Inspection on 14/02/07 for Victoria

This inspection was carried out on 14th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Victoria 16/01/06

Victoria 15/06/05

Victoria 25/01/05

Victoria 20/07/04

Similar services:

The Shelley

Thorndene

Springfield House

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 96 The Drive Hove East Sussex BN3 6GP Lead Inspector Linda Boereboom Key Unannounced Inspection 14th February 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Victoria DS0000014073.V324204.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. Victoria DS0000014073.V324204.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Address 96 The Drive Hove East Sussex BN3 6GP 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) 01273-723938 01273 881627 suekingths.victorianursing home@virgin.net Victoria Nursing Homes Limited Elizabeth Jayston Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23), Physical disability (23), Terminally ill (23) of places Victoria DS0000014073.V324204.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is twenty-three (23) Service users must be older people aged sixty-five (65) years or over on admission Service users may have a physical disability or terminal illness Date of last inspection 16th January 2006 Brief Description of the Service: Victoria 96 The Drive was the first established home of the five homes owned by the Victoria Group. All are situated in Hove. This home is registered to provide care with nursing, care of the terminally ill and care for those with a physical disability. Registration is for 23 older people. The home is a detached property, on three floors, all served by a passenger lift. It has a pleasant lounge on the lower ground floor that looks onto an attractive garden that is easily accessed by wheelchair users. There are parking spaces for approximately five cars directly in front of the home on the small forecourt. There is also a regular number 81 and 81a bus service that stops near to the home. Hove mainline station is close by and Brighton mainline station can be reached by public transport. There is meter parking in Grand Avenue, The Drive and The Upper Drive. Hove promenade, George Street shopping area and the Sussex County Cricket Ground are all within a short distance. Those who wish to walk into town or to the seafront may have to take transport back as it is uphill. Hove Park is also within easy walking distance and has a café. Victoria 96 The Drive, with the other four homes in the Victoria group, has the Quest for Quality Award. Victoria DS0000014073.V324204.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Victoria Highgrove will be referred to as ‘residents’. This inspection took place over a period of 6 hours and was undertaken by the Inspector who was accompanied by a PhD student Miss Jan Smith, funded by the Commission for Social Care Inspection, who wanted to understand more about the Inspection process and content. Mrs Ann Jayston the Registered Manager and her Deputy Miss Tracey Lenton, assisted with the inspection. The Inspector was able to speak at length with care staff on duty, visit residents in their own rooms and look at the home’s administrative processes as well as tour the premises. Staff records had been looked at prior to the inspection when the Inspector spoke with four trained nursing staff who work throughout the Victoria Group of homes on either day or night duty, this was done at the Victoria Head Office. Unfortunately the Inspector did not meet any resident’s relatives during the inspection but was able to telephone two on the following day. The cost of care in the home varies from £595 to £795 a week; items not covered by the fee include hairdressing, chiropody, some incontinent products, toiletries and magazines. Ten resident surveys and care staff surveys were sent out randomly by the Commission for Social Care Inspection prior to the inspection and at the time of writing this report seven resident surveys had been returned. Comments made in the surveys and to the Inspector during the Inspection have been reflected throughout this report. The Inspector discussed the outcome of the inspection and the requirements resulting from it with the Registered Manager and Deputy Manager at the end of the day. The Inspector would like to than Mrs Jayston, Miss Lenton and all the care staff for their helpfulness and hospitality. The inspection was a pleasure to undertake. Victoria DS0000014073.V324204.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Victoria DS0000014073.V324204.R01.S.doc Version 5.2 Page 7 During the inspection the Inspector found some requirements necessary and discussed them fully with the Registered Manager both during, and at the end of the inspection when the Deputy Manager was present. These include the following: 1 The Registered Provider must make sure that the statement of purpose has information telling prospective residents that the home does not provide outings or accept residents suffering with MRSA or Clostridium Difficile. The statement of purpose also needs to include relevant qualifications being studied for or achieved by the care staff. The home also needs to make sure that the administration of medication follows current good practice and guidance that is in agreement with The Nursing and Midwifery Council and the Department of Health Building a Safer NHS’ The ‘potting-up’ of medication to be reviewed and all staff to have training in understanding medication and its uses. 2 Care staff require training to understand the different levels of investigation should there be an incidence relating to the protection of vulnerable adults. 3 Residents need to be risk assessed for the option of having a key to their individual accommodation within the home. 4 Receipts for small amounts of money held in the office for hairdressing or similar should be given. 5 Staff need to be updated in the new fire safety legislation and the policies and procedures reviewed. Although requirements have been made in this report all standards have been scored as being met because the Inspector decided that the home does provide a good service to residents and addresses their safety and security. 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. Victoria DS0000014073.V324204.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 Victoria DS0000014073.V324204.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 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a statement of purpose and service user guide that is available for residents and relatives; in addition the home ensures the latest inspection report is also available. There is a procedure in place for residents to be properly assessed before admission and residents are invited to visit the home before making a decision to move in. The statement of purpose requires updating in some areas. EVIDENCE: Victoria 96 The Drive has sufficient information for residents and their relatives to read that is available in the home with the latest inspection report. The Director of Nursing Services takes responsibility for all the pre-admission assessments and at that time she verbally gives information about the home and offers prospective residents written information. In addition the Victoria DS0000014073.V324204.R01.S.doc Version 5.2 Page 10 Registered Manager has devised an information booklet for all new residents and their relatives that is both informative and easy to read, giving the names of staff and when they are on duty, explaining the key-worker system, and details of bath days, how the home operates and other points of interest. She told the Inspector this had been well received by those who had read it. The Inspector requested that the home’s statement of purpose be brought up to date with appropriate information being included on the qualifications of care staff i.e. NVQ achieved or being undertaken, explanation that the home does not provide outings for residents, and the identification of medical conditions that are not accepted in the home. Care needs assessments undertaken by the Director of Nursing Services for the Victoria Group act as a basis for the ongoing care planning. The qualified nursing staff provide any specialised care for residents should it be necessary however care staff are trained to manage catheters and to understand any specialised needs that a resident may have. Care staff do not undertake any invasive nursing procedures. Discussion took place about pre-admission assessments and the Registered Manager told the Inspector that the home rarely accepted emergencies however should one take place the senior staff were aware of the need to comply with standard 5.3. Trial visits to the home are encouraged and prospective residents are encouraged to visit the home for either a meal or afternoon tea and to meet the residents and staff prior to making the decision to move in, if they are unable to do so their relatives or friend’s are invited to visit on their behalf. The home does not have any specific intermediate care beds however some residents do come from hospital to Victoria 96 for a short while to gain strength and confidence prior to returning home. Victoria DS0000014073.V324204.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 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home delivers a good quality of care that is well documented. All residents’ have an individual plan of care that is well maintained. Although the procedure for the administration of medication is addressed with care the home must ensure its policies are in line with good practice and guidance as in agreement with the Nursing and Midwifery Council and the Department of Health. Residents are treated with respect and their privacy acknowledged. The home is empathetic to the care of residents nearing the end of life. EVIDENCE: Victoria DS0000014073.V324204.R01.S.doc Version 5.2 Page 12 All residents have a plan of care that is reviewed as an ongoing process, especially for residents who are unwell and their condition unstable. Residents who remain in a stable condition are reviewed for risk and care on a monthly basis. The pre-inspection questionnaire confirmed that the home has access to support services which includes the wound care specialist, continence nurse specialist and dietician for the community; the home has access to all professionals within the Healthcare Trust e.g. physiotherapist, occupational therapist and the community psychiatric nurse. Included in the professionals who work closely with Victoria 96 is the Care Homes with Nursing Support team who visit residents on admission and are available during office hours and at weekends for ongoing support. The requirement from the last inspection relating to a suitable record keeping system for the administration of medication when resident’s are away from the home had been addressed. The Inspector discussed with the Registered Manager the process for storing, checking and administering medication in the home, which remains the same as in the other homes in the Victoria Group. It had been agreed with the Director of Nursing Services during the inspection of another home int the group that appropriate training take place before any member of the care staff is allowed to check medication. Care staff confirmed they are asked to check medication in the home. The system at Victoria 96 The Drive includes a ‘potting up’ system for the administration of medicines and following consultation with the CSCI (Commission for Social Care Inspection) Pharmacist Inspector a requirement will be shown in this report requesting that medication is delivered to the residents using a method that follows current good practice and guidance that is in agreement with the Nursing and Midwifery Council and the Department of Health ‘Building a Safer NHS’. The Inspector spoke at length with the Registered Manager and Deputy Manager about the ‘potting – up’ system, which they said is done immediately before delivering medicines to the residents, attending to one floor of the home at a time. They confirmed they had weighed up the alternatives and found this the safest method of giving medicines. The Inspector decided that care was taken with the procedure but that the home, and Victoria Group needs to ensure the practice is in line with current legislation. The Registered Manager has instigated a new practice in the home called ‘Topic of the Month’ this involves simplified teaching and handouts to staff on specific medication or illness to give care staff more knowledge to help them in their work. All residents and relatives spoken with by the Inspector said they found staff to be respectful and kind. Residents have their own telephone lines and when asked said they open their own post and are able to see visitors in their own room’s or the communal sitting room. The Inspector noted that care staff Victoria DS0000014073.V324204.R01.S.doc Version 5.2 Page 13 knocked on doors and observed they had a pleasant, friendly attitude towards residents and colleagues. One resident survey read ‘I came directly from hospital and was lucky enough to find a place here. I have made a very good physical recovery due to the care given’. The Inspector spoke with the Registered Manager about the emotional and care needs of residents nearing the end of life. The Registered Manager told the Inspector that residents are able to stay in the home and in their own rooms as long as their care needs can be fully met. Relatives are invited to stay with the resident sharing the home’s facilities. She said staff support each and the relatives with a focus on good communication and empathy. The home works closely with the local Martletts Hospice who provide a nursing team for advice and support and some specialised training in palliative care. Residents from the home are able to visit the Martletts and attend their day care centre if they have a terminal illness. During the inspection the Inspector observed a resident being collected and escorted to The Martletts and noted that there was a thorough exchange of information about the resident’s progress prior to the visit taking place. Victoria DS0000014073.V324204.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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents in the home are encouraged to maintain contact with family and friends, who are made welcome and encouraged to visit. The Activities Coordinator provides regular activities for those residents who wish to participate. Residents have choice in their everyday lives and benefit from a varied and balanced diet. EVIDENCE: The home has an Activities Co-ordinator who visits the home at least once a week and sometimes twice. She undertakes group activities and one to one activities depending on residents choice; included in activities are reminiscence therapy, which is done through quizzes and conversation. On the day of inspection a group quiz was taking place. The Activities Co-ordinator having been in post for many years knows the residents and their preferences. The Registered Manager told the Inspector that the home’s staff are very active in raising funds solely for the residents entertainment. Over the Christmas period Victoria DS0000014073.V324204.R01.S.doc Version 5.2 Page 15 they raised £260 to fund future musical events. The home does not offer group or individual outings; this needs to be reflected in the statement of purpose and service user guide. With reference to activities, one resident survey read ‘I feel that this (activities) is important. I enjoy the word games and it keeps my brain active!’. All other surveys confirmed that activities took place’. Visitors are made welcome in the home, residents and relatives confirmed this. They also said meals and snacks are also offered to them. A visitors’ book, used daily, gives a record of all visitors to the home. The Registered Manager said there are no fixed visiting times but relatives are asked to avoid visiting first thing in the morning and last thing at night if at all possible. Meals in Victoria 96 The Drive remain well balanced, good in quality and sufficient in quantity. Everyone spoken with during the inspection process confirmed this. At the time of the inspection eight residents were currently eating together in the dining room. 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 DS0000014073.V324204.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): 16,17 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents in the home are protected by the home’s attitude towards complaints and staff have an awareness of protecting staff from potential abuse. Residents are able to participate in the process of voting if they so wish and information on advocacy services is made available to them if necessary. EVIDENCE: The pre-inspection questionnaire sent to the home prior to the inspection was returned to CSCI saying there had been no complaints and no incidences reported since the last inspection. The Registered Manager was aware of the need to record all concerns and complaints no matter how minor. A complaints log is used by the home that is familiar to all the homes in the group. In addition there is a complaints book left in the entrance hall for anyone to use if they wish although staff, residents and relatives all said they would feel confident in going to the Registered Manager if they were not happy about something. One resident’s survey read ‘Complaints are always rectified as far as possible!’. Victoria DS0000014073.V324204.R01.S.doc Version 5.2 Page 17 Residents are encouraged to use the postal voting system, forms for which were with the residents to complete at the time of inspection. Should a resident require an advocacy service in the absence of a friend or relatives, the Registered Manager said they would be referred to Brighton and Hove Social Care and Health Department for assistance. Prior to the inspection the Inspector spoke with senior staff working throughout the Victoria Homes about the protection of vulnerable adults and although they showed knowledge of the process not all fully understood it. Following inspection of other homes in the Victoria Group, The Inspector spoke with the Responsible Individual and the Registered Provider and they agreed to address the issue as a matter of urgency with the new Trainer who started in post in January 2007, because of this a requirement will not appear in this report on the understanding that training will be completed for senior staff by 28 February 2007. Care staff spoken with in Victoria 96 showed a common sense approach to the protection of vulnerable adults and were very clear of their role and to whom to report, however they do need confirmation of the latest local guidelines on how the different levels of abuse are investigated. Victoria DS0000014073.V324204.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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The maintenance team for the Victoria group of homes make sure that attention is paid to any work, inside or out to maintain the safety and comfort of the residents and staff. The home has sufficient lavatories and washing facilities and each resident has a room that suits their individual needs. The home is kept clean and tidy and is well equipped with specialist equipment to maximise the independence of residents. EVIDENCE: A requirement was made during the last inspection referring to the cleanliness of the kitchen area. This had been addressed and the Registered Manager told Victoria DS0000014073.V324204.R01.S.doc Version 5.2 Page 19 the Inspector she had requested a steam cleaner from the Registered Provider for regular deep cleaning of the kitchen. Since the last inspection, in one room a ceiling had been replaced, another had been re-plastered and various other rooms had been refurbished, some with carpets. The conservatory roof had been replaced and new steps fitted to the front door to accommodate a ramp. These were confirmed in the preinspection questionnaire received by the Inspector and also by the Registered Manager for the home. All rooms in the home have a sink and toilet and fourteen rooms have a bath or shower, in addition the home has one bathroom and one shower room. There are sufficient communal spaces and a passenger lift between floors. The last Occupational Therapists assessment in the home took place within two years prior to the inspection. The Victoria Group has an equipment store based in one of the other homes for any extra aids, adaptations or specialised equipment. The home at the time of inspection was well equipped for the current residents with no one requiring a wheelchair. Five residents were using adjustable beds. The Registered Manager told the Inspector that for any resident going home a referral would be made to the Older People’s Care and Assessment Team at Brighton and Hove Council to make sure they received any equipment necessary. The Inspector and Registered Manager spoke about residents being offered a key to their individual rooms, this is not current practice at Victoria 96. A requirement will be made in this report that residents are risk assessed for the choice to have a key and the outcome recorded in their individual care plans and personal records. All residents have lockable facilities for their personal items of value and private papers. Personal laundry is undertaken in the home for which industrial machines are used. The laundry is situated away from the kitchen area. All other laundry is undertaken at another home in the Victoria Group. On the day of inspection the home was clean, tidy and organised. Residents confirmed their rooms were cleaned each day and that the cleaner was very helpful. Victoria DS0000014073.V324204.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 good. This judgement has been made using available evidence including a visit to this service. The home’s recruitment practice is thorough and protects residents as far as it is able. Care staff undertake mandatory training in addition to being offered NVQ training thus ensuring they are competent in the work they do and care they offer to residents. On the day of inspection the home appeared to be adequately staffed. EVIDENCE: On the day of inspection the home appeared to be adequately staffed. Residents said their call bells were answered quickly and in the majority of cases staff spent time talking to them as well as providing care. Staff work a fixed rota and the home has a key-worker system in place allowing each member of staff to have responsibility for a number of residents. Each day a trained nurse is on duty with four care staff in the morning, and two care staff in the afternoon. At night one trained nurse and one member of the care staff cover the home. Extra staff are provided if necessary from the Victoria DS0000014073.V324204.R01.S.doc Version 5.2 Page 21 Victoria staff bank. The Registered Manager said this worked very well. In addition to working on the rota the Registered Manager works two extra shifts a month to allow her time to catch up with her administrative responsibilities. Care staff confirmed that both she and the Deputy Manager worked with them in the home caring for the residents. The home has a kitchen server each morning with care staff preparing and serving evening suppers. The home’s domestic cleaner has extra help once a week. The Inspector looked at recruitment files prior to the inspection and found that a thorough system was in place. All staff have contracts of employment, job descriptions, undertake trial shifts and shadowing of experienced staff and receive induction and mandatory training which includes three days training a year. In addition all are CRB (Criminal Records Bureau) checked They also have the opportunity to undertake NVQ 2 once they have passed through their probationary period and have shown a commitment to working for the Victoria Group of homes. Care staff confirmed undertaking shadowing of experienced staff prior to working alone. Four staff in the home had just completed NVQ2, one member of the care staff was also a trained nurse but had let her registration lapse therefore the home has reached the target of 50 of the care staff being sufficiently trained to meet standard 28. Victoria DS0000014073.V324204.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): 31,32,33,24,35,36,37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and the outcomes for residents’ are good. The home has systems in place to ensure it runs smoothly and residents are safeguarded by accounting and financial procedures. Residents and staff are protected by the home’s attitude to health and safety however the home needs to review its policies and procedures to accommodate the new fire safety legislation. EVIDENCE: Victoria DS0000014073.V324204.R01.S.doc Version 5.2 Page 23 The Registered Manager is a qualified nurse with a certificate in management, she also attends training locally and in-house to support her role and assist her with her job. She has the support of the Deputy Manager, also a qualified nurse who, in addition has a business degree. The Registered Manager has experience in the care home environment and is familiar with the care needs of the elderly frail residents. Care staff said of the Registered Manager ‘She is lovely, helpful, supportive and very caring’. A relative told the Inspector that she found both the Registered Manager and Deputy Manager ‘delightful and helpful’. The Registered Providers visit the home on a regular basis either during the day or evening; care staff throughout the Victoria Group, have told the Inspector the Registered Providers’ are supportive and caring to staff, and are well respected. One staff member told the Inspector ‘The Registered Provider is brilliant, wonderful and very fair, she will put herself out for the staff and always listens’. Staff meetings are recorded and take place six monthly. Residents meetings take place yearly. Minutes of meetings were seen by the Inspector and also copies of notices put in the home to remind residents and staff of forthcoming meetings. Copies of the staff meetings are kept on the notice boards and items for the agenda arranged in advance to enable staff to bring forward their own ideas and views. Matrons meetings for the Registered Managers working for the Victoria Group take place monthly with information later being fed down to care staff. All the homes in the Victoria Group have the Quest for Quality Award. The Registered Manager told the Inspector that the last questionnaires sent out to residents was during 2006, however the Victoria Group are changing their provider for quality assurance. The Registered Provider has resumed undertaking monthly Regulation 26 inspections of the home when the environment and resident satisfaction is looked at. Copies of the reports are based in the home for future inspections. Both care staff and the residents were made aware that this inspection was taking place and the Registered Manager was helpful in asking permission from relatives to be contacted by the Inspector. Surveys returned by the Inspector all stated that the residents did not wish to see the Inspector on the day of inspection. The home has relevant insurance in place and certificates are on view in the entrance hall. Residents manage their own financial affairs or have the assistance of relatives or a solicitor. The home has a small petty cash allowance in place and the Registered Manager does hold small amounts of money (up to £25) for residents to go towards hairdressing or other in-house costs. The Inspector requested that all money held for residents should be receipted formally ; a requirement will be made in this report. Victoria DS0000014073.V324204.R01.S.doc Version 5.2 Page 24 The Inspector also requested that the Registered Manager make sure that an inventory of all resident’s possessions and furniture brought into the home had been completed. Care staff receive supervision approximately every two to three months with records kept. Supervision is used to make sure care staff are confident in their role and as an exchange of information relating to their work. Staff said they have yearly appraisals. The office is lockable and is only kept locked if the Registered Manager or Deputy Manager are working in the home, the Registered Manager told the Inspector that locking of the office is being promoted with staff for good practice. The Inspector reminded the senior staff that the filing cabinets holding personal records should be kept locked when not in use. Staff are trained in moving and handling, basic first aid, fire safety and infection control. All new staff are given the fire procedure to learn and the next fire safety training is due in July 2007. As with the other Victoria homes a requirement will be made in this report that staff are made aware of the new fire safety legislation. All gas and electrical appliances are checked regularly with records kept. The home has a system in place for risk assessing residents for safety in their environment and risk assessing the environment itself. Accidents and injuries are recorded and staff are aware of the need to report all communicable diseases to the Environmental Health Department at Lewes. The Registered Manager told the Inspector that the home does not accept prospective residents who are known to have clostridium difficile or MRSA therefore this information should be incorporated in the homes statement of purpose to make sure relatives and prospective residents are aware of the situation. Victoria DS0000014073.V324204.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 3 3 3 3 3 X 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 Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Victoria DS0000014073.V324204.R01.S.doc Version 5.2 Page 26 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. 1 Standard OP1 Regulation 4(1) Requirement The statement of purpose to reflect the following: Standard 13: that outings are not provided for residents. Standard 27: The qualifications of care staff and those undertaking NVQ2 or 3. Standard 38: that the home does not admit residents suffering from Clostridium difficile or M.R.S.A 31/03/07 The home to ensure that the administration of medication follows current good practice and guidance as in agreement with the Nursing and Midwifery Council and the Department of Health ‘Building a Safer NHS. The ‘potting –up’ system to be reviewed for safety and all care staff to be trained in medication, its administration and uses including the checking of medication for safety. 3 Victoria Timescale for action 31/03/07 2 OP9 Schedule3 (2)13(2) OP18 13(6) Care staff to be trained on the DS0000014073.V324204.R01.S.doc 31/03/07 Page 27 Version 5.2 4 5 6 OP24 OP35 OP38 12(4)a 16(2)L 23(4) latest Brighton and Hove Council guidelines for the protection of vulnerable adults to give information on how different levels are investigated. All residents to be risk assessed to have keys to their individual rooms if they so wish. Receipts to be given when residents hand over amounts of money for safekeeping. The fire safety policies and procedures to be reviewed to include the new fire safety legislation and staff to receive updates. 31/03/07 01/03/07 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Victoria DS0000014073.V324204.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. 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