Inspection on 12/08/05 for Victoria

This inspection was carried out on 12th August 2005.

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

Victoria 06/02/07

Victoria 30/12/05

Victoria 18/01/05

Victoria 27/07/04

Similar services:

Springfield House

The Shelley

Thorndene

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Victoria 81 Dyke Road Avenue Hove East Sussex BN3 6DA Lead Inspector Linda Khot Unannounced 12 August 2005; 9.30am 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 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. Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Victoria Address 81 Dyke Road Avenue Hove East Sussex BN3 6DA 01273 551355 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Victoria Nursing Homes Ltd Mrs Pauline Winbow Care Home with nursing 24 Category(ies) of Old age, not falling within any other category registration, with number (OP), 24 of places Physical Disabilty (PD), 24 Terminally Ill (TI), 24 Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. That there is adherence to the staffing levels set down. 2.That Mrs Winbow obtains a certificate in Management before 2005. Date of last inspection 18 January 2005 Brief Description of the Service: Victoria 81 Dyke Road Avenue is one of five homes in the Victoria Group. It is located in a residential area on the outskirts of the city of Brighton and Hove.The home is registered for twenty-four residents in the categories of elderly, physically disabled and terminally ill.The home is a large detached property set back from the road with a swing drive that can accommodate up to ten cars. Parking is also available in the adjoining roads and the no 27 bus stops directly outside the home.The home is well maintained throughout to a high standard. Gardens at the back of the home are easily accessed by wheelchair users and there is a portable ramp that can be used from the dining room. The home has a passenger lift that serves both floors. The rooms overlooking the garden on the top floor also have views of the sea. All homes in the Victoria Group have the Quest for Quality certificate and the Registered Providers are committed to working with the Commission for Social Care Inspection and the homes Matrons and staff to ensure consistency of care and administration processes throughout all the Victoria homes. Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place at 9.30am and the Inspector was assisted by the staff until Mrs Winbow arrived for her afternoon shift. Staff were extremely busy as the home was full however the Inspector was able to meet with Mr K Miles one of the Registered Providers look at records, tour the premises and speak with residents and their visitors and a member of the maintenance team. The Inspection was a positive one and lasted for three and a half hours. What the service does well: What has improved since the last inspection? What they could do better: On the day of Inspection the Inspector found the door of the home had been left ajar and the front office was unattended with free access to the filing cabinets that had not been locked. Visitors were able to wander in when the doorbell was not answered although they did sign the visitors’ book as requested by a sign in the entrance hall. Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 6 On a tour of the premises the Inspector found that some of the bathrooms and shower rooms were untidy and incontinence products had been stored in the baths and shower trays. In one bath a commode had been stored. The Inspector was concerned that a senior member of staff was unable to describe the action required for an adult protection alert and complaint.A Requirements will be made in this report that these points are addressed. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 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 standard(s) 1,2,3,4,5 and 6. The home has sufficient information in place to enable prospective residents and their families to make an informed choice about whether they wish to live in the home and encouragement is given by the home for visits to be made to the home prior to making a decision. Residents are also protected by the pre-admission assessment that is informative and comprehensive. EVIDENCE: The home has a statement of purpose and service user guide in place that is readily available in the entrance hall of the home. The latest inspection report was seen to be available in the office should a relative or service user wish to see it. The CSCI certificate on the wall was of the old type however the Inspector had arranged with the Business services team to renew it at their earliest convenience, prior to the inspection. The Director of Nursing Services undertakes all pre-admission assessments and these form the basis for the care planning once the resident is in the home. All residents and/or their relatives or advocates are able to visit the home prior to admission if they so wish. Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 9 The home is not specifically registered for intermediate care however there is general basic nursing equipment on site and residents frequently use the home for short spells to convalesce or have respite care. Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 10 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 standard(s) 7,8,9,10 and 11. The home delivers a good quality of care that is well documented. All residents’ appear to be cared for very well and the home involves other specialist services for advice where necessary. Procedures for the administration of medicines are undertaken in a manner that safeguards the residents. EVIDENCE: Each resident has a care plan that is reviewed on a daily basis if they are particularly unwell. Records and care planning are efficiently undertaken and those seen by the Inspector were up-to-date. Residents spoken with by the inspector reported feeling well cared for; all said they were treated with kindness and respect. The home has a medication policy in place and only trained staff are permitted to administer medication. Residents said that their medication arrived on time and that they were listened to by staff if they felt unwell or required a doctor. The Inspector, Registered Provider and Registered Manager discussed the new legislation in relation to the disposal of medicines and the Inspector was satisfied that this was in-hand and the new arrangements being addressed. The home has a death and dying policy in place that is regularly reviewed and relatives are invited to be involved and to share the home’s facilities if they so wish. Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 11 All the Victoria homes are in the process of adopting the Liverpool Pathway Tool in conjunction with terminally ill residents to help ensure that all their needs can be fully met. Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 12 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 standard(s) 12,13,14 and 15. Staff encourage residents to make choices in their daily life and try to support them in making decisions and join in with activities. The standard of food is good and the presentation ensures that those residents with poor appetites are encouraged to eat. EVIDENCE: Activities are provided in the home and on the day of inspection the Inspector met with the retired Activities Co-ordinator playing scrabble with a resident. Activities are encouraged in the home but residents have a choice of whether or not they join in. All residents spoken with said that their visitors were made welcome; a visitor spoken with by the Inspector supported this. The home does have a visitors’ book in place. The residents said they liked the food and that it was enjoyable and well presented; all confirmed they had a choice of menus. The dining room provides a relaxed and homely atmosphere and although only four residents decided to eat there they seemed to get on very well. The majority of the residents spoken with by the Inspector said they preferred to eat in their rooms. The main kitchen is at Victoria 39 Dyke Road Avenue and food is delivered twice daily for lunch and supper. Menus are faxed to the home on the previous day for residents to make their choice. Records of meals eaten are kept for six weeks. Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 13 The kitchen was very clean and well organised with staff wearing appropriate protective clothing. Food in the store cupboard was in-date. The home has a policy statement for kitchen cleanliness and fridge and freezer temperatures are taken daily with records kept. Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 14 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 standard(s) 16 and 18. Residents in the home are protected by the home’s attitude towards complaints although the Inspector was concerned that the senior member of staff on duty was unaware of the relevant recording system and although staff receive training in the protection of vulnerable adults the senior staff member was unaware of the system to be used should an alert be raised. EVIDENCE: The home has a complaints policy in place and a book for recording. Complaints are initially dealt with by the Registered Manager/Matron or Deputy Matron; if they cannot solve the problem the Registered Providers are informed however the senior staff member in charge on the day of inspection could only find a register of complaints but not the actual complaints records. She seemed unclear as to the correct procedure to take should a complaint be made whilst she was on duty and in charge of the home. The home provides in-house training for the Protection of Vulnerable Adults that is supported by a policy and procedure shared by each of the Victoria Homes. The senior member of the care team was unable to tell the Inspector the correct procedure to use should an adult protection alert be raised and the Inspector later discussed this with the Registered Provider and Registered Manager. Requirements will be made in this report that these issues are addressed ensuring that all staff left in charge are aware of how to deal with a complaint or adult protection alert. Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 15 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 standard(s) 19,20,21,22,23,24,25 and 26. The home is maintained to a good standard and is decorated to meet residents’ needs. The garden is also well maintained and also arranged to meet the needs of the residents. EVIDENCE: The Inspector toured the premises and saw that the home is focussed on providing a comfortable and homely environment for the residents. Most residents’ rooms, through the choice of each individual resident were like a sitting room in their own home, with all the comforts, furnishings and ornaments they liked. Some said they had brought with them small items of furniture and pictures. Some of the residents had new bedcovers and all expressed pleasure in how they looked on the bed. The Inspector noted that some baths and shower units had been used for the storage of residents incontinent products due to lack of space and a requirement will be made in this report that this is addressed although a scoring of 3 will be given as the home meets the requirement for a well maintained environment. Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 16 The home has a sitting/dining room for residents to use and a no-smoking policy is in place. There is a ramp in place for residents to access the garden at the rear of the building. Each room has en-suite facilities with the exception of two. In both cases there is a bathroom/shower room very close to the residents bedroom. The home does have assisted bathing facilities. There are two sluices; one on the ground floor and one on the first floor, both were seen to be clean and tidy at the time of inspection. If a resident requires any specific equipment to enable his/her needs to be met these can be obtained, there is a store of equipment kept at one of the other Victoria homes. The home was very clean with no noticed offensive smells. The home has a professional washing machine and drier for residents’ personal washing and the heavy laundry is sent to another home in the Victoria Group that has a larger purpose built laundry. Each resident has his/her own laundry basket for easy identification of clothing. The kitchen was also very clean and well organised. Throughout the kitchen and laundry room there are health and safety and hygiene notices to refresh staff memories on control of infection. Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed during this inspection but will be looked at during the next inspection due in 2005-2006. EVIDENCE: Although these standards were not assessed the inspector did note that there were enough staff on duty to meet the needs of the residents. Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 38 The home overall takes precautions to ensure the health, safety and welfare of residents as far as possible however the security of residents personal files and care plans was at risk on the day of inspection and staff in the home had over Looked securing the front door. EVIDENCE: The home has an in-house trainer who oversees the training of staff in all the Victoria Homes this includes, moving and handling, food hygiene, health and safety, fire safety and first aid. The Inspector spoke with one of the maintenance staff who confirmed that the fire alarms are tested on a weekly basis with records kept. The emergency lighting system is checked monthly, and following checks on the temperature of hot water throughout the home, a plumber is given a list of the irregularities to address. A qualified electrician is used for any electrical emergencies or maintenance to comply with the latest legislation. The home has appropriate signage throughout for health and safety. Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 19 The Inspector was concerned that on arrival the front door had been left ajar and the office housing residents care plans and records was unlocked breaching confidentiality. Requirements will be made in this report that these points are addressed. The Inspector did discuss this with the Registered Provider and Registered manager. Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 x x x x x x 2 2 Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 21 yes Are there any outstanding requirements from the last inspection? 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 16 Regulation 22 Requirement The home to ensure that senior members of staff who are left in charge are aware of the complaints procedure and recording system. The home to ensure that the senior members of staff who are left in charge are aware of the procedure to take in the event of an adult protection alert. Bathrooms and shower rooms to have the appropriate facilities for the storage of residents incontinence products. For confidentiality of residents records and care plans the home to ensure that either the filing cabinets are locked at all times or the door to the office is locked when staff are away and working in the home. For the security and safety of service users the front door to be secure at all times. Timescale for action 20 August 2005 2. 18 13(6) 20 August 2005 3. 19 23(2)f 3(2)l 17(1)b 1 October 2005 Immediate 4. 37 5. 38 13(4)ac Immediate Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 22 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 Good Practice Recommendations Victoria H59-H10 s14074 Victoria v224996 120805 stage 4.doc Version 1.20 Page 23 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 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. 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