Inspection on 10/12/07 for Victoria Court

This inspection was carried out on 10th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 Court 08/03/06

Victoria Court 05/09/05

Victoria Court 31/01/05

Victoria Court 23/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Victoria Court 127 York Road Southend On Sea Essex SS1 2DX Lead Inspector Pauline Marshall Unannounced Inspection 10th December 2007 08:40 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 Court DS0000015479.V348905.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 Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Court Address 127 York Road Southend On Sea Essex SS1 2DX 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) 01702 465574 01702 464041 Mr Keith Powell Mrs Fenella Dela Court Powell Mrs Jennifer Jane Varrier Care Home 28 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (28) of places Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Victoria Court is a private care home located in a residential area of Southend on Sea with easy access to shops, seafront and public transport. The home is detached with limited parking to the front of the building. It has an attractive courtyard garden. The registered providers, Mr and Mrs K. Powell have made many improvements to the building. There are twenty-six single bedrooms and one double bedroom. Twenty-two bedrooms have en suite facilities. The bedrooms and office are located on two floors of the building, and two lifts enable access to each floor. There are two lounges on the ground floor, the dining room is large and has an easy chair area and the home has two separate conservatories. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplies them with up to date information on the home. Fees range from £352.73 to £620.00 per week and there are additional charges for hairdressing, chiropodist, newspapers, magazines, toiletries, clothing and reflexology. Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that lasted for seven hours; the process included a tour of the building, inspection of a random sample of staff and residents’ files, the homes policies, procedures and safety records. Discussions took place with the manager, the deputy manager staff on duty, visiting relatives and a visiting professional. The manager completed an annual quality assurance assessment (AQAA) document and this has been used throughout this report in addition to any information that was received at the CSCI offices since the last inspection. The Commission sent surveys to ten residents, ten relatives, six health and social care professionals and ten care staff to obtain their views on the service that the home provides. Comments from these are reflected throughout this report. What the service does well: The manager provides people with good up to date information on the service provided at Victoria Court and offers them a through assessment of their needs before they are admitted. Peoples’ health, personal and social care needs are all set out in the homes care plan paperwork enabling staff to provide the correct level of support. A variety of activities are offered daily and they take into account what individual people need and want. The food is of an excellent quality and people are offered a range of different meals each day and the dining area is spacious and comfortable. There is a good complaints procedure and staff are trained in safeguarding adults. The home is clean and well looked after and repairs are carried out quickly after being reported. Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 6 The manager employs a good amount of staff with different skills and qualifications, they are well trained and the recruitment process protects the residents. An experienced well-trained manager runs the home in the best interests of its residents. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 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 Court DS0000015479.V348905.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect good up to date information on the services that the home provides and a thorough assessment process provides people with assurance that their needs will be met. EVIDENCE: The homes Statement of Purpose and Service User Guide were last reviewed by the manager in July 2007 and contain up to date information on the service the home provides. Four residents care files were examined and all contained a thorough preadmission assessment that detailed the level of assistance people required prior to admission; these assessments were all reviewed within a month of admission to ensure that any changing needs were met. The manager said in Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 9 her annual quality assurance assessment (AQAA) that all assessments are carried out by two senior members of staff; one in the prospective residents own home and another in Victoria Court. Relatives’ surveys made comments that, “residents are regularly re-assessed” and residents spoken with confirmed that the pre-assessment process was thorough. Each of the four care files examined contained a copy of the individuals terms and conditions with the home, all were appropriately signed and dated by either the resident or their next of kin. Victoria Court does not provide intermediate care. Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People can expect their personal, health and social care needs to be fully met in a respectful and dignified manner. EVIDENCE: Four care files were examined and contained details of all areas of personal care and how it is managed. The care plans looked at getting up and going to bed including preferred times, bathing/washing, toileting, dressing, feeding, behaviour, physical well being and moving and handling. There was a personal profile, a dependency profile and risk assessments and management plans for falls, fractures, nutrition, pressure area care, moving and handling and activities. All of the care files had been reviewed within the last six months and the manager said that reviews are held more often if required. A relatives survey states, “ the home bothered to find out what kind of person and life my relative led before dementia set in”. The manager identified in her Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 11 annual quality assurance assessment that the care plan documentation has been improved upon and that the care plan system is robust. The care plan system includes detailed entries for all health care activities including regular and non-routine appointments and outcomes are recorded and followed up if necessary. The manager said that if a resident needs to go to hospital for any reason and there are no family available to accompany them, one of the homes staff will escort them and stay with them for the duration of the hospital visit. Professional surveys received commented that “the home has always met the health care needs of its residents” and “I have been impressed by the care and concern given to residents and any advice I may give is always acted upon and I feel my professional expertise is valued and respected”. The manager reviewed the medication policy in August 2007. Four medication administration sheets (MARS) where checked and were all appropriately completed; however on checking the amount of medication against the level in stock there was a discrepancy. The manager undertook a full investigation into how this had occurred and rectified the records and returned what was over stock to the pharmacy. The medication is appropriately stored in a locked cabinet within a locked medical room. All staff has received medication training and relatives said when surveyed that staff “understand my relatives condition and have an understanding of various illnesses through the courses they do”. Staff interacted with residents in a respectful manner, always explaining their requests clearly and listening to what the resident was saying to them. Residents spoken with confirmed that staff treated them with dignity and respect and that nothing was too much trouble for them. A relatives survey states “the family feel that my relative is not just a patient but a person who is treated with respect by the care home staff and staff are dedicated and caring”. Another relatives survey commented that the home has “good contact with a personal and professional approach and I feel that no improvements are needed”. Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The range of activities offered both in and out of the home and the good quality meals supplied provide residents with excellent outcomes. EVIDENCE: Victoria Court offers its residents a good range of activities that have included garden parties, clothing parties, BBQ’s, quiz nights, pub visits and outings to local parks. In August 07 a coach was hired and twenty residents visited Tiptree where they had a strawberry and cream tea. An activities co-ordinator is employed and she keeps a diary of all planned activities. The manager said in her annual quality assurance assessment that there is a multi dominational religious service every 4 weeks and at residents request a remembrance service is carried out by the vicar for residents that have passed away. A relatives survey states that activities are thoughtful and creative and are tailored to meet the individual and “Victoria Court are very good at providing the residents with a fun and enjoyable life”. The team now offers more Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 13 opportunities for outdoor actives such as trips to local hairdressers, coach outings and visits to a cricket ground. Residents meetings do take place but are not always fully recorded; residents and relatives spoken with confirmed that they are consulted on all areas of the running of the home. The activities co-ordinator organises additional smaller residents meetings where activities mainly are discussed and keeps a note of these discussions in the activities folder. Victoria Court offers residents a daily choice of four different meals and two different sweets at lunchtime; there is always an option of fresh fruit, yoghurt or cheese and biscuits in addition to the sweets on offer. The home purchases their meat and egg supplies from a local butcher and their fruit and vegetable supplies from a local greengrocer. Residents spoke very highly of the food and said that the range on offer was excellent and that they could always have an alternative if they did not fancy any of the four choices on offer. One relative’s survey commented on how well her relative eats and how good the quality of food is. The kitchen has recently been replaced and there were ample food stocks in the cupboards and freezers. Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that their complaints are listened to and acted upon and that they are protected from abuse. EVIDENCE: The complaints policy was reviewed by the manager in August 07 and provides residents and their relatives with clear information on how to raise any concerns that may arise. The manager said in her annual quality assurance assessment that all complaints are dealt with immediately and the records showed that there had been seven complaints in the last twelve months that had all been dealt with appropriately. The complaints records book is kept by the visitors’ book to enable ease of use. The manager reviewed the homes prevention and reporting of abuse policies in August 2007 and all staff has received in house abuse training. The manager has been trained by Action for Elder Abuse to deliver abuse training to the staff. Many staff, including the manager, has attended the Local Authority Protection of Vulnerable Adults training in addition to their in house training. The manager also provides regular annual updates for staff. Relatives’ surveys state that their relatives are “made to feel cared for and Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 15 safe and that “Victoria Court staff from manageress to care staff look after their relative with patience and understanding”. Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 16 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, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a clean, comfortable well-maintained and safe environment that provides them with good outcomes. EVIDENCE: The manager said that there are two handymen employed by the home and any repairs that need doing are recorded in the homes maintenance book. One of the handymen is in the home most days and was carrying out minor repairs on the day of the inspection. The additional handyman works one day each week and mainly carries out repairs outdoors. There were new chairs in both lounges and a good deal of decorating has been carried out throughout the home since the last inspection. There have been new doors and windows fitted to both lounges and door closers have been fitted to all doors. Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 17 The home has a new fitted kitchen and appliances and was clean, comfortable and odour free. Relatives and professionals spoken with and surveyed as part of this inspection commented on how spotlessly clean and comfortable the home always is and that there were never any odorous smells. Staff spoken with and surveyed said that Victoria Court is a most pleasant environment to work in and they confirmed that any repairs to the building are carried out swiftly once reported. Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 18 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, 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People can expect to be protected by the homes recruitment policies and practice and the well-trained staff provides residents with excellent outcomes. EVIDENCE: Victoria Court is currently fully staffed and the homes rota corresponded with those on duty and provided appropriate staffing levels to meet the needs of the residents. In addition to management and care staff the home employs two cooks, two kitchen assistants and three domestics. Staff spoken with was very clear about their roles and responsibilities and said they were confident of the manager dealing with any issues. Most of the care staff have undertaken NVQ at a minimum of level 2; senior carers have completed NVQ level 3 and the manager and deputy manager intend to undertake NVQ level 4 in care during 2008. The manager last reviewed the home recruitment policy in August 2007 and states in her annual quality assurance assessment that the whole recruitment process will be reviewed in 2008. Three staff files were examined and all contained the relevant documentation and evidence of a thorough induction Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 19 having taken place. Staff spoken with said how they felt that the homes induction process was excellent and that they were not allowed to work alone until the manager felt that they were competent. The three staff files examined contained evidence of a good range of staff training that includes moving and handling, first aid, food hygiene, dementia, diabetes, control of substances hazardous to health (COSHH) and abuse. The home has also purchased training materials that include DVD’s on activities and reminiscence, caring for confusion and customer care; the manager ensures that all staff have the opportunity to participate in this training. Staff spoken with said the home offered good training and that they attended external training in addition to the in house training. Staff surveyed said, “care assistants are very well trained”. The home has been awarded the Investors in People award for the third time. Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 20 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, 33, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be assured that they live in a well run home that is managed in their best interests and provides them with the best possible outcomes. EVIDENCE: The manager has been in her post for the past ten and a half years and works in partnership with the owner. The manager has achieved the City and Guilds Advanced Management for Care and the National Examination Board certificate in Supervision and Management and expects to begin her NVQ Level 4 in Care in January 2008. The manager regularly updates her practice and has undertaken updates in moving and handling, first aid, dementia and fire in addition to further training in the new smoking laws and immigration. An open Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 21 door management system is in place and the manager works alongside staff on a daily basis and staff meetings are held at least six times a year in addition to any informal meetings that are held daily. The deputy manager will be commencing her NVQ level 4 in Care in January 2008. Victoria Court has its own quality assurance system in place that consults residents, their relatives and other interested parties on the quality of services it provides. Questionnaires are sent annually and a report and action plan is devised based on the findings of the consultation. The manager completed the homes annual quality assurance assessment (AQAA) by the due date and provided all of the required information. One of the CSCI surveys received from a health care professional states “the home provides an exceptional service and the manager is outstanding and a relatives survey states “I feel the management and staff of Victoria Court have always seemed to us to put the welfare, comfort and needs of all the residents at the top of their priorities and everybody seems to be one big happy family”. The manager reviewed the homes policy for the management of residents’ monies in August 2007. Four residents cash transaction records were checked and all entries were appropriately documented and the amounts of cash held in each of the four residents’ wallets corresponded to the written transaction records. There was evidence on each of the staff files examined that supervision takes place and the homes diary also contained evidence that supervision sessions had been booked. The manager said in her annual quality assurance assessment that supervision does not take place as often as it should. Staff spoken with said that they felt well supported by the management of the home and that they were able to share concerns with the manager on a daily basis, which they felt supplemented formal supervision sessions. All safety certificates were examined and were up to date. The home carried out a fire risk assessment and was last visited by the fire safety officer on 20th November 2007 who advised the manager in writing that the home has a satisfactory standard of fire safety. Fire drills are carried out in the form of role-plays and residents are not evacuated as part of these drills; the manager said that this had been discussed fully with the fire safety officer during his visit. There were no records of the fire drill role-plays having taken place, however staff spoken with confirmed that these take place regularly. Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 22 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP36 OP38 Good Practice Recommendations All care staff should receive formal supervision at least 6 times a year and the outcomes should be recorded. All fire drills including role-plays acted out by staff should be recorded. Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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. Extracts may not be used or reproduced without the express permission of CSCI Victoria Court DS0000015479.V348905.R01.S.doc Version 5.2 Page 25 - 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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