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Inspection on 09/02/06 for Victoria Cottage Residential Home

Also see our care home review for Victoria Cottage Residential Home for more information

This inspection was carried out on 9th February 2006.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Evidence gained through speaking with residents, observing documentation and practices, suggests that residents receive a good standard of care in a pleasant environment. The residents feel the home is domestic and comfortable and they commented that it feels a `home from home`. They also feel that staff are very pleasant, polite and professional.

What has improved since the last inspection?

The standards of care remain high. There were no requirements set at the previous inspection. A number of standards were not assessed. Some parts of the building have been refurbished.

What the care home could do better:

The office does not facilitate efficient storage for records and does not provide an area for the manager to work efficiently or effectively in. It is acknowledged that plans are in place to convert outbuildings to provide a dedicated administration area. There was no evidence of the control of water outlet temperatures.

CARE HOMES FOR OLDER PEOPLE Victoria Cottage Residential home 13 Station Road Lowdham Nottingham NG14 7DU Lead Inspector Andrew Sales Unannounced Inspection 9th February 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 Cottage Residential home DS0000063057.V283246.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 Cottage Residential home DS0000063057.V283246.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Victoria Cottage Residential home Address 13 Station Road Lowdham Nottingham NG14 7DU 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) 01246 558828 Sun Care Homes Ltd Position Vacant Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Victoria Cottage Residential home DS0000063057.V283246.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Victoria Cottage is a care home providing personal care and accommodation for 18 older people. The home is owned by Mr Pancholi.The home is located in the village of Lowdham, close to shops, pubs and other local amenities.The home was opened in 1984 and consists of a converted 2 storey house with a newer purpose built extension.All the home’s bedrooms are single and 9 of the bedrooms have en-suite facilities. There is a passenger lift. The home has small gardens which are well maintained and easily accessible. Victoria Cottage Residential home DS0000063057.V283246.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted by A.J.Sales on 9 February 2006. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting two residents and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. The inspector also spent time talking to other residents in the home and two members of staff. Overall the feedback was very good. Residents were happy to express their views about the home, they were positive in terms of the skills and attitude of the staff and of the overall standards of care, food, social recreation and the environment. What the service does well: What has improved since the last inspection? The standards of care remain high. There were no requirements set at the previous inspection. A number of standards were not assessed. Some parts of the building have been refurbished. Victoria Cottage Residential home DS0000063057.V283246.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 Cottage Residential home DS0000063057.V283246.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 Cottage Residential home DS0000063057.V283246.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): 3,4.6. Thorough assessments of need have been carried out prior to admission and the residents were fully involved in the process. Residents’ quality of life has been enhanced through the services provided by the home. Intermediate care is not a service provided by the home. EVIDENCE: Two residents were case tracked and a number of others spoken with. All of the assessments were comprehensive and contained sufficient information to enable staff to ensure that they could meet the residents assessed needs. Victoria Cottage Residential home DS0000063057.V283246.R01.S.doc Version 5.1 Page 9 One resident in particular spoke of her admission to the home, which has greatly improved her quality of life in terms of stimulation, environment and services available. Many others echoed these feelings. In a discussion with the member of staff it was clear they had a thorough understanding of the emotional impact admission to residential care may have on individual residents and were able to describe how they support residents to come to terms with such a transition. Observations were made of professional interaction with residents, which supported resident’s comments that they feel well respected, supported and in safe hands. Staff spoke of a number of training subjects and courses they have attended, which evidence that the staff team is well equipped with a range of skills and experience to meet the needs of residents. Victoria Cottage Residential home DS0000063057.V283246.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): 7,8,9,10. Residents receive a comprehensive assessment. Assessments are updated following a review. The home is able to meet the healthcare needs of it’s residents. Medication issues are manager appropriately. Residents are treated appropriately. EVIDENCE: Both of the residents whose records were checked as part of this inspection had comprehensive service user plans. The records show that the plans are being reviewed at least once each month and that residents, and where appropriate their representatives, are being involved in the review process. The service user plans also contained risk assessments, which are also reviewed each month. Service user plans contain details of each residents individual health care needs, including a tissue viability and continence risk assessments. There is evidence that people have been appropriately referred to health care professionals. Care plans viewed contained records of visits by district nurses, General Practitioners and other professionals. Healthcare professionals were Victoria Cottage Residential home DS0000063057.V283246.R01.S.doc Version 5.1 Page 11 observed visiting on the day. The inspector was informed that a number of doctors surgeries are used to ensure that the residents can register with a GP of their choice. Staff training records that were viewed, evidenced that medication training was provided for staff responsible for the administration of medication. At the time of the inspection no residents self medicate. The home has a standard policy and procedure for receipt, recording, storage handling administration and disposal of medication. The home’s medication records were observed as part of this inspection. Staff were observed during the visit interacting positively with individuals, a relative spoken with, reported staff provide a good standard of care and areas of concern would be discussed with the registered manager. Four residents spoke with the Inspector and commented very positively on the conduct and attitude of the staff. Induction and training records viewed, included instruction on entering residents rooms, care practices and confidentiality. Victoria Cottage Residential home DS0000063057.V283246.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): 12,13,14,15. Residents are supported to pursue, religious and social interests. Residents are helped to exercise choice and control over their lives. Residents receive good quality food and a balanced diet in a relaxing atmosphere with support from staff where required. EVIDENCE: Residents spoken with, said they were happy with the level of activities within the home and outside. Residents commented that the philosophy of the home and the attitude of the staff enabled them to make choices and felt they were generally well respected. The staff reported that they encourage residents to participate in events and outings. Although there is no formal activities program, the manager arranges for local artists to visit the home, who provide mainly musical entertainment. Victoria Cottage Residential home DS0000063057.V283246.R01.S.doc Version 5.1 Page 13 Residents spoken with, all stated their satisfaction at the quality of meals provided. A number stated that they could have food at any time of the day if they wished. A large proportion of those asked, said they thought the food was ‘excellent’. Cooked breakfasts are available as required. Drinks are available throughout the day. Meal times are reasonably flexible and choices are offered at breakfast, lunch and tea. The main meal is served midday and this was observed as being of a high standard. The cook who spoke with the inspector is clearly experienced and committed to providing quality meals. Victoria Cottage Residential home DS0000063057.V283246.R01.S.doc Version 5.1 Page 14 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): 16,18. The home has satisfactory procedures in place to deal with adult protection and complaints. Measures are in place to protect residents. EVIDENCE: The home has a comprehensive complaints procedure that meets the National Minimum Standards, which is appropriately displayed throughout the home. Residents and relatives spoken with, stated they would raise concerns with the registered manager and the proprietors if they needed to. Complaints records were not observed on this occasion. The home has an appropriate Whistle Blowing Policy and a policy detailing Adult Protection Procedures. The homes policies and procedures for responding to suspicion or evidence of abuse, or neglect, are all satisfactory. The home has comprehensive policies regarding residents money and financial affairs. The two staff members spoken with, had attended training in adult protection and demonstrated a positive awareness of exposing abuse and bad practice. Training certificates were observed on staff files. Victoria Cottage Residential home DS0000063057.V283246.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26. The home was clean and tidy at the time of this inspection. The home is well maintained. EVIDENCE: The general standard of cleanliness throughout the home is good. Infection control policies and practices are present. The cleaning is conducted by care staff, when rostered for these duties. Residents felt their rooms and the rest of home are kept clean and tidy. They are particularly pleased how the home maintains a particularly non-institutional atmosphere. Victoria Cottage Residential home DS0000063057.V283246.R01.S.doc Version 5.1 Page 16 The home has been maintained to a good standard in most parts. The manager stated that as far as she is aware there are no requirements outstanding from the Fire Officers or the Environmental Health Officers last inspection of the home. Rooms were individually and naturally ventilated with windows conforming to recognised standards. Central heating could be controlled in each room. Emergency lighting was fitted throughout with records of appropriate testing taking place. Room lighting was domestic with bedside lights available. Systems and appliances are tested at appropriate intervals. No evidence has been provided as to how water temperatures at outlets are managed or controlled. The manager will therefore need to conduct risk assessments for all residents in order to minimise the risk of scalding and consult with the Environmental Health Department. The home is generally clean and procedures are in place to promote hygiene. Victoria Cottage Residential home DS0000063057.V283246.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. There were adequate staff on duty at the time of this inspection. The domestic and catering hours are appropriate to the number of residents. Staff are recruited and employed in suitable numbers. Staff are trained in mandatory subjects required by this standard and for care specific support. Residents feel support is timely and there are sufficient staff to provide unhurried assistance. EVIDENCE: On the day of inspection there were two care staff and the cook on duty. From the staff rota provided, the staffing levels meet requirements, with the current resident occupancy levels being 15. Residents spoken with stated that they felt support was timely and there were sufficient staff to provide unhurried assistance. There are suitable recruitment policies and procedures that have been observed at previous inspections. Two staff files were sampled at random. These contained evidence of applications, interviews, pre employment checks, criminal declarations, confidentiality agreements, supervision and training plans. One file contained a CRB with disclosures. Victoria Cottage Residential home DS0000063057.V283246.R01.S.doc Version 5.1 Page 18 Staff spoken with informed the inspector of various training courses they had attended, which included, adult protection and the safe handling of medicines. Of the staff files examined, they all contained evidence of training in a number of health and safety subjects, dementia awareness, NVQ level 2, along with staff supervision and appraisal plans. Victoria Cottage Residential home DS0000063057.V283246.R01.S.doc Version 5.1 Page 19 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): 31,33,35, 36,38. The home is very well managed with residents interests put first. Health and safety management is well documented. Staff are well supported and supervised. EVIDENCE: Residents said they felt the home was extremely well run and the manager and proprietor were always on hand for support and advise. Staff spoken with confirmed that they felt supported by the manager and that they are approachable to discuss any issues. They confirmed that there is an open management approach and a culture within the home, which promotes development of new initiatives and individual staff development. The Staff confirmed they receive monthly supervision and attend regular team meetings. Victoria Cottage Residential home DS0000063057.V283246.R01.S.doc Version 5.1 Page 20 The manager stated that the staff have received training updates in the last year on moving and handling, first aid, basic food hygiene, administration of medication and health and safety issues including hygiene control. The senior care staff confirmed this. Equipment is serviced and maintained on an annual basis by agreed contracts. There is a written health and safety policy to guide staff. In addition to individual risk assessments for residents, there are risk assessments recorded on the use of equipment inside and outside the home. Records of fire system tests, legionella control and other health and safety records were observed and were found to be carried out at the required intervals. Victoria Cottage Residential home DS0000063057.V283246.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 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 Standard No Score 16 3 17 X 18 3 3 X X X X X 2 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 X 3 x 3 3 x 3 Victoria Cottage Residential home DS0000063057.V283246.R01.S.doc Version 5.1 Page 22 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 25 Regulation 13. (3) (4) (a-c) Requirement Ensure water temperatures are controlled appropriately and risk assessments are conducted for each resident. Timescale for action 30/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Victoria Cottage Residential home DS0000063057.V283246.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Cottage Residential home DS0000063057.V283246.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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