Inspection on 06/02/07 for Victoria

This inspection was carried out on 6th February 2007.

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 30/12/05

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 Boereboom Key Unannounced Inspection 6th February 2007 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 DS0000014074.V324087.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 DS0000014074.V324087.R01.S.doc Version 5.2 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 01273 881627 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.V324087.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-four (24) 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 30th December 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. Victoria 81 is well maintained throughout to a high standard. Wheelchair users can easily access the gardens at the back of the home and there is a portable ramp that can be used from the dining room. The home has a passenger lift that serves both floors. Rooms overlooking the garden on the top floor 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. Victoria DS0000014074.V324087.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 81 Dyke Road Avenue will be referred to as ‘residents’. This inspection took place over a period of two days with the help of Mrs Pauline Winbow the Registered Manager, and staff; it was unannounced. On the first day the Inspector looked at the administrative processes in the home and at residents care records, toured the premises and discussed the National Minimum Standards with Mrs Winbow. Staff records had been looked at prior to the inspection when the Inspector spoke with four trained staff who work throughout all the Victoria homes on either day or night duty; In addition staff were spoken with on the second day of inspection when the Inspector was also able to see five residents, unfortunately there were no relatives visiting at the time with whom to speak and ask their views on the home. Three relatives were later contacted by telephone. The Inspector also met with the Registered Providers for the Victoria Group who were very helpful. The cost of care in the home varies from £595 to £730 a week; items not covered by the fee include hairdressing, chiropody, some incontinent products, toiletries and magazines. Ten resident surveys and care staff surveys were sent out randomly by the Commission for Social Care Inspection prior to the inspection and at the time of writing this report one resident survey had been returned. Comments made in the survey and to the Inspector during the Inspection have been reflected throughout this report. The Inspector discussed the outcome of the inspection and the requirements resulting from it with the Registered Manager. The Inspector would like to thank Mrs Winbow and the staff for being flexible and helpful throughout the inspection making it both positive and enjoyable. What the service does well: Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 6 Victoria 81 continues to provide a good standard of care for its residents allowing them structure to their days as they wish with staff enabling them to remain as independent as possible. Care and support are provided in a caring, homely and relaxed atmosphere that places the needs of residents first. Each resident is properly assessed prior to being offered a place in the home and having made the decision to move in they are protected from the risk of harm by suitable adult protection and health and safety procedures. The management approach of the home is positive and supportive taking into account the wellbeing of residents and staff. Relatives of residents said they were made very welcome in the home and were happy with the care provided. During the inspection residents told the Inspector they felt safe and secure in the home and one commented ‘I couldn’t pick one nurse that isn’t nice, they all have a good sense of humour and are more like friends than nurses’. What has improved since the last inspection? What they could do better: There are few requirements in this report and those made have not restricted the standards in being scored as meeting the standard. The home needs to make sure that the administration of medication follows current good practice and guidance as in agreement with the Nursing and Midwifery Council and the Department of Health ‘Building a Safer NHS. The ‘potting–up’ system of medication needs to be reviewed for safety and all care staff to be trained in medication, its administration and uses including the checking of medication for safety. Despite the requirement the Registered Manager does take full responsibility for the administration of medicines and takes care with the practice. The new Registered Provider has agreed to undertake monthly Regulation 26 reports for the home and to keep them in the home to be looked at during inspection however the Registered Provider’s are pro-active in visiting each home within the Victoria Group regularly throughout the working week. The fire safety policies and procedures must be reviewed to include the new fire safety legislation. Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 7 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 DS0000014074.V324087.R01.S.doc Version 5.2 Page 8 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.V324087.R01.S.doc Version 5.2 Page 9 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): 1,2,3,4,5 and 6. 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: Each resident had a service user guide in his/her individual room. Both the service user guide and statement of purpose had been reviewed in December 2006 showing that the management structure for the Victoria Group of homes had changed. 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. At the initial assessment details of how the home runs are Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 10 also explained. All residents are provided with a contract of residency that are signed by the resident or his/her representative and kept with the resident’s notes. Care needs assessments undertaken by the Director of Nursing Services for the Victoria Group act as a basis for the ongoing care planning. The qualified nursing staff provide any specialised care for residents should it be necessary however care staff are trained to manage catheters and to understand any specialised need that a resident may have. Care staff do not undertake any invasive nursing procedures. The Registered Manager told the Inspector that residents are encouraged to visit the home for either a meal or afternoon tea and to meet the residents and staff prior to making the decision to move in, if they are unable to do so their relatives or friend’s are invited to visit. The home does not have any specific intermediate care beds however residents do come from hospital to Victoria 81 for a short while prior to returning home, to gain strength and confidence. Discussion with the Registered Manager revealed that emergency admissions to the home are a rare occurrence however both she and the staff were aware of standard 5.3 relating to how emergency admissions are managed. Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 11 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 three times a day to ensure efficient exchange of information to all staff. Reviews of care plans take place on a monthly basis where a resident’s condition is stable, the Inspector noted these were last done on 9 January 2007. Residents with Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 12 whom the Inspector spoke confirmed they are involved in their care planning and that communication between the staff and their relatives relating to care was good. 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 and dietician for the community as appropriate and the Registered Manager confirmed that the home has access to all professionals within the Healthcare Trust e.g. physiotherapist, occupational therapist and the community psychiatric nurse. Included in the professionals who work closely with Victoria 81 is the Care Homes with Nursing Support team who visit residents on admission and are available during office hours and at weekends for ongoing support. The Inspector discussed with the Registered Manager the process for storing, checking and administering medication in the home, which remains the same as in the other homes in the Victoria Group. 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 81 Dyke Road Avenue includes a ‘potting up’ system for the administration of medicines and following consultation with the CSCI (Commission for Social Care Inspection) Pharmacist Inspector a requirement will be shown in this report requesting that medication is delivered to the residents using a method that follows current good practice and guidance that is in agreement with the Nursing and Midwifery Council and the Department of Health ‘Building a Safer NHS’. The Registered Manager confirmed that discussion had taken place at the last management meeting and the new inhouse trainer would be organising a training course to ensure that all staff understood medication, its administration and uses including the checking of medication for safety. The Registered Manager takes full responsibility for the medicines in Victoria 81 which includes checking the medication fridge temperatures weekly and the shelf life of the medicines stored. During the Inspection, the Inspector met a nurse from the Community Hospice Team Macmillan nurses who regularly visits the home to provide support to both residents and staff. The Inspector noted that great care was taken with both the emotional and care needs of residents nearing the end of life. The Registered Manager told the Inspector that residents are able to stay in the home and in their own rooms as long as their care needs can be fully met. Relatives are invited to stay with the resident sharing the home’s facilities. The Macmillan nurse supports the staff following the death of a resident and helps to assist them with coming to terms with the bereavement and closure of the care. Victoria DS0000014074.V324087.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, who are made welcome and encouraged to visit. The Activities Coordinator 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. EVIDENCE: The Victoria Group has an Activities Co-ordinator who has been employed for many years apart from one short break. The Inspector was able to speak with her during the inspection. She knows the residents well and organises activities in Victoria 81 on a one to one basis as this is what current residents prefer. Activities include playing scrabble, painting, and helping with reading and writing letters. Throughout the year a musician with a keyboard also visits the home to entertain the residents. The Registered Manager said he knows the residents and the music they each enjoy and recently appreciative relatives had donated funds for extra sessions. The Registered Manager confirmed that she talks to prospective residents and relatives about their interests prior to Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 14 admission and also spoke of the importance of allowing residents to decide on how they wish to spend their time in the home, some are taken out for walks by care staff and others by relatives; records are kept in each resident’s notes of preferred activities and those undertaken. She confirmed that she makes prospective residents and their relatives aware that the home does not provide outings. Relatives told the Inspector that the home’s staff are helpful in assisting them in organising small parties for residents birthdays and at Christmas. Residents agreed with this ; two made the following comments to the Inspector ‘They gave me a lovely birthday party with a cake procession and lit candles!’ and ‘I had a wonderful birthday party in the dining room with twenty five of my family and friends, the staff were most helpful!’. The residents said they liked the food and that it was enjoyable and well presented; residents and relatives confirmed with the Inspector they had a choice of menus. The dining room provides a relaxed and homely atmosphere and staff make sure it is attractively set for the lunchtime meal however the Registered Manager told the Inspector that the number of residents eating in the dining room varies although staff encourage them to do so. One relative confirmed that staff are very flexible if a resident prefers to eat in his/her own room. Another told the Inspector that each daily menu is discussed care staff and the residents to enable them to make a choice. On the second day of inspection the Inspector saw that all residents preferred to eat in their own rooms. 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. Comments about the food included ‘The starters are lovely and the sandwiches, especially the egg mayonnaise’ ‘It always arrives hot and usually I have been given too much’ and ‘I don’t think they could improve the food, I enjoy everything’. The kitchen was very clean and well organised with staff wearing appropriate protective clothing. The home has a policy statement for kitchen cleanliness and fridge and freezer temperatures are taken daily with records kept. The last Environmental Health Inspection took place on 10/10/06. The home has the Clean Food Award. During the inspection the Inspector spoke to care staff about residents from social, ethnic and cultural minorities and any special requirements they might have. Staff showed an appreciation of care and social needs and gave Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 15 examples of such cases. The Inspector was satisfied that staff would be empathetic and any special needs would be met in Victoria 81. Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 16 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. Residents are able to participate in the process of voting if they so wish and information on advocacy services is made available to them if necessary. EVIDENCE: The home has a complaints procedure in place with a recording system that is common to each home within the group. 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 and no incidences requiring investigation relating to the protection of vulnerable adults. There is a comments book in the main hall for residents or relatives to use if they wish. One resident told the Inspector when asked if she would feel comfortable in making a complaint - ‘If anything went wrong we’d put it right quickly’. The home is registered for postal voting but residents are able to go to a local polling station if they wish to and should a resident require an advocacy service in the absence of family or friends’ help is sought for them Prior to the inspection the Inspector spoke with senior staff working throughout the Victoria Homes about the protection of vulnerable adults and although they Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 17 showed knowledge of the process they did not all fully understand it. Following inspection of two other homes in the Victoria Group, The Inspector spoke with the Responsible Individual and the Registered Provider and they agreed to address the issue as a matter of urgency with the new Trainer who 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. The Inspector spoke with care staff on the second day of the inspection and put forward a scenario to them relating to the protection of vulnerable adults. They had received training in the subject and were aware of the correct reporting procedure showing a sound approach. The Registered Manager showed the Inspector minutes of a meeting held by Brighton and Hove City Council for the new levels of adult protection investigation in the area. Although there was not a representative from the Victoria Group in attendance the Registered Manager had received a new flow chart for the staff room and was acquainting herself with the procedure to discuss with staff. Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 18 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 make sure that attention is paid to any work, inside or out to maintain safety and comfort for the residents and staff. 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 and is well equipped with specialist equipment to maximise the independence of residents. EVIDENCE: The Victoria Group has a maintenance team who visit each home on a daily basis to ensure that repairs and maintenance work is addressed and kept up to date, this includes the grounds that residents are able to use in fine weather. The Inspector saw a programme of routine maintenance for Victoria 81 showing a list of refurbishments both inside and out that included the painting Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 19 of the summerhouse, redecoration of three rooms and replacement of some carpets and furniture. A new cooker had also been brought for the kitchen. The home has communal spaces that are pleasant for residents to use, however in this home residents prefer to stay in their own room and few use these areas. Residents spoken with by the Inspector all said this was through choice. Residents bedrooms are kept clean and tidy and regularly cleaned. One resident told the Inspector that the cleaner cleaned her room five days a week and was a very friendly and helpful person should anything extra require doing. Lighting through the home is domestic in character and the furnishings ‘homely’ with eighteen of the twenty-two rooms having en-suite facilities. During the visit the Inspector saw that all residents had a call alarm system and those spoken with had their call bells readily to hand. The home was assessed by an occupational therapist in the two years prior to the inspection. 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, hoists, adequate moving and handling equipment and a lift were in place. Health and safety is a priority within the home and the Registered Manager showed the Inspector records of servicing and checks to both gas and electrical installations including the lift, call alarm system, emergency lighting and portable appliance testing to the electrical appliances. The home does not have any CCTV cameras on site. Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 20 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 thus ensuring they are competent in the work they do and care they offer to residents. On both days of inspection the home appeared to be adequately staffed. EVIDENCE: On both days the Inspector visited the home there appeared to be enough staff on duty for the needs of the resident. Each day there is one trained nurse on duty with four care staff in the morning and two each afternoon. At night the home is covered by one trained member of staff, and one member of the care staff. The Victoria Group also have a number of bank holiday relief carers who can work extra shifts if necessary. The Registered Manager has one extra shift allocated to her for administrative work and told the Inspector that she is able to ask the Registered Provider for extra staff if a resident requires additional care or there is a planned admission. Care staff have a fixed rota but are able to be flexible as long as the Registered Manager is informed of any changes to the rota thus promoting good working relationships. The home also has domestic and housekeeping staff with two cleaners in the home on three days a week and one on the other days including Sunday Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 21 morning. Kitchen staff cover seven days a week during the lunch period, they serve the lunches sent from the central kitchen and prepare afternoon teas in advance for the care staff to serve. The in-house trainer for the Victoria Group has recently retired and her replacement, appointed from within the Victoria Group took over in January 2007. All training is provided by the Victoria Group for staff, however some sessions are organised that staff contribute towards the cost, one example being Heartguard sessions, the Inspector found that few nursing and care staff attended these sessions to support their existing knowledge despite being encouraged to do so; the Registered Provider discussed this with them and has now offered to contribute towards the cost. 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. Care staff spoken with at Victoria 81 said they would prefer to have ID badges as they felt it would help the residents and relatives to know who they were. In Victoria 81 two members of the care staff have the NVQ 2 qualification and two are undertaking it, one member of staff has achieved NVQ 3, all other staff are qualified nurses. The Inspector looked at recruitment files prior to the inspection 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 have shown a commitment to working for the Victoria Group of homes. Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 22 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 however the home needs to review its policies and procedures to accommodate the new fire safety legislation. EVIDENCE: All requirements from the last inspection relating to the security of the front door and the locking of the Registered Manager office have been addressed, Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 23 staff told the Inspector that both are now kept locked if there is no-one in the office area. The Registered Manager is an RGN (Registered General Nurse) who has worked with the Victoria Group since 1989 and has been manager of Victoria 81 since it started in 1990, she is aware of the need to have a certificate in management. The Registered Manager attends periodic training with other Victoria staff and attends all training that is provided by the Martletts Hospice for palliative care. She has a job description and is only responsible for the one home. The Inspector discussed staff meetings and found that Victoria 81 does not have formal meetings for staff but uses handover time between shifts. The Registered Manager assured the Inspector that information was repeated to include all members of staff. Matrons meetings take place monthly and are used as an exchange of information that is also shared with the care staff, and all other information is kept on-file for reference. The Inspector spoke to staff and asked if they felt they had enough information given to them on the residents and other issues in the home, they confirmed they did. All residents have a quality questionnaire attached to their service user guide, these were discussed with the Registered Manager who said that family are often involved in completing them. Since the inspection of other Victoria homes it has been agreed with the Registered Provider that a new system of getting residents and relatives views will be put in place. The Registered Manager showed the Inspector letters of appreciation from relatives that had been shared with the care staff. Comments included‘You could not have done more for her, she had the best of care’ and ‘Thank you for taking care of my lovely xxxx so well’. Although this inspection was unannounced both staff and residents were made aware of the presence of the Inspector and the Registered Manager was helpful in identifying relatives who the Inspector could contact and ask their views. Both the Registered Provider and Registered Manager have been pro-active in making sure that requirements and recommendations from previous reports have been addressed and any issues that may have arisen have been fully discussed with the Inspector. Victoria 81 has the Quest for Quality Award. During the inspection the Inspector spoke with the Registered Provider about Regulation 26 reports for the home that had not been undertaken for some time in all homes in the Victoria Group. It was agreed a requirement would appear in this report and Regulation 26 reports would be available in the office for future inspection purposes. Staff throughout the Victorias’ commented to the Inspector that communication with the Registered Providers is good and confirmed they do visit the homes almost daily. The main offices for the Victoria Group are situated in Victoria 81. Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 24 Staff in the home do not take responsibility for residents finances and any allowances are kept at the Head Office, however there is a petty cash system in place for up to £50 for emergencies that is managed by the Registered Manager. Any expenditure made by the home for a resident is invoiced to them at the end of the month. Both staff and residents confirmed that relatives undertake any extra shopping that may be required. The Inspector spoke with both the Registered Manager and care staff about supervision. All confirmed that the Registered Manager worked alongside staff in the home to support good practice however staff spoken with had not received regular supervision although they said communication was good and that all staff supported each other. Annual appraisals take place yearly with attention now being paid to bank staff who work between the homes on occasional shifts. The home has policies and procedures in place to maintain a safe environment that are the responsibility of the Director of Nursing Services who reviews them regularly. All staff are trained in moving and handling and fire safety although during discussion the Inspector noted that the fire safety policies and procedures required updating to accommodate the new fire legislation. The last fire drill took place on 12/1/07 and training had been organised. The Registered Manager takes responsibility for the first aid box in the home and care staff receive training in first aid, food hygiene and infection control. All electrical and gas appliances are regularly checked with records kept; in addition water temperatures are taken and safe water samples sent to a laboratory for testing. Accidents and injuries are recorded and staff are aware of the need to report all communicable diseases to the Environmental Health Department at Lewes. Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 25 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 3 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 DS0000014074.V324087.R01.S.doc Version 5.2 Page 26 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 Schedule3 (2)13(2) Requirement The home to ensure that the administration of medication follows current good practice and guidance as in agreement with the Nursing and Midwifery Council and the Department of Health ‘Building a Safer NHS. Timescale for action 31/03/07 2. OP33 26(4)(5) 3. OP38 23(4) The ‘potting–up’ system to be reviewed for safety and all care staff to be trained in medication, its administration and uses including the checking of medication for safety. The Registered Provider to 28/02/07 undertake monthly Regulation 26 reports for the home to be kept in the home for inspection purposes. The fire safety policies and 31/03/07 procedures to be reviewed to include the new fire safety legislation. Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP36 Good Practice Recommendations Care staff to receive regular one to one supervision to help them in their role. Victoria DS0000014074.V324087.R01.S.doc Version 5.2 Page 28 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. 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