Inspection on 19/12/06 for Victoria

This inspection was carried out on 19th December 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 05/01/06

Victoria 05/05/05

Victoria 27/01/05

Victoria 14/07/04

Victoria 15/08/02

Similar services:

Springfield House

The Shelley

Thorndene

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Victoria 63 Dyke Road Avenue Hove East Sussex BN3 6DA Lead Inspector Linda Boereboom Key Unannounced Inspection 18th December 2006 13:00 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 DS0000014070.V320579.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 DS0000014070.V320579.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Address 63 Dyke Road Avenue Hove East Sussex BN3 6DA 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) 01273-564471 01273-881516 Victoria Nursing Home Limited Mrs Patricia Jane Evett 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 DS0000014070.V320579.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 Date of last inspection 5th January 2006 Brief Description of the Service: Victoria Nursing Home at 63 Dyke Road Avenue is one of a group of five homes all under the same ownership. All homes are in Hove and in close proximity of each other. This home is a recently extended detached property with wellmaintained gardens. The extension took place in 2002 and at that time a decking terrace was added for wheelchair users to overlook the large garden. There is a passenger lift servicing the first floor. The home has been registered for 23 older people who require nursing care due to a physical disability or terminal illness. Victoria Nursing Home is situated in a residential area that is serviced by the No 27 bus service that goes to nearby Hangleton or the centre of Brighton and Hove. It is close to the A27 and A23. Parking is available in the drive directly in front of the home or in the side roads nearby. The home is comfortable, well maintained and provides a calm and relaxed atmosphere to its service users, their relatives and friends. Victoria DS0000014070.V320579.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 three half days. On the first day the inspector visited the Head office at 81 Dyke Road Avenue to look at staff recruitment files and also interview four trained staff who work throughout all the Victoria homes on either day or night duty. One half day was spent talking to residents and relatives and a third looking at the home’s administrative procedures, touring the premises and observing kitchen and care staff at work. Ten resident surveys and care staff surveys were sent out randomly by the Commission for Social Care Inspection and at the time of writing this report four resident and two care staff surveys had been returned. Comments made in the surveys and to the Inspector during the Inspection have been reflected throughout this report. The Inspection was facilitated by Mrs Phillipa Watson-Smith RGN (Registered General Nurse) who has recently been appointed as the Deputy Manager of the home. The Inspector also spoke briefly with the Registered Manager who was officially off-duty. The Inspector discussed the outcome of the inspection with the Deputy Manager and on the following day with the Director of Nursing Services. The cost of care in the home varies from £595 to £795 a week; items not covered by the fee include hairdressing, chiropody, incontinent products, toiletries and magazines. The Inspector would like to thank Mrs Watson Smith and the staff for helping with the inspection, their hospitality and enthusiasm in making the Inspection pleasant and positive. What the service does well: Victoria 63 Dyke Road Avenue continues to provide a good standard of care to its residents in a caring, homely and relaxed atmosphere. The management approach to the home is positive and supportive and staff are committed to ensuring that residents are assisted to be as independent as possible. Residents told the Inspector that the Registered Manager visits them regularly in their rooms to make sure they are happy and have all they want and that staff are friendly one resident commented ‘staff are very nice and cheerful, they liven the place up!’ whilst another said ‘I feel as safe and secure as I can be’. Care staff also made positive comments about their work in the home Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 6 saying they felt lucky to work for the organisation and they had learned so many new skills; in addition one member of the care staff told the Inspector ‘everyone cares about everyone else from the kitchen staff to the nurses’. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Victoria DS0000014070.V320579.R01.S.doc Version 5.2 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 DS0000014070.V320579.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. 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. EVIDENCE: The Victoria Group of Homes has a Director of Nursing Services who takes full responsibility for ensuring that residents are properly assessed before moving into the home and have sufficient information for them to make an informed choice. Looking through residents’ files the Inspector noted that a recently admitted resident had been assessed after arrival and was not an emergency admission. This was later discussed with the Director of Nursing Services who confirmed that at least one resident had not been assessed and that another had transferred from another home within the group. It was agreed that as Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 9 these were isolated cases a requirement would not appear in this report however the home needs to ensure that all residents are properly assessed prior to admission. Some residents also said they had not received sufficient information on the home although the Deputy Manager and Director of Nursing Services confirmed it is customary for information to be offered at the preadmission assessment and be lodged in residents individual rooms in the home. The Deputy Manager was aware of the need for a full assessment to be undertaken within 48 hours of admission for emergency admissions. Some residents spoken with by the Inspector said they were unsure if they had a contract of residency however later discussion revealed they had. The pre-admission assessment undertaken by the Director of Nursing Services provides the basis for the care needs assessment undertaken in the home once a resident has been admitted. Care staff receive training in the needs of the elderly and trained nursing staff provide any specialist care. The home is not registered for Intermediate Care however some residents are admitted to the home for respite and to gain confidence and strength between leaving hospital and going home either acting on their own initiative or suggestion from the hospital service. Victoria DS0000014070.V320579.R01.S.doc Version 5.2 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. 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: All residents have a plan of care that is kept within the daily recording system in the home. Residents are monitored at least once a day and the home has in-depth handovers to staff coming on to the next shift. The Inspector read through care plans and found them to provide clear indication of the nursing and general care needs of each resident including information about visits from healthcare professionals from outside the home. The home liaises with the wound care specialist, continence nurse specialist Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 11 and dietician for the community as appropriate and the Deputy Manager confirmed that the home has access to all professionals within the Healthcare Trust e.g. physiotherapist, occupational therapist and the community psychiatric nurse. Residents confirmed having been weighed on a monthly basis. The Deputy Manager confirmed that only trained staff are able to give medication. All residents spoken with said they received their medicines at the correct time. The Inspector looked at the procedures for the disposal of medication and found them to be appropriate with the Deputy Manager keeping a list of medication returned and any controlled medication requiring de-naturing for safety. There is a controlled medication register and separate lockable facility for storage in place. The Inspector and Deputy Manager discussed the administration and checking processes used by the home as there is only one trained Registered General Nurse on at any one time which might cause a problem with the checking of medication. It had been agreed with the Director of Nursing Services that appropriate training take place before any member of the care staff is allowed to check medication. The system at Victoria 63 Dyke Road Avenue includes a potting up system for the administration of medication and following consultation with the CSCI pharmacist a requirement will be shown in this report requesting that this method follows current good practice and guidance in agreement with the Nursing and Midwifery Council and the Department of Health ‘Building a Safer NHS’. The Inspector also spoke with care staff about the administration of medication and they confirmed checking controlled medication before it is administered; one had received training from a local pharmacist whilst the other had not. The Deputy Manager told the Inspector that she checks the medication cupboard at random for cleanliness, organisation and the shelf life of the medication, this was also undertaken by the Inspector who found medication to be efficiently stored. Fridge temperatures in the fridge used for storage of medication are checked weekly and the care of syringe drivers to ensure they are in good working order is organised by the Director of Nursing Services via the local Healthcare Trust. When a resident dies medication is kept for 7 days in case a coroner’s inquest is required. All residents spoken with by the Inspector said they are treated with respect are given their own post to open and are able to have their own telephone lines. The Inspector noted whilst walking through the home that care staff and residents appeared to share friendly relationships and care staff knocked on doors before entering. The Inspector noticed that all staff treated visitors to the home in a friendly manner, and were seen to be very helpful to them. The home has a death and dying policy and works with a local hospice that provide some training on palliative care and the use of syringe drivers, offering support to the Victoria staff when necessary. Relatives of a resident’s nearing Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 12 the end of life are invited to be as involved as they wish and to share the home’s facilities. From a survey sent at random to the care staff, one replied; ‘I think the care of the residents in the five homes is excellent, each resident is treated as an individual and their likes and dislikes are listened to. I like the friendly and relaxed feeling in each home between the staff, staff to residents and their families’. Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 13 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, inviting them to share meals in the home by arrangement. The Activities Co-ordinator 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 however some residents’ requests had not been addressed. EVIDENCE: Residents in Victoria 63 Dyke Road Avenue are encouraged to maintain their social contacts and visitors are made welcome. There is an Activities Coordinator who has worked for the Victoria Group for many years who visits the home regularly to organise bingo sessions and other group activities as well as one-to-one activities and chats with those residents who prefer not to socialise in a group however, one survey sent at random to the care staff did state that he/she felt that many residents would benefit by having more social activities organised for them. A volunteer visitor comes to the home on a regular basis with a dog (PAT dog) that the relatives enjoy the company of. Two residents told the Inspector they would like the opportunity to attend a church service in Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 14 the home and the inspector discussed this with the Registered Manager, a requirement will be made in this report that the home addresses the request. The Inspector spoke with care staff in the home about caring for residents with social, cultural and specific needs of ethnic minorities. They were very definite about treating all residents equally and gave examples that showed they understood the need to respect other people’s beliefs and traditions. Residents spoken with by the Inspector commented that their visitors are always made welcome and are able to share mealtimes by prior arrangement. This is made more personal when staff organise separate family tables. All said their visitors are offered tea or coffee and cake or biscuits during their visit and can be seen either in individual rooms for privacy or in the main sitting room that is comfortable for a larger group. The home also encourages small family parties for residents. There is a visitor’s book in place to record visits to residents; the Inspector noted this was in use. Residents make their own financial arrangements and the home does not have any involvement in resident’s finances, all are able to bring possessions into the home by prior arrangement. Rooms visited by the Inspector had been personalised and were comfortable and inviting. Mealtimes in the home are flexible and residents are encouraged to eat in the dining room but stay in their individual rooms if they prefer to eat alone. The Inspector spoke to care staff about ‘special’ dietary requirements of residents and the involvement of the Community Dietician. Main meals are cooked at another of the homes nearby, in the Victoria Group and distributed to each home. Residents are given a choice a day ahead and records are kept of what residents eat during the day. The home has a central kitchen with ovens for re-heating food with meal servers coming in on a daily basis. Residents spoken with by the Inspector commented - ‘the meals couldn’t be better, they are variable and there is choice’, however another resident said that despite asking for plain yoghurt her preference had not been acknowledged. One resident spoken with said she was on a limited diet but staff always ensured her meals consisted of foods that were light and enjoyable. Another resident was concerned that her meals weren’t always warm enough and the Inspector later discussed this with the Registered Manager to address as part of the quality monitoring process. The Inspector saw a report of the Environmental Health Inspection of the kitchen and dry store area undertaken on 19/10/06 that stated hot and cold food preparation in Victoria 63 Dyke Road Avenue was satisfactory. Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 15 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 however senior staff require up-to-date information on managing protection of vulnerable adults should an incident occur. EVIDENCE: The home has a complaints procedure in place with a recording system that is common to each home within the group. The Deputy Manager did not know of any recent complaints made to the home and on the day of inspection the complaints log-book could not be located although the Deputy Manager did confirm it existed. The pre-inspection questionnaire returned to the CSCI prior to the inspection stated there had been no complaints received by the home in the last twelve months. There is a comments book in the main hall for residents or relatives to use if they wish. Residents spoken with by the Inspector all said they would feel confident in going to the Registered Manager, Deputy Manager or Registered Provider for the home with a concern or complaint. The home is registered for postal voting but residents are able to go to a local polling station if they wish to. Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 16 The Inspector spoke with senior staff who might be left in charge of a home within the Victoria Group, and also with care staff. Some of the senior staff revealed that they had not had up to date training and information on the protection of vulnerable adults and although they had a common sense approach did not fully understand the procedure whereas the care staff and Deputy Manager were all clear on their role and who to report to should an incident occur. A protection of vulnerable adults scenario was given to the staff interviewed in the home and all showed a common sense approach and what the immediate priorities were should an incident occur. The Inspector spoke with the Responsible Individual and the Registered Provider following interviews with senior nursing staff who agreed to address the matter as a matter of urgency when the new Trainer started in post in January 2007, therefore a requirement will not appear in this report on the understanding that training will be completed for senior staff by 28 February 2007. All staff are Criminal records Bureau checked prior to commencing work within any home in the Victoria Group. Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 17 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 ensure that attention is paid to any work, inside or out to maintain safety and comfort. 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. EVIDENCE: Victoria 63 Dyke Road Avenue provides a warm and pleasant environment for the residents. The Victoria Group of homes share a maintenance and gardening team who regularly visit to undertake any repairs or improvements. The Deputy Manager told the inspector that rooms are re-decorated as soon as they become vacant and before another resident moves in, often a new carpet is laid at the same time. Residents spoken with by the Inspector commented that they found their rooms comfortable with one saying ‘I’m very comfortable, I like this room and I’m glad I chose it of the two offered to me’, all said their rooms were kept warm enough and all had call bells within easy reach of both Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 18 the bed or chair, residents said their call bells were answered within five minutes of ringing for attention. The Inspector asked residents if they felt the home was kept clean enough and all replied that the cleaner was very thorough and went everywhere with the home comments made included ‘they are very good with cleaning’ and ‘the cleaner comes in daily’. Each bedroom in the home has an ensuite toilet and hand washbasin, twelve of the rooms have individual baths and one has a shower. In addition to this the home has a communal shower and a communal bath with a bath hoist and space for a portable hoist. An OT assessment was undertaken of the home and the report seen by the Inspector at the last inspection in January 2006. The home did not have any shared bedrooms although the registration allows for one room to be shared. The Inspector noted that aids and equipment were in place as required and the home had a passenger lift to both floors. There was adequate safety signage in place and on a tour of the premises all radiators seen by the Inspector had been covered. There were no obvious draughts in any room visited by the Inspector. 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 main bulk of laundry is done at another home within the Victoria Group and only personal laundry is undertaken at 63 Dyke Road Avenue. The home has commercial washing machines and driers and staff receive appropriate training for cleanliness with different aprons worn for different duties. All staff spoken with by the Inspector confirmed they had received training in the control of infection. Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 19 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. Staff undertake mandatory training in addition to being offered NVQ training for care staff to ensure they are competent in the work they do and care they offer to residents. On the day of inspection there appeared to be sufficient care staff on duty. EVIDENCE: The staffing levels in Victoria 63 Dyke Road Avenue are kept consistent with extra staff brought in from the bank staff employed by the Victoria Group of homes as necessary i.e. if one resident requires extra care and attention or care staff are on annual leave or sick leave. Some staff work between the homes in the Victoria Group and prior to the inspection the Inspector interviewed four of the senior staff that work between the homes. The Deputy Manager told the Inspector that the Registered Provider for the Victoria Group is always willing to provide extra staff if necessary. The Inspector found that each morning there is a qualified member of staff on duty (RGN) with four care staff, in the afternoon one qualified member of staff (RGN) with two care staff and night staff consist of one qualified nurse (RGN) and one member of the care staff. When asked some residents did say that staff often seemed ‘rushed off their feet’. Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 20 The in-house trainer for the Victoria Group has recently retired and her replacement, appointed from within the Victoria Group takes over in January 2007. All training is provided by the Victoria Group for staff, however some are organised that staff contribute towards the cost, one example being Heart guard sessions, the Inspector found that few staff attended these sessions to support their existing knowledge despite being encouraged to do so. This was discussed with the trained staff and the Registered Provider however, two care staff at the home told the Inspector that they enjoy the training provided, confirmed they had learned many new skills and said they felt lucky to work for the organisation. The Inspector also learnt that the Registered Manager and Deputy Manager work regularly with new staff to assist them in learning their role and to give them a good grounding that would eventually benefit the home. The Inspector noted on both days of inspection that care and nursing staff did not wear identification badges and was told that the Victoria Group of homes did not supply badges for staff. This was discussed with care staff on duty who assured the Inspector that they always introduced themselves to new residents and made sure they always told partially sighted residents their names when assisting them. The Inspector spent time at the Head Office of the Victoria Group looking at recruitment files for staff 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, which includes three days training a year. They also have the opportunity to undertake NVQ 2 once they have passed through their probationary period and shown a commitment for working for the Victoria Group of homes. Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 21 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): 31,32,33,34,35,36,37 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 and staff and residents enjoy good relationships. EVIDENCE: The Registered Manager is a qualified Registered General Nurse and has worked within the Victoria Group for seven and a half years. Although she has not obtained a management certificate in that time the Registered Providers have decided on a relevant management certificate that all managers within the Group will be offered the opportunity to take early in 2007. The Registered Manager is responsible for Victoria 63 Dyke Road Avenue and undertakes Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 22 periodic training that is provided by the Victoria group. There are clear lines of accountability throughout the Victoria Group and the individual homes such as no 63 with the Registered Provider and Director of Nursing Services in regular contact with each home. There is a Deputy Manager also in post who is committed to her role within the home and hoping to take the management course in the future. Care staff told the Inspector that the Registered Manager holds staff meetings regularly that are recorded and care staff are supervised both working in the home and on a one to one basis. They also confirmed having yearly appraisals when they are specifically asked if there is any extra training they would like organised and gave examples of topics of interest to them. One member of the care staff told the Inspector she really enjoyed working at Victoria 63 Dyke Road Avenue and that she had received a lot of support during her time at the home. The Inspector spoke to both staff and relatives about communication between staff and themselves and if they had the opportunity to give their own views on life in the home. All said that although organised meetings do not take place that communication is good and relatives confirmed they are kept in touch with the progress of the residents. However no one had any knowledge of a quality monitoring questionnaire having been sent out and therefore a requirement will be made in this report that the issue is addressed. Following the inspection, the Inspector spoke with the Registered Provider who had in fact issued questionnaires to service users but they had not been acknowledged. The home does not manage the financial affairs of the residents but does have a receipting system in place for any small amounts of shopping that may be purchased, although this is rare. There is a petty cash arrangement for small items and the Head Office holds larger amounts of personal allowances should a resident request it. All residents have a lockable facility in their individual rooms. Records kept in the home are in hard copy only; the home does not have a computer system. Records are kept daily on each resident’s progress. The Inspector noticed that the filing cabinets did not lock however the Deputy Matron did say that the maintenance team had been asked to rectify the matter, therefore a requirement will not be made in this report. Care staff are trained in moving and handling, fire safety, first aid, food hygiene and infection control; staff spoken to by the Inspector confirmed this. Maintenance records are kept and PAT (portable appliance testing) takes place and is due again on 10/2/07. The fire alarm panel in the home has been modernised and is self-testing however the Deputy Manager told the Inspector it is still tested weekly by the maintenance team. A local organisation takes care of the wheelchairs and bath hoists on an annual basis. The passenger lift Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 23 is regularly serviced; this was last undertaken during November 2006. The home has records of all servicing and tests to installations within the home. Although the maintenance team check the maintenance book daily for any repairs or faults that need undertaking the management must ensure that records and logs of servicing are entered and dated correctly. Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 24 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 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 DS0000014070.V320579.R01.S.doc Version 5.2 Page 25 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) Requirement Timescale for action 2. OP12 16(3) 3. OP33 24(1)2 The home to ensure that the administration of medication follows current good practice and 15/01/07 guidance as in agreement with the Nursing and Midwifery Council and the Department of Health ‘Building a Safer NHS. The home to make enquiries 01/02/07 about the provision of a church service for residents who wish to attend but are unable to leave the home. The home to ensure that a 01/03/07 suitable quality assurance system is in place for residents to seek their views on life in the home. Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 26 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 DS0000014070.V320579.R01.S.doc Version 5.2 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Victoria DS0000014070.V320579.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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