CARE HOMES FOR OLDER PEOPLE
The Victoria Royal Beach 12 Grand Avenue Worthing West Sussex BN11 5AW Lead Inspector
Mr P Barker Unannounced Inspection 2nd February 2006 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 Royal Beach DS0000058056.V280542.R01.S.doc Version 5.1 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 Royal Beach DS0000058056.V280542.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service The Victoria Royal Beach Address 12 Grand Avenue Worthing West Sussex BN11 5AW 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 246499 Victoria Care Elite Limited Mrs Coral Anita Jackson Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places The Victoria Royal Beach DS0000058056.V280542.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 11th July 2005 Brief Description of the Service: Victoria Royal Beach is situated in a quiet residential area within easy walking distance from the seafront and all its attractions. Accommodation is on three floors accessible by a vertical passenger lift. There is a lounge/diner and a quiet reading room. Thirteen bedrooms have en-suite facilities. The Registered Manager is Coral Jackson. The home is one of a number of homes owned by Victoria Care Elite Ltd. The Victoria Royal Beach DS0000058056.V280542.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place from 9:30am to 1:15pm. The Victoria Royal Beach has performed well over the past years. At the last inspection two requirements were made: one concerned ventilation and the other heating. Both issues have been dealt with satisfactorily. During the course of this inspection the inspector spoke to residents and staff. The manager was present throughout the inspection. Records and Care Plans were looked at and a tour of the home was conducted. All the residents that were spoken to were very positive about the care they were getting at the home. One said, “I am very well looked after”, another said, “I haven’t eaten so well for years”. Several residents said that, “nothing was ever too much trouble for the staff.” One resident told the inspector, “I couldn’t have believed how happy I am here”. All the residents that were spoken to were very positive about the care they were getting at the home. One said, ”staff look after me very well”, another said, ”I am spoilt”. Several residents said that, “nothing was ever too much trouble for the staff.” One resident told the inspector, “I like it here”. All records inspected were found to be in order and up to date. At the last inspection, the inspector commented that staff records were incomplete. Having looked at a couple during this inspection they are now in order and complete. The Care Plans have been re-written and contained all of the information needed to look after the residents. They were reviewed regularly. The inspector looked at several care plans and found them easier to use than the previous ones. However, it was agreed that they would improve with the addition of dividers so that each section could be found more easily. Staff training was ongoing and it was noted that the majority of staff were either National Vocational Qualification (NVQ) trained or were on training. The training records of all staff were well documented and up to date. The manager was supervising staff and detailed notes had been kept of these sessions. The building was warm, clean and welcoming. There was three care staff on duty plus the manager with two domestics, a cook and a kitchen domestic. At night there were two staff awake on duty. The rotas showed this to be the case. Recent visits from Environmental Health and Health and Safety had been made and all requirements had been met.
The Victoria Royal Beach DS0000058056.V280542.R01.S.doc Version 5.1 Page 6 No requirements were made at the time of this inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Victoria Royal Beach DS0000058056.V280542.R01.S.doc Version 5.1 Page 7 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 Royal Beach DS0000058056.V280542.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Residents and their families have the information they need to make an informed choice about where they live and are suitably assessed before placing. EVIDENCE: The manager or proprietor assesses all residents before they join the home either in their own home or in hospital. These completed assessments are kept in the Care Plan. A recent assessment was done in the home when a prospective resident called to enquire about a vacancy. That prospective resident is now permanent and confirmed to the inspector that she was asked “lots of questions about what I could or couldn’t do.” The Victoria Royal Beach DS0000058056.V280542.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The resident’s health, personal and social care needs are well met through training and supervision of the staff. EVIDENCE: Care Plans were well written and contained all the information necessary to look after the residents. They were updated regularly and reviewed at least once a month. The inspector looked at the Care Plans of some of the residents he had spoken with and felt that the care given was accurately recorded. District nurses visit the home when requested and records are kept of all such visits. Medication was stored safely and records were well kept in regard to the administering and disposing of them. Staff were well trained and some had recently attended an outside course on ‘Care and Control of Medicines’. The Pharmacist trained others. One resident is able to look after their own medication and it is kept in a locked drawer in their room. When looking around the home the inspector noticed staff knocking before entering rooms. Residents were called by their chosen name; others preferred to be addressed as Mrs.
The Victoria Royal Beach DS0000058056.V280542.R01.S.doc Version 5.1 Page 10 The inspector spoke to residents in their rooms and privacy was observed. The Victoria Royal Beach DS0000058056.V280542.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Residents say that they are happy with their lifestyle, are able to keep in contact with their family and friends and able to have control over their daily tasks. Good home cooked food is provided. EVIDENCE: The home realises that activities within the home are limited but try to put on entertainment when they can. Activities in the home include regular Art and Craft sessions from outside agencies. When the weather is warmer, they all enjoy the fortnightly minibus trips to local places, usually ending up somewhere for tea and cakes! Others enjoy a sing-a-long or the occasional outside entertainer. Residents like visits from their families and friends and often go out with them. Facilities are available in a lounge for residents to offer their visitors refreshment. Six residents are able to go out on their own locally. The food is of an extremely high standard. The Victoria Royal Beach DS0000058056.V280542.R01.S.doc Version 5.1 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Any complaint is taken seriously and staff and residents know how to complain. Staff are well aware of the Adult Protection Procedures and a Whistle Blowing Policy is in evidence. EVIDENCE: Staff have been trained in recognizing signs of abuse and know who to inform if they suspect anything is wrong. Records were seen showing this to be the case. There have been no formal complaints made to the Commission for Social Care Inspection (CSCI). The Victoria Royal Beach DS0000058056.V280542.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The home is well maintained, safe and clean with no nasty smells. EVIDENCE: The home is well kept and is clean and tidy. The inspector observed the cleaners doing their rounds and every room was left clean and tidy. The Victoria Royal Beach DS0000058056.V280542.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 There is usually sufficient staff employed to ensure that residents’ basic needs are met. The home has a sound recruitment policy and all checks are made. There has been considerable input into staff training. EVIDENCE: All staff have undergone Criminal Records Bureau (CRB) checks and copies of these were kept in the office. Prospective staff are invited to complete an application form and attend an interview. Staff training had been undertaken in all areas and the evidence showed that all staff were offered training relevant to their work. Most of the staff were either National Vocational Qualification (NVQ) trained or were training. The Victoria Royal Beach DS0000058056.V280542.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The home is well managed. It is apparent that the needs of the residents are paramount and that things happen for their benefit. The home has no dealings with any personal finances preferring to leave that to families or other professionals. The home is considered a safe environment. EVIDENCE: The manager is qualified to Registered Manager’s Award (RMA) standard and also holds an NVQ Assessor’s award. She is well respected by staff and residents and “always has time” to deal with any issues. The home was constantly updating their practices to ensure that residents received the best care that they could. The home does not have any dealings with any money belonging to residents.
The Victoria Royal Beach DS0000058056.V280542.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x x 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 x x 3 The Victoria Royal Beach DS0000058056.V280542.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Victoria Royal Beach DS0000058056.V280542.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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