Inspection on 16/01/06 for Victoria

This inspection was carried out on 16th January 2006.

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 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 Unannounced Inspection 16th January 2006 09:00 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.V276388.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Victoria DS0000014073.V276388.R01.S.doc Version 5.1 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 Victoria Nursing Homes Limited Elizabeth Jaystone 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.V276388.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 3 The maximum number of services users to be accommodated is 23 Service Users must be older people aged sixty five (65) years or over on admission. Service users may have a physical disability. 15th June 2005 Date of last inspection 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 DS0000014073.V276388.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the morning. During the inspection the Inspector was able to look through the administration, tour the premises, see staff and work, speak to residents and also the Registered Providers. The Inspection was facilitated by Mrs Ann Jayston the Registered Manager who received feedback at the end of the inspection. Requirements were discussed in full at that time. An inspection comment sheet was left with a pre-inspection questionnaire to be completed and returned to the Commission for Social Care Inspection at a later date. The Inspector would like to thank Mrs Jayston and the staff for making the inspection a pleasant and positive one. What the service does well: What has improved since the last inspection? The home has undergone refurbishment in some areas since the last inspection and rooms 1,2,7,14,15 and 20 have been re-decorated as they have become vacant. Five rooms have new carpets. The extension to the dining room has a new roof and has been decorated; in addition the home has a new fire alarm system that is addressable and pin-points rooms instead of zones should a fire break out. Requirements from the last inspection had been addressed. Victoria DS0000014073.V276388.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Victoria DS0000014073.V276388.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria DS0000014073.V276388.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 4. All other standards were fully assessed at the last inspection. The home provides sufficient information for prospective residents to make an informed choice about where they live. Residents are provided with terms and conditions of residency and both prospective residents and their advocates are invited to visit the home prior to admission to ensure it is suitable for them. EVIDENCE: The Inspector noted that the home has a statement of purpose and service user guide, the registration certificate and insurance certificates are on view in the main entrance and the latest inspection report is available should anyone wish to see it. The Quest for Quality Award has been awarded to all the homes in the Victoria Group and is due to be renewed in March 2006. In the entrance hall there is a notice board holding information, a visitors’ book for visitors to sign ensuring that staff know who is in the home. All residents have a contract of terms and conditions of residency, which includes a four-week notice period on either side, and insurance details of the home. All residents have the opportunity to visit prior to admission assuming they are well enough or wish to; often a friend or relative undertakes the first visit. Victoria DS0000014073.V276388.R01.S.doc Version 5.1 Page 9 Victoria DS0000014073.V276388.R01.S.doc Version 5.1 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 the following standard(s): 7,9 and 11. All other standards were assessed at the last inspection. 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. Medication is administered in a manner that protects the residents. The Registered Manager and staff are proactive in ensuring that residents are made as comfortable as possible especially towards the end of their lives at which time relatives are invited to be as involved as much as they wish. EVIDENCE: All residents have care plans and those sampled were seen to be up-to-date, signed and included goals, action and outcome. All visits by GP’s and other healthcare professionals were recorded. Resident’s daily progress is recorded twice daily and was seen to include prompts on any investigations due on the following day, and evidence of information provided by other healthcare professionals. Each resident has a key worker. The Inspector was able to look at the clinical room and found it to be clean tidy and well organised with an excellent stock control system instigated by the Registered Manager. A safe disposal system is in use that is in line with Victoria DS0000014073.V276388.R01.S.doc Version 5.1 Page 11 current legislation. All MAR (mediation administration records) were up to date and all residents’ files had a photograph of the individual resident for easy recognition, especially for visiting staff (i.e. bank or agency staff). Those that did not have a photograph were new residents, however the Registered Manager said these were at the central office awaiting developing. A requirement will be made in this report that when residents spend a day or time away from the home, a suitable system is put in place to ensure that a record of the administration of their medication is kept. This was discussed between the Registered Manager and Inspector. In all other aspects the home meets this standard and will still be scored as such. The home has a privacy and dignity policy in place that includes care of the dying. With regard to the use of the Liverpool Pathway for terminally ill residents, the Victoria Group has chosen to take time before deciding whether to use it and are in discussion with a representative from The Martletts Hospice with whom they work closely. Relatives and close friends of residents who are nearing the end of their life are invited to be as involved as they wish and are able to stay in the home, sharing the facilities. Victoria DS0000014073.V276388.R01.S.doc Version 5.1 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 the following standard(s): 15. All other standards were inspected at the last inspection. The standard of food is good and the presentation ensures that those residents with poor appetites are encouraged to eat. EVIDENCE: As with all the homes in the Victoria Group, the main meals are cooked and delivered by staff at Victoria 39 Dyke Road Avenue. Residents spoken to by the Inspector said they enjoyed their meals very much. The Inspector noted that residents are given a choice of meals. On the day of inspection five residents were eating in the dining room whilst others chose to eat in their own individual rooms. Records, although kept of meals eaten by residents, could not be easily found for reference, some had not been dated; a requirement will be made at the end of this report that this is addressed. Victoria DS0000014073.V276388.R01.S.doc Version 5.1 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 the following standard(s): 16,17 and 18. The home does not receive many complaints however attention needs to be paid to regular record keeping for the protection of both the home and the residents. Residents in the home are protected by training provided for staff in the protection of vulnerable adults. All residents are able to use the postal voting system if they so wish. EVIDENCE: The Registered Manager and Inspector discussed the need for reporting all complaints no matter how minor even if complaints and concerns are resolved. The Inspector explained that this can protect both residents and the home should an adult protection investigation take place. A requirement will be made at the end of this report to support this. All staff receive mandatory training in the protection of vulnerable adults and the Inspector saw records showing this had been included in study days for staff. There is a flow chart on view in the office to assist all staff should an incident occur. Victoria DS0000014073.V276388.R01.S.doc Version 5.1 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 the following standard(s): 19,20,21,22,23 ,25 and 26. Overall the home is clean and tidy with attention paid to making it a homely environment for the residents. The Victoria Group is pro-active in ensuring that the maintenance team visits the home regularly to undertake any repairs. The kitchen area needs to be addressed and a cleaning schedule re-established to eliminate the build up of sticky surfaces and food containers. EVIDENCE: The Victoria group of homes share a maintenance and gardening team who regularly visit to undertake any repairs or improvements. Recently the home has undergone improvements to the extension of the residents’ sitting room where a new roof has been erected and the room decorated. This provides an excellent view of the small courtyard garden at the back of the home. The home has sufficient en-suite and additional bathrooms and toilets for residents to use. All rooms visited by the Inspector were comfortably furnished and were clean and tidy with personal items from the individual Victoria DS0000014073.V276388.R01.S.doc Version 5.1 Page 15 residents’ own homes. The Registered Manager told the Inspector that a number of rooms have been refurbished since the last inspection when they have become vacant and five rooms been fitted with new carpets. The home has appropriate equipment to meet the needs of the residents. Victoria Oaklands, another home in the group, has an equipment store with a supervisor who distributes aids and equipment to all the Victoria homes as the need arises. The Inspector noted that grab rails, sitting and standing hoists, adequate moving and handling equipment and a lift are all in place. The home also has a passenger lift. The laundry was well organised with each resident allocated a personal laundry basket. All heavy laundry is undertaken at one of the other homes within the Victoria Group, however items of personal laundry are dealt with on site in industrial machines. The Inspector was concerned about the cleanliness of the kitchen area and found the cupboards to hold sticky containers and the shelves in both the kitchen cupboards and the residents’ dining room in need of cleaning. The Inspector and Registered Manager discussed the possibility of the kitchen itself being ‘deep cleaned’; a requirement will e made in this report that the problem be addressed. The dry stores for food packets and tins was organised and containers and packets looked at were found to be in-date. Throughout the kitchen and laundry area there is adequate safety signage. Victoria DS0000014073.V276388.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30. All other standards were inspected at the last inspection. The home has a thorough recruitment policy in place, which protects the residents, this is supported by an established training procedure organised by the in-house trainer for the Victoria group of homes. Staff undertake mandatory training in addition to being offered NVQ training for care staff 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 well staffed. EVIDENCE: The home has a thorough recruitment procedure in place. The Inspector was able to look at staff recruitment and training files prior to the inspection and found that each member of staff had been employed with two references and a new Criminal Records Bureau check. Other information showed that staff receive job descriptions, induction training and terms and conditions of employment. All staff have a probationary period to complete before becoming permanent members of staff. The Victoria Group has an in-house trainer who provides the regular training for staff. All staff are offered five days training a year, which includes, moving and handling, food hygiene, infection control, fire safety, health and safety and d basic first aid. Records of training undertaken by staff are kept in the home and the Inspector saw that reminder letters are sent out to staff who miss training sessions to remind them of the importance of attending. The Registered Manager has an information file available for all visiting staff (i.e. Victoria DS0000014073.V276388.R01.S.doc Version 5.1 Page 17 .bank or agency) to assist them in their duties relating to routines. There is also specific information available on training sessions for RGN’s and other qualified staff. The Registered Manager told the Inspector that there are 4-6 care staff who are either undertaking or interested in achieving the NVQ 2 certificate in care. Victoria DS0000014073.V276388.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,36,37 and 38. 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. Supervision is undertaken for all staff. Residents and staff are protected by the home’s attitude to health and safety however records of maintenance and system checks have, in some cases, been overlooked. EVIDENCE: The Registered Manager holds regular staff meetings with a record kept of items discussed from the agenda, staff are able to contribute as they wish. These are used to provide relevant information from the manager’s meetings that take place on a monthly basis with the Registered Providers. The home does not keep money on site, however should they be asked to hold small amounts for residents for an interim period, a receipt system is in place. Victoria DS0000014073.V276388.R01.S.doc Version 5.1 Page 19 The Inspector was able to see that staff supervision takes place and discussed with the Registered Manager that some staff had not received supervision for more than four months. The format used by the home was also a point of discussion with both the Registered Providers and the Registered Manager and it was agreed that the format would be looked at and revised to make it easier to use for both the supervisors and staff. The home has a new ‘addressable’ fire alarm system that pinpoints room’s instead of zones should a fire break out. It is also self testing. The Registered Provider undertakes environmental risk assessments of the home. Whilst looking through records the inspector found that maintenance and servicing records had not always been kept up to date. Records in the kitchen of meals eaten by residents were not in any particular order and the last days’ meal plan not evident, some records were found not to have been dated. The accident book was up to date however some entries still required filing away. Records were discussed with the Registered Manager and when looking through both she and the Inspector found that the system was often duplicated. There were queries relating to entries and records kept for tests and maintenance to:- the nurse call system, water temperatures in residents rooms, water temperature limiters, conflicting information on the records relating to the bath hoists, the fire risk assessment was in place but not dated. Although the home was overall clean and tidy, there was concern from both the Inspector and Registered Manager about the cleanliness of the kitchen, especially the cupboards, and the shelves in the dining area, used to house the tea condiments. This was discussed in full with the Registered Manager who agreed to address the concerns with the relevant staff and also organise deep cleaning of the kitchen. During the inspection of the kitchen area the Inspector also noted that the recording of fridge and freezer temperatures, although undertaken, did not clearly identify the piece of equipment being tested and was solely based on kitchen staff’s familiarity with the fridge or freezer. Victoria DS0000014073.V276388.R01.S.doc Version 5.1 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. 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 X 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 3 3 3 3 X 3 2 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X 3 X 3 2 2 Victoria DS0000014073.V276388.R01.S.doc Version 5.1 Page 21 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 OP9 Regulation 13(2) Timescale for action The home to devise a suitable 10/02/06 record keeping system for the administration of medication when resident’s are away from the home and take medication with them. All complaints to be recorded no 10/02/06 matter how minor. The kitchen cupboards, work 01/02/06 surfaces and floors to be cleaned and all storage containers to be assessed for stickiness. All maintenance records to be 01/02/06 kept up-to-date and a system to be set up to avoid duplication. Fridge and Freezer 01/02/06 temperatures: records to clearly identify the equipment and not base record keeping on familiarity. Records of meals eaten by 01/02/06 residents to be collated and readily available in the kitchen. All records to be dated. Requirement 2 3 OP16 OP38OP26 22(1)(2) 13(3)(4)c 4 5 OP38OP37 OP38OP37 17(3) 17(3) 6 OP38OP37 17(3) Victoria DS0000014073.V276388.R01.S.doc Version 5.1 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 OP36 Good Practice Recommendations The format used for staff supervision to be reviewed to make it easier for staff to use. Victoria DS0000014073.V276388.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection East Sussex Area Office 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 DS0000014073.V276388.R01.S.doc Version 5.1 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!