Inspection on 30/12/05 for Victoria

This inspection was carried out on 30th December 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Victoria 06/02/07

Victoria 12/08/05

Victoria 18/01/05

Victoria 27/07/04

Similar services:

Springfield House

The Shelley

Thorndene

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Victoria 81 Dyke Road Avenue Hove East Sussex BN3 6DA Lead Inspector Linda Khot Unannounced Inspection 30th December 2005 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 DS0000014074.V254567.R01.S.doc Version 5.0 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 DS0000014074.V254567.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Victoria Address 81 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) 01273-551355 Victoria Nursing Homes Limited Mrs Pauline Winbow Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24), Physical disability (24), Terminally ill (24) of places Victoria DS0000014074.V254567.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That there is adherence to the staffing levels set down That Mrs Winbow obtains a certificate in Management before 2005 Date of last inspection 12th August 2005 Brief Description of the Service: Victoria 81 Dyke Road Avenue is one of five homes in the Victoria Group. It is located in a residential area on the outskirts of the city of Brighton and Hove. The home is registered for twenty-four residents in the categories of elderly, physically disabled and terminally ill. It also houses the main administrative offices for the Victoria Group of Homes. The home is a large detached property set back from the road with a swing drive that can accommodate up to ten cars. Parking is also available in the adjoining roads and the no 27 bus stops directly outside the home.The home is well maintained throughout to a high standard. Gardens at the back of the home are easily accessed by wheelchair users and there is a portable ramp that can be used from the dining room. The home has a passenger lift that serves both floors. The rooms overlooking the garden on the top floor also have views of the sea. All homes in the Victoria Group have the Quest for Quality certificate and the Registered Providers are committed to working with the Commission for Social Care Inspection and the homes Matrons and staff to ensure consistency of care and administration processes throughout all the Victoria homes. Victoria DS0000014074.V254567.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place between Christmas and the New Year. On the day of inspection a member of the bank staff was in charge therefore the Director of Nursing Services facilitated the inspection. During the inspection the Inspector was able to speak with staff and residents and spend time in the office with the Administrative Assistant and the Registered Providers. On the day of inspection the home had 23 residents. Feedback was given to the member of staff left in charge and a written copy left for the Registered Manager. An inspection questionnaire was left for the Registered Manager to complete on her return. What the service does well: What has improved since the last inspection? Some of the requirements from the last inspection had been addressed and the bathrooms and shower rooms were tidier than during the last inspection. Victoria DS0000014074.V254567.R01.S.doc Version 5.0 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 DS0000014074.V254567.R01.S.doc Version 5.0 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 DS0000014074.V254567.R01.S.doc Version 5.0 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): These standards were all assessed during the last inspection in August 2005. EVIDENCE: Although these standards were not assessed during this inspection the Inspector discussed them with the Director of Nursing Services and felt there had been no change during that time however it was noted that the Commission for Social Care Inspection had not forwarded the new registration certificate and the Inspector apologised and agreed to look into the matter. Victoria DS0000014074.V254567.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9 and 10. The home delivers a good quality of care that is well documented. All residents’ appear to be cared for very well and the home involves other specialist services for advice where necessary. Procedures for the administration of medicines are undertaken in a manner that safeguards the residents however the Inspector did find that some medication charts did not have a photograph of the resident for identification. EVIDENCE: Each resident has a care plan that is reviewed on a daily basis if they are particularly unwell. Records and care planning are efficiently undertaken and those seen by the Inspector were up-to-date. All held records of Doctors visits and other appropriate information including Waterlow scores. Residents spoken with by the inspector reported feeling well cared for; all said they were treated with kindness and respect. The home does include privacy and respect in their staff induction and ongoing training. The Inspector found the clinical room to be well organised with records kept up-to-date and no evidence of stock-piling. All medication and dressing looked at were in date. The home disposes of all medication in the correct way by Victoria DS0000014074.V254567.R01.S.doc Version 5.0 Page 10 using a DUPE container, controlled drugs are disposed of in the correct solution. On looking at the prescription sheets it was noted that some did not have photographs of the resident concerned and a requirement will be made in this report that this is undertaken. The home ensures that staff signatures are recognisable by keeping sample copies for referral. Equipment is serviced and medicine fridge temperatures are on view and recorded. Victoria DS0000014074.V254567.R01.S.doc Version 5.0 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 the following standard(s): 15. All standards were fully assessed in August 2005. The standard of food is good and the presentation ensures that those residents with poor appetites are encouraged to eat. EVIDENCE: The residents said they liked the food and that it was enjoyable and well presented; all confirmed they had a choice of menus. The dining room provides a relaxed and homely atmosphere and was attractively set for the lunchtime meal however staff reported that the majority of the residents preferred to eat in their rooms. Residents confirmed this when the Inspector spoke with them and on the day of inspection all ate in their own room. The main kitchen is at Victoria 39 Dyke Road Avenue and food is delivered twice daily for lunch and supper. Menus are faxed to the home on the previous day for residents to make their choice. Records of meals eaten are kept for six weeks. The kitchen was very clean and well organised with staff wearing appropriate protective clothing. Food in the store cupboard was in-date. The home has a policy statement for kitchen cleanliness and fridge and freezer temperatures are taken daily with records kept. Victoria DS0000014074.V254567.R01.S.doc Version 5.0 Page 12 Victoria DS0000014074.V254567.R01.S.doc Version 5.0 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. Residents in the home are protected by the home’s attitude towards complaints and staff receive training in the protection of vulnerable adults however, the home needs to ensure that all part-time staff receive appropriate training to enable them to manage an adult protection alert should the situation occur. EVIDENCE: On looking through the complaints records there had been no complaint recorded since September 2002. The Inspector discussed with the Director of Nursing Services the importance of recording any complaint or concern no matter how minor ensuring that the complaint, action taken and outcome are outlined. The Director of Nursing Services agreed that this would be addressed. All residents are enabled to vote by using the postal voting service although friends or relatives take some to their local polling station. Although staff are trained in the protection of vulnerable adults and evidence was seen in the staff training record book, it was apparent that some part-time staff had not attended training sessions. The home must ensure that all staff including ancillary staff, part-time staff and bank staff attend training sessions. A flowchart is on view in the staff room however senior part-time staff admitted to not knowing it was there as they use the main office. It was agreed a copy would be on view in the office for quick reference. Staff records showed that all staff had been Criminal Records Bureau checked prior to commencing work in the home. Victoria DS0000014074.V254567.R01.S.doc Version 5.0 Page 14 Victoria DS0000014074.V254567.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, all standards were assessed fully in August 2005. The Home is well equipped with specialist equipment to maximise the independence of residents. EVIDENCE: The home has appropriate equipment to meet the needs of most prospective residents. Victoria Oaklands has an equipment store with a supervisor who distributes equipment to all the homes in the group as the need arises. The Inspector noted that grab rails, sitting and standing hoists, adequate moving and handling equipment and a lift were in place. Victoria DS0000014074.V254567.R01.S.doc Version 5.0 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): 27,28,29 and 30 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 the home appeared to be adequately staffed. EVIDENCE: The Victoria Group of Homes has its own Bank team of staff who are able to work in any of the homes as the need arises. Each day there are four care staff in the home with an RGN. The Registered Manager has two supernummary shifts each month to enable her to undertake administrative duties. Rotas are fixed and on view in the home for easy reference. The home has a thorough recruitment procedure in place. The Inspector was able to look at staff recruitment and training files 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 home has an in-house trainer who is pro-active in ensuring that staff do attend training sessions. Records are kept of all staff training undertaken and reminders sent to those who miss mandatory training e.g. fire safety and Victoria DS0000014074.V254567.R01.S.doc Version 5.0 Page 17 moving and handling. During the inspection the Inspector noted that some part-time staff appeared not to have received training updates in moving and handling although it was agreed that this could have been due to an error in record keeping. Victoria DS0000014074.V254567.R01.S.doc Version 5.0 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): 31,32,34,36,37 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. Residents and staff are protected by the home’s attitude to health and safety however concerns are raised in this report about the security of the front door and the security of residents personal files and care plans. EVIDENCE: Victoria DS0000014074.V254567.R01.S.doc Version 5.0 Page 19 The Registered Manager (Matron) of the home has considerable experience in running the home and is a qualified RGN (Registered General Nurse) however she does not have a management qualification. The Registered Providers and Matrons of the Victoria Group are aware of the need for a management qualification by the Registered Managers and are looking into suitable courses. As the Registered Manager was off duty at the time of inspection the Inspector did not see any recorded evidence of staff meetings however staff did confirm that both staff meetings and staff supervision do take place. Evidence was seen of management meetings and this was supported by the Director of nursing Services who confirmed that staff meetings are intended to follow management meetings to provide and transfer up to date information to staff. The Registered Providers ensure through regular meetings and contact that the home has anything necessary for the well-being and care of the residents. The Director of Nursing Services confirmed that new requisitions are supplied when requested. The home ensures that staff receive training in fire safety and recently a new addressable system has been installed that is self checking with a warning system. The home now has over 60 fire detectors and rooms rather than zones can be pin pointed in the event of a fire. Records showed that the home last undertook a safe water analysis in January 2005. The temperature of water in resident’s rooms was last checked on 20 December 2005. Electrical portable appliances are due to be checked in January 2005. All equipment is regularly checked and serviced however records showed that the nurse call system had not been checked since September 2005. The home has adequate safety signage on view. Victoria DS0000014074.V254567.R01.S.doc Version 5.0 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 X X X 3 X X X X 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 X 3 X 3 3 2 Victoria DS0000014074.V254567.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 Scedule3 (2) 13(2) 13(6) Requirement Timescale for action 10/01/06 2 OP18 3 4 OP38 OP38 13(4)abc 17(1)b The home to ensure that photographs are on-file for easy recognition when administering medication. All part-time and bank staff to be 01/02/06 trained in the protection of vulnerable adults with priority given to senior staff who may be left in charge. For the security and safety of the 01/01/06 residents, the front door to be secure at all times. For the confidentiality of 01/01/06 resident’s records and care plans the home to ensure that either the filing cabinets are kept locked at all times or the office door to be kept locked when senior staff are away and working in the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Victoria DS0000014074.V254567.R01.S.doc Version 5.0 Page 22 No. 1 2 3 Refer to Standard OP18 OP37 OP38 Good Practice Recommendations The Adult protection flowchart to be on view in the main office for quick reference should a senior member of staff require to use2 it. Staff training records to be kept up to date. The maintenance staff to ensure that all maintenance and servicing records are kept up to date. Victoria DS0000014074.V254567.R01.S.doc Version 5.0 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 DS0000014074.V254567.R01.S.doc Version 5.0 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!