Inspection on 05/01/06 for Victoria

This inspection was carried out on 5th 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 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 19/12/06

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 Unannounced Inspection 5th January 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Victoria DS0000014070.V272332.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 DS0000014070.V272332.R01.S.doc Version 5.1 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.V272332.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th May 2005 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 an extended detached property with well-maintained 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.V272332.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the afternoon over a period of four hours. It was facilitated by Mrs Patricia Evett, to whom feedback was given at the end of the inspection. During the inspection the Inspector was able to speak with residents and some relatives, there were only two care staff on duty who were busy with residents especially during the supper period. The home had a relaxed atmosphere and residents were happy to spend time speaking about their lives in the home. The Inspector noted that staff communicated well with both residents and visitors to the home. What the service does well: What has improved since the last inspection? Requirements from the last inspection were discussed and the Registered Manager who did not facilitate the last inspection told the Inspector she was aware of them and said they had been addressed. Where there was some doubt it was agreed this would be looked into as soon as possible. Victoria DS0000014070.V272332.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 DS0000014070.V272332.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 DS0000014070.V272332.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, 4 and 5 The home has a statement of purpose and service user guide in place that demonstrates all aspects of the service that residents and their relatives need to know. The home takes care in its assessment of new residents to ensure that it is suitable for them; visits to the home before admission are invited. EVIDENCE: The home has a statement of purpose and service user guide; both are available in the main entrance hall along with the home’s philosophy of care and a comments book. 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, however the Registered Manager reported that often a friend or relative undertake the first visit. The Commission for Social Care Inspection registration certificate is on view in the entrance hall with the Quest for Quality certificate that expires in March 2006. Victoria DS0000014070.V272332.R01.S.doc Version 5.1 Page 9 Victoria DS0000014070.V272332.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): 7,8 and 11 all other standards were fully assessed in May 2005 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. The Registered Manager and staff are pro-active 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: Care plans were looked at by the Inspector and showed that they are regularly reviewed. Content was informative and comprehensive paying attention to both medical and social needs of each resident. Residents spoke highly of the care given and the support and help given them by staff in the home. Staff receive training on pressure relief and tissue viability, assessments and treatment are undertaken by RGN’s for pressure area care with support from the specialist nurse in the community if necessary. The home has pressurerelieving equipment in place. The continence advisor for the community provides additional support for any resident who suffers from continence problems. The home has access to all specialist services, which include the dietician, optician, dentist, chiropodist and the local hospice team. The home Victoria DS0000014070.V272332.R01.S.doc Version 5.1 Page 11 has a privacy and dignity policy in place that includes care of the dying. The Registered Manager and Inspector discussed 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. Medication was discussed though not assessed. Residents told the Inspector that they received their medication on time and that staff are ‘very thorough’. All residents when asked said that the home is very quick in asking for the assistance of a GP and one said ‘The Doctor is called quicker than I would at home!’. Victoria DS0000014070.V272332.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): All standards were assessed and fully met at the inspection earlier in the year. EVIDENCE: The Inspector did not assess these standards but spoke to residents about the food, whether or not their visitors were welcomed into the home and if they saw the Activities Co-ordinator. All comments made were positive by both residents and their visitors. On the day of inspection the Activities Coordinator was working in the home. Victoria DS0000014070.V272332.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 and 18 Residents in the home are protected by the home’s attitude towards complaints and the staff have an awareness of protecting staff from potential abuse. EVIDENCE: Systems are in place for the reporting of complaints and residents spoken with by the Inspector clearly stated they would not be afraid to make a complaint and would go to the Registered Manager. The complaints register showed that no complaint or concern had been recorded for over two years. The Inspector and Registered Manager discussed the importance of recording any concern or complaint no matter how small for future reference e.g. items of laundry that sometimes go missing. The Training Officer for the Victoria group trains all staff in the protection of vulnerable adults. The Registered Manager had a good awareness of the process. The home needs to ensure that the latest information is sought from Brighton and Hove Council concerning the Adult Protection grading that is to be put in place in the future. All staff records looked at by the Inspector showed that Criminal Records Bureau checks had taken place. Victoria DS0000014070.V272332.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): 21,22 and 23 The home provides each resident with a pleasant and comfortable room, each one with the minimum of an ensuite toilet and hand-wash basin. Specialist equipment is provided to help each resident maximise his/her independence. EVIDENCE: Each bedroom in the home has an ensuite toilet and hand wash-basin, 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. 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. All residents’ rooms visited by the Inspector were comfortable, clean Victoria DS0000014070.V272332.R01.S.doc Version 5.1 Page 15 and tidy, giving each resident privacy to receive visitors. Each resident spoken with by the Inspector said that his/her room was cleaned on a daily basis. Victoria DS0000014070.V272332.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): 27,28 and 29 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 Inspector felt it would have been beneficial for more care staff to have been on duty during the afternoon, especially during the resident’s supper time. EVIDENCE: On the day of inspection there were two care staff on duty and the Registered Manager. The Inspector noted that staff seemed to be extremely busy, especially during the time that the Registered Manager was giving out the residents’ medication and during the suppertime however, the Inspector was aware that the Registered Manager was unable to help staff as she usually would due to helping facilitate the inspection. Residents spoken with by the Inspector all said that their call-alarm bells were answered quickly and that the home appeared to be adequately staffed, however through discussion during feedback the Inspector concluded that when the home is full, staff are under a certain amount of pressure to fulfil their roles within the time frame available therefore a requirement will be made in this report that the situation is reassessed. The Registered Manager is allocated two supernummery shifts each month to complete paperwork. The Inspector looked at staff files and found the recruitment procedure to be thorough, all files held relevant information including Criminal Records Bureau checks, terms and conditions of employment and records of induction. The Victoria DS0000014070.V272332.R01.S.doc Version 5.1 Page 17 Victoria group has an in-house trainer who takes responsibility for ensuring that staff are appropriately trained. Victoria DS0000014070.V272332.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): 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 and staff and residents enjoy good relationships. There are no deep- based concerns about the health and safety aspects of the home however attention needs to be paid to the delegation of supervision for all staff within the home. EVIDENCE: The Registered Manager has worked within the Victoria Group for six and a half years and has not obtained a management certificate in that time however the Registered Providers are aware of the deadline and are looking into specific management training for all Registered Managers within the Victoria Group. The Registered Manager told the Inspector that staff meetings take place on a Victoria DS0000014070.V272332.R01.S.doc Version 5.1 Page 19 three monthly basis with records kept. Records were seen to be in place, however they were in some incidences undated and unsigned. A requirement will be made in this report that this be addressed. Meetings take place monthly for the Registered Managers who then communicate information to staff as appropriate. 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 Registered Manager confirmed that new requisitions are supplied when requested. The home does not manage residents finances, this was supported by each resident spoken with during the inspection, all said they had a relative or advocate to act for them, however small amounts of money up to a maximum of £50 are kept for residents and a system used for receipts. The Registered Manager also holds a small amount of petty cash should it be required when the main office is closed. Staff supervision, although started in the home no longer takes place. The Registered Manager told the Inspector that there is a shortage of time for her to undertake this although she does speak with staff each day and does work with them within the home. The Registered Manager does not receive supervision but did comment that she felt supported by the Registered Providers and her senior colleagues. Discussion followed about formats for supervision and the need to delegate the task should the Registered Manager not have the time to spare. This also led to the importance of each member of staff receiving a full and regular training needs analysis and yearly appraisal, a process partly shared with the Training Officer. A requirement will be made in this report that the matter is addressed. Records are kept in lockable filing cabinets in the Registered Manager’s office with staff records kept in the main Head office of the Victoria Group. Records will in future be kept on a database once the system has been reviewed by the Registered Providers. The Inspector noted that staff are trained in all aspects of health and safety and safety posters are available in the kitchen and staff areas. The home has adequate signage throughout that is checked by the Fire officer when he visits the home. Fire drills are undertaken three monthly and are due during January 2006. A PAT (portable appliance test) is also due in January 2006). The Matron told the Inspector that she thought a safe water analysis test had taken place in November 2005. The maintenance person for the home who was spoken with by the Inspector reported that all other tests to services take place on a regular basis with records kept. The home now has a new addressable fire alarm system in place that pinpoints rooms rather than zones should a fire break out, it also has a warning system and is self-checking. The home is risk assessed by the Registered Provider. Victoria DS0000014070.V272332.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 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 x x 3 3 3 x x x STAFFING Standard No Score 27 2 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x 3 x 1 2 3 Victoria DS0000014070.V272332.R01.S.doc Version 5.1 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 OP36 Regulation 18(2) Requirement All staff to receive regular supervision, appraisals, and where necessary training needs analysis. Where possible supervision to be delegated within the senior staff team. All records to be kept up to date and signed and dated as appropriate. Timescale for action 28/02/06 2 OP37 17(3)a 01/01/06 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 2 3 Refer to Standard OP16 OP18 OP27 Good Practice Recommendations All concerns or complaints to be recorded no matter how minor. The in-house trainer and senior staff to ensure that the latest guidelines issued by Brighton and Hove Council on the protection of vulnerable adults are obtained. Staffing levels to be reviewed during the busiest times of the day ensuring there are enough care staff on duty to comfortable fulfil their roles. Victoria DS0000014070.V272332.R01.S.doc Version 5.1 Page 22 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 DS0000014070.V272332.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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