Inspection on 15/06/05 for Victoria

This inspection was carried out on 15th June 2005.

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 14/02/07

Victoria 16/01/06

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 Khot Unannounced 15 June 2005 14:00 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 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Victoria Address 96 The Drive Hove East Sussex BN3 6GP 01273 723938 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 Limited Vacant Care Home 23 Category(ies) of Terminally Ill (TI) 23, Old age, not falling within registration, with number any other category (OP) 23, Physical disability of places (PD) 23. Victoria H59 H10 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. That there is adherence to the staffing levels set down. Date of last inspection 25 January 2005 Brief Description of the Service: Victoria 96 The Drive is one 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,along with the other four homes in the Victoria group, has the Quest for Quality Award. Victoria H59 H10 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the afternoon of 15 June 2005. The inspection lasted four hours and during that time the Inspector was able to meet residents and their visitors. All said they were very happy with the care provided and that the Matron and her staff were kind to them. Mrs Ann Jayston facilitated the inspection; she is currently applying to the Commission for Social Care Inspection to become the Registered Manager for the home and has been in her current post for three months. What the service does well: What has improved since the last inspection? What they could do better: The four residents who are on permanent bed-rest may benefit from more mental stimulation. At the end of the inspection two immediate requirements were left in relation to the door to the generator for the lift shaft and the sluice on the ground floor. Mrs Jayston agreed to address them straightaway. Victoria H59 H10 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 Page 6 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 S14073 Victoria 96 The Drive V218996 150605 Stage 02.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 S14073 Victoria 96 The Drive V218996 150605 Stage 02.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) 3,5 and 6 Pre-admission assessments were appropriate to identify meet residents needs and were carried out by people Assessments were looked at by the Inspector and they information concerning the care of the residents. The equipment to provide intermediate care if necessary but registered to do so. EVIDENCE: if the home could trained to do so. contained relevant home has suitable is n ot specifically The Acting Manager (Mrs Ann Jayston) told the Inspector that the Director of Nursing Services undertakes all pre-admission assessments to ensure that all new residents meet the criteria of the home. Care plans seen by the Inspector were informative and comprehensive. Pre admission visits take place and residents spoken with said they had previous knowledge of the home before making the decision to move in permanently. On the day of inspection there were some residents staying on a short-term basis for respite. Victoria H59 H10 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 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 standard(s) 7,8,9,10 and 11. Residents have their personal and nursing care needs addressed by staff, those who are able to be more self caring receive appropriate assistance and prompting from staff. All residents appeared to be well cared for and comfortable and those spoken with stated that they received a good quality of care that they were happy with. The method of administering medication ensures that residents are protected. EVIDENCE: Care plans are based on the pre-admission assessment, these include consent for treatment forms and monthly reviews that are signed by either the resident or his/her representative. On the day of inspection all residents had their medication administered by staff. The Clinical Room was clean, tidy and organised, all medication checked by the Inspector was seen to be in-date and the Controlled Drug register upto-date. An outside firm for nursing supplies is used for the servicing of nursing equipment and records are kept in the home. The home has a privacy and dignity policy in place and potential double rooms have screening. Residents receive treatment in their individual rooms and can receive guests there or in the communal sitting room. Victoria H59 H10 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 Page 10 The Acting Manager said that when a resident dies, relatives are encouraged to be involved and are able to share the home’s facilities. The home does have a death and dying policy in place. Victoria H59 H10 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 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 standard(s) 12,13 and 14. The home works hard to allow residents choices in their activities of daily life and to support them in making decisions. Visitors are made welcome and encouraged to visit and take part in activities in the home. Although standard 15 was not assessed at this inspection, the Inspector thought that the evening supper was well presented and looked nourishing. EVIDENCE: Visiting times in the home are flexible, preferably between 11am and bedtime. During the inspection the Inspector noticed that visitors were all made welcome and one resident was enjoying a party with family and friends. Residents have a choice of who they see and a visitors book is in place for visitors to sign in and out. Residents spoken to all spoke highly of the Acting Manager and care staff saying that they were kind and chatted to them. The home has a new activities co-ordinator due to the retirement of the regular person who was a familiar figure throughout all the Victoria Nursing Homes. The Acting Manager told the Inspector that the new person will visit as regularly. The Acting Manager has prepared an information leaflet for residents and their representatives that includes, staff names, layout of the home, information on the key worker system, mealtimes, visiting times, and a list of all the activities that the home provides. Victoria H59 H10 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 Page 12 The home does not have any involvement in the residents financial affairs but will keep small amounts of money for anything extra that a resident may need. Receipts for this are given. Some residents had brought their own furniture with them but this was by prior arrangement. Victoria H59 H10 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 Page 13 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 are protected by the homes attitude to complaints and staff are aware of their responsibilities in ensuring that residents are protected from abuse. EVIDENCE: The home protects residents by having appropriate policies and procedures in place for both complaints and the protection of vulnerable adults. Training records sampled by the Inspector showed that staff had received training in the protection of vulnerable adults and the Acting Manager was aware of the procedure and the necessity of contacting the Commission for Social care Inspection and the Adult Protection Co-ordinator at Brighton and Hove Council in the event of any alert raised. During conversation it was clear that minor complaints are not being recorded. The Inspector stressed the importance of a record being kept of all complaints for future reference and the Acting Manager agreed to this. A requirement will be made in this report. Victoria H59 H10 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 Page 14 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) 19,24 and 26 The home has been well maintained and decorated to meet residents needs with refurbishment and redecorating still going on. Care is provided in a homely environment. In some areas more care could be given to locking doors and storing cleaning solutions. Locks to residents private accommodation has been overlooked. EVIDENCE: On a tour of the home the Inspector noted that refurbishment and maintenance work was being undertaken on the lower ground floor conservatory where the walls are damp and stained and the wall-paper lifting, however the adjacent resident’s bedroom was not affected. A requirement will be made in this report that the broken drawer in room 18 is repaired, a call alarm to be push button connection to be put in the socket in the ground floor toilet and that cleaning equipment is kept stored safely and away from communal areas. The home was clean and tidy with no offensive smells. The Kitchen area was seen to be clean with foodstuffs in date and the laundry organised with Victoria H59 H10 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 Page 15 individual baskets for residents’ own clean laundry. Protective clothing is available for all staff for providing either care or serving food. The Victoria Group has a maintenance and gardening team in place who were working in the home on the day of inspection. The Inspector witnessed the fire alarms being tested and spoke to the maintenance person about the improvement in recording since the last inspection. The next fire inspection is due after July 2005. Victoria H59 H10 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 Page 16 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) 27 and 28 The home has sufficient staff on duty to meet the needs of the residents and takes into account that more staff are required at certain times. Staff are encouraged to undertake further training to ensure residents care needs are met. EVIDENCE: Almost 50 of care staff in this Victoria Nursing Home either have NVQ2 or are in the process of attending the course. On the day of Inspection the home had sufficient staff on duty and the rota showed that each morning 4 staff and an RGN (Registered General Nurse) are on duty, the afternoon shift has 2 staff and an RGN and at night 1 member of staff and an RGN. Extra staff are brought into the home if necessary as part of the 24 hour care service. Victoria H59 H10 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 Page 17 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) 31,33,35,37 and 38 The home is well managed and the outcomes for the residents is good. Health and safety issues are generally addressed but there are a few areas where they have been overlooked. Policies and procedures are informtive and updated thus ensuring that residents and staff are protected. EVIDENCE: The Acting Manager has the Registered Managers Award and is currently applying to become the home’s Registered Manager with the Commission for Social care Inspection. She has 19 years experience of care of the elderly in both nursing and care homes. She told the Inspector that she attends all training provided by the Victoria Group and that the Registered Providers are very supportive. Regulation 26 reports are sent to the Commission as required. Staff supervision and staff meeting take place regularly with records kept. The home does not hold residents meetings but residents and relatives are able to see the person-in-charge at any time if there is something they wish to Victoria H59 H10 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 Page 18 discuss. Those spoken with by the Inspector said they found the staff very approachable. During the Inspection staff and relatives were seen to communicate freely. Since the last inspection a new system has been put in place for recording the servicing and testing of equipment. Policies and procedures are updated and reviewed continually by the Director of Nursing Services. The home does not have any involvement with residents finances and receipts are given for small amounts of money with records kept should a resident wish to make small purchases. During the inspection the Inspector spoke with the maintenance staff and discussed their routine of maintenance on the home. It was established that the home uses a qualified electrician for electrical faults and installations and is aware of current legislation. Water temperatures are taken twice a month as was agreed with the Inspector at an earlier inspection; the fire alarm system is tested weekly, fire drills are arranged on a monthly basis. All staff require updating on fire safety. A risk assessment needs to be undertaken on the building in its entirety, this includes all bedrooms, communal areas and the kitchen and associated areas. The Acting Manager was unclear if this had taken place as no evidence could be found in the office. Victoria H59 H10 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 Page 19 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 x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 x COMPLAINTS AND PROTECTION 2 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 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 3 2 x 3 x 3 x 3 2 Victoria H59 H10 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 Page 20 NO 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. 2. 3. 4. Standard 18 19 19/38 19/38 Regulation 22 23(2) 23(2)c 23(2)1 Requirement All complaints to be recorded, no matter how small. The broken drawer to the wardrobe in room 18 to be repaired and replaced. The call alarm bell to be replaced in the Lower ground floor toilet, Cleaning equipment to be kept safetly away from communal areas (Vacuum and floor cleaner). All staff to receive a fire training update. The building to be risk assessed and to include, all residents bedrooms, all communal areas, the kitchen and associated areas. A copy to be kept in the home for future refefrence. The generator cupboard in the laundry to be kept locked with the key in a safe place. De-scaling solution to be kept locked in a COSHH cupboard. The sluice on the ground floor to be kept tidy, and free of hazardous materials. Timescale for action Immediate 15 July 2005 15 July 2005 1 July 2005 5. 6. 38 38 23(4)d 13(3) 13(4) 23(1)(2) 1 August 2005 1 August 2005 7. 8. 9. 38 38 38 13(4) 13(3) 13(3)(4) Immediate Immediate 1 July 2005 Victoria H59 H10 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 Page 21 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 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Victoria H59 H10 S14073 Victoria 96 The Drive V218996 150605 Stage 02.doc Version 1.20 Page 23 - 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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