Inspection on 05/05/05 for Victoria

This inspection was carried out on 5th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Victoria 19/12/06

Victoria 05/01/06

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 Khot Unannounced 5 May 2005 at 12.30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Victoria Address 63 Dyke Road Avenue Hove East Sussex BN3 6DA 01273 564471 01273 881516 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Victoria Nursing Home Ltd Mrs Patricia Jane Evett Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (OP) 23 of places Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27 January 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 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 H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place at midday and over the lunch-time to enable the Inspector to speak with residents and staff during a quieter time of day. The Deputy Matron helped with the inspection which was an enjoyable one. The home had a relaxed and friendly atmosphere and residents were happy to spend time speaking about their lives in the home. During the visit the Inspector noted that relatives were made welcome and that staff communicated well with the residents and each other. What the service does well: What has improved since the last inspection? What they could do better: Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 6 Attention must be paid to all care plans and risk assessments being undertaken on a monthly basis, if there has been no change to a residents condition this must be recorded. Entries to the accident book must show the correct name of the person who experienced the accident. Residents’ should be asked if they would like a lock to their bedroom doors and the outcome of the conversation or risk assessment be included in the relevant care plans and risk assessment. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 6.Preadmission assessments were appropriate to identify if the home could meet residents needs and were carried out by people trained to do so. Assessments were looked at by the Inspector and they contained relevant information concerning the care of the residents. The home has suitable equipment to provide intermediate care if necessary. EVIDENCE: The Inspector spoke with three residents who had been in the home from between five years and six months. They could not recall a pre-admission assessment taking place however following a discussion with the Deputy Manager it was clear that assessments had taken place. Care plans showed that an assessment of care needs that included a comprehensive history of care needs had taken place. Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10. Each resident in the home has their personal and nursing care needs addressed by the staff. All residents appeared to be well cared for and comfortable and those spoken with stated that they received a good quality of care that they were happy with. The method of administering medication could be made easier for the trained staff if a medication trolley is purchased. EVIDENCE: Each resident has a plan of care however those looked at showed that reviews of the care plans and risk assessments had not taken place on a monthly basis. Care plans include information about their personal details, care needs and leisure requirements. All nursing, medical and other health care treatment takes place in the residents own rooms. All medication is administered by staff and the storage and recording of medication undertaken efficiently by the trained staff. The delivery of medication to residents in done with care. The Deputy Matron felt that a Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 10 medication trolley that could be locked and left would be beneficial to the need to lock the clinical room each time staff need to answer a call bell. The majority of residents think they are treated respectfully and well by the staff. They feel the Matron is very approachable and contacts the doctor quickly if they are unwell. All residents spoken with felt that staff are friendly and spend time chatting with them. Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15. The home works hard to allow residents choices in their activities of daily life and to support them in making decsions. The standard of the meals provided is good and residents are given encouragement to eat. Meals are nicely presented and residents are given a choice of menu. EVIDENCE: The home does have an activities co-ordinator who visits one or two times a week. Residents spoken with said that they enjoyed her visits and she often spent time alone with them chatting. Residents are given notice of other activities in the home e.g. concerts, parties and shopping visits into town. Some residents stated that they did not wish to be involved in activities whereas others said they enjoyed them immensely. The hairdresser was busy on the day of inspection making sure all the residents who required their hair being done were attended to. The home has a visitors book in place and an improvement has been made of visitors signing in and out of the home since the last inspection. Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 12 Residents said that they had either relatives or a solicitor to handle their financial affairs. Some residents had taken their own possessions into the home by prior arrangement. All residents with the exception of one said that the variety, quality and quantity of food was good. The food for the home is cooked at one of the other homes in the Victoria Group that houses the main kitchen. All staff handling food have a food and hygiene certificate. The cook reported that all certificates are updated regularly. The home accommodates residents with either health or denture problems by ensuring that their food is appropriate for their condition. The kitchen was very clean and tidy cook and food stored in appropriate containers and cupboards. The Cook said that in the next few weeks a new floor is being installed in the homes kitchen. The home celebrates residents’ birthdays and makes visitors welcome at all times, inviting them to share mealtimes if they wish to. Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 and 18 Residents are protected by the homes attitude to complaints and staff are aware of their responsibilities in ensuring that residents are protected from abuse. EVIDENCE: A complaints policy is available in the home and in the service user guide that contains information about how complaints are investigated. There have been no complaints made to either the home or via the Commission for Social Care Inspection since the last inspection. Residents spoken with were aware of the complaints procedure and all said they would speak directly with the Matron of the home. There is a book in place for the recording of complaints. The Deputy Matron said that all staff are now trained in the Protection of Vulnerable Adults. Residents are able to vote via the postal voting service and those who are able can be taken to their local polling station. Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 24, 25, and 26 The home has been well maintained and decorated to meet residents needs.Care is provided in a homely environment. Locks to residents private accommodation has been overlooked. EVIDENCE: The Deputy Manager had records of fire drills in the home and a fire inspection report was undertaken in June 2004. The building and grounds are maintained by maintenance teams and gardeners employed specifically for the Victoria Group of homes. The home has a no smoking policy in place. All areas in the home were clean including the clinic room and the laundry. Residents spoken with all said that they found the home very clean and that their private rooms were cleaned daily. The home has policies and procedures and training in place for the control of infection. Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 15 Rooms had lockable facilities for residents’ personal possessions but doors to residents private accommodation did not have locks, there was no reference to this in the care plans or risk assessments. Windows on the ground floor in residents’ rooms were not restricted but the relevant pipe-work and radiators have been guarded. Rooms are decorated as necessary prior to new residents being admitted to the home. Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30. The home has sufficient staff on duty to meet the needs of the residents and takes into account that more staff are required at certain times. Staff are encouraged to undertake further training to ensure residents care needs are met. EVIDENCE: Staff rotas show there are sufficientstaff on duty to meet the needs of the residents. Extra staff are called in to work shifts should residents’ needs increase or a resident need to be accompanied to an appointment outside the home. The Matron works a supernummery shift each month to enable her to complete her administration. The Victoria Group of homes has its own in-house trainer who provides ongoing training for all staff including induction training. Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35 and 38. The home is well managed and the outcomes for the residents is good. Health and safety issues are generally addressed but there are a few areas where they have been overlooked. EVIDENCE: The home does have a quality monitoring system in place and the Deputy matron said that quality questionnaires were sent to residents in April 2005. Feedback is actively sought from residents and their relatives and a ‘comments’ book is available in the main reception area. The home does not get involved in managing residents finances but will hold a maximum of £50 in-case a resident wishes to purchase something. The Deputy Matron had a receipt book in place for this purpose. Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 18 Training takes place within the Victoria Group for fire safety, medication, infection control, moving and handling; policies are available that cover all aspects of safe working practices and security. All visitors to the home must sign the visitors’ book as part of the fire safety procedures. The home undertakes safe water analysis checks on a regular basis and water temperatures throughout the home are tested by the maintenance team however these were not up to date at the time of inspection. Whilst looking at the residents care plans and risk assessments it was clear that not all the risk assessments had been updated and this needs to be done. The home has a special HSE accident book in place but some of the residents’ names have been entered incorrectly and the home must address this error. Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x 2 3 x STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x 3 x 3 x x 2 Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 20 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 7 24 Regulation 15 23 12(4)a 13(4)a-c 12(1) 13(3)(4) 17 13(4)abc Schedule 4(12)c Schedule 3(3)j 12(1) 13(3)(4) 17 Requirement All care plans and risk assessments are to be undertaken monthly. All residents to be risk assessed for locks to their private accommodation and a record kept. All records of tests to water temperatures throughout the home to be kept up-to-date. All ground floor windows to be restricted to ensure resident safety when they are open. All records in the accident book to be accurate. All records of gas and electricall installations to be available and up-to-date Timescale for action 1 June 2005 1 July 2005 3. 4. 5. 25/38 25/38 38 1 June 2005 15 June 2005 Immediate 6. 38 Immediate 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. Victoria Refer to Standard 9 Good Practice Recommendations The home to consider the purchase of a medication trolley H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 21 to avoid the potting-up method currently used and ensure that staff can safely leave medication should they need to answer a call bell. Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 22 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Victoria H59-H10 s14070 Victoria v218990 040505 stage 4.doc Version 1.20 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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