skilled and experienced, there is a low turnover of staff that means people receive care from a consistent group of people who understand their needs. There were sixteen people staying in the home. Staffing numbers have been reduced to three carers in the morning and two in the afternoons. The manager is undertaking hands on duties in the mornings. Two people at the moment need two care staff for mobilising, this means that when there are two staff on duty other people could be put at risk. The manager said that she or the deputy are on call at these times if additional support is needed. The staffing numbers will need to be reviewed when the number of people living in the home increases. Eight of the sixteen care staff have achieved the National Vocational Qualification (NVQ) at level 2 or 3 and two others are enrolled on the The Victoria Lodge DS0000058057.V357033.R01.S.doc Version 5.2 Page 21 programme. The home has achieved the target of fifty percent of care staff achieving NVQ level 2 or above. No new staff have been appointed since the previous inspection. The recruitment policy has been reviewed but does not yet include guidance about the need for CRB or POVAfirst checks to be carried out before a new member of staff begins work. The policy does not provide guidance about the measures to be put in place if someone begins work before the enhanced CRB disclosure is received. Mr Burtenshaw has confirmed that no care staff will begin work before the necessary checks have been carried out. The manager confirmed that a full employment history is required as part of the application process. A new induction programme is to be introduced that is recommended by the Skills For Care department. The induction and foundation programme will link in with the NVQ programme and provide staff with the knowledge and skills they need to do their work. All staff have now had an annual appraisal and a training programme is in place. There were records to show that a number of staff have attended training updates in mandatory topics. There were records to show that while there is a training programme however not all staff have attended updated training in mandatory topics although this is planned. There was no evidence to show that staff have been provided with training in specialist topics that would support them in providing care for people who need specialist support. The Victoria Lodge DS0000058057.V357033.R01.S.doc Version 5.2 Page 22 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, 32, 33, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a home that is run by a manager who has the knowledge and experience to do so. The views of people living in the home are sought. People’s finances are being protected. Staff are well supported; they have not yet received regular supervision to make sure that they have all the training and support that they need. The recruitment policy does not yet fully protect people living in the home. The health, safety and welfare of people living in the home is now being promoted and protected. EVIDENCE: The manager has six years experience in managing a care home and has achieved the Registered Manager’s Award. There was no evidence to show that The Victoria Lodge DS0000058057.V357033.R01.S.doc Version 5.2 Page 23 the manager is supported to attend training to further develop her own skills and knowledge. Mrs Walker said that there is an informal link with other managers in the group and this is helpful. Staff and people living in the home said that the manager is always available and very supportive. Fourteen of the eighteen requirements have been addressed including those relating to the health and welfare of people living in the home and staff. The manager has made progress in taking action to fully address the remaining four requirements that are not yet fully met. The manager has set up a system for monthly monitoring of the premises to make sure that the health and safety of people living in the home is being protected. The provider visits the home on a regular basis however it was not clear that the Regulation 26 monthly visits to monitor the home are documented so that issues raised can be addressed. A requirement has been made regarding this matter. There is no written maintenance and development plan for the home to show that the plan for improvement is ongoing with agreed timescales in order to maintain and further develop the progress made in the past twelve months. A recommendation has been made regarding this issue. There is a quality monitoring system to gain the views of people living in the home, that has been carried out every year and people have been asked about their views of the home. The manager said that she is planning to carry out quarterly monitoring of different topics that affect people’s lives. She is due to circulate a short questionnaire about the activities programme to gain people’s views. Residents meetings are held regularly and minutes are kept. The procedures for supporting people with their money has been seen. Records and receipts are kept so that people’s finances are protected. The staff spoken with said that they feel well supported and the manager and deputy are approachable. All staff have had an annual appraisal with the manager to identify their training needs and review their personal development. The manager is planning a system to ensure that all care staff receive supervision every six weeks. The medication and fire policies have been updated. The recruitment policy has been updated but needs further review as it is not clear that the necessary checks have to be carried out before a new member of staff begins work and the measures that need to be put in place if staff begin work before a full enhanced CRB disclosure has been received. The requirements relating to the health and safety of staff and people living in the home have now been addressed. The manager has carried out risk assessments of the building and is monitoring all areas of the home to make sure that health and safety is maintained. All staff receive training in health and safety topics when they begin work. The home now has a set of training The Victoria Lodge DS0000058057.V357033.R01.S.doc Version 5.2 Page 24 DVDs so that the manager can provide individual or small group sessions as the need arises. Accidents are recorded and preventative action taken where possible. The Victoria Lodge DS0000058057.V357033.R01.S.doc Version 5.2 Page 25 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 2 3 2 2 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 2 3 The Victoria Lodge DS0000058057.V357033.R01.S.doc Version 5.2 Page 26 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 Regulation Reg 4 (1) (c) Requirement People must be provided with an up to date Statement of Purpose to show that the home is able to meet their needs. This requirement is outstanding from the previous inspection. 2. OP2 Reg 5(c) 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. This requirement is outstanding from the previous inspection. 3. 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. 4. OP36 Reg 18 (2) The manager must ensure that staff receive appropriate DS0000058057.V357033.R01.S.doc Version 5.2 Page 27 Timescale for action 31/03/08 29/02/08 31/03/08 The Victoria Lodge supervision. This requirement is outstanding from the previous inspection. 5. OP29 Reg 19 (5) (d) The recruitment policy should be reviewed and updated to ensure that the correct procedures are followed with regard to the required checks to be carried out prior to a member of staff beginning work. The provider should prepare a written report of the unannounced visits to the home each month. 31/03/08 31/03/08 6. OP33 Reg 26 (4) (c) 29/02/08 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. OP19 2. OP23 Refer to Standard Good Practice Recommendations It is recommended that a written maintenance and development plan is drawn up to show the plan for ongoing development of the service. It is recommended that the advice of the fire officer is sought in relation to the storage facility for linen. The Victoria Lodge DS0000058057.V357033.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Way Maidstone ME16 9NT 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.V357033.R01.S.doc Version 5.2 Page 29 - 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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