Inspection on 08/03/06 for Victoria Court

This inspection was carried out on 8th March 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Victoria Court 10/12/07

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 8:40 8 March 2006 th 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.V283483.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 Court DS0000015479.V283483.R01.S.doc Version 5.1 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.V283483.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th September 2005 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 (one is specifically for smokers), the dining room is large and has an easy chair area and the home has two separate conservatories. Victoria Court DS0000015479.V283483.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection that lasted for 7 hours and 35 minutes. The inspection process included a tour of the building, an examination of a random sample of staff and residents’ files and policies and procedures. Twenty-one of the thirty-eight standards were inspected. Discussions were held with the manager, the deputy manager, four care staff, one domestic staff, one visiting relative, one visiting professional and twelve residents. What the service does well: What has improved since the last inspection? What they could do better: Information could be more detailed in the homes documents; this includes the care plans, the statement of purpose, the service user guide and the homes policies and procedures. Recruitment practices could be reviewed to make sure that they meet with other legislation as well as ensuring that all information is obtained for each staff member. More frequent checks on residents’ cash balances would ensure that all monies are correct. Supervision needs to be put on a more formal basis and done 6 times a year, with written records kept of the outcomes. Victoria Court DS0000015479.V283483.R01.S.doc Version 5.1 Page 6 The owner needs to visit and inspect the home monthly, talking to the staff and the residents and checking on the standard of care that is provided. They need to write a report on the conduct of the home and give copies to the registered manager and the CSCI. 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 Court DS0000015479.V283483.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 Court DS0000015479.V283483.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 The written information that is supplied to prospective residents and their relatives does not include all the relevant details. The home ensures that prospective residents have a thorough assessment before admission and have ample opportunity to visit the home. EVIDENCE: The homes Statement of Purpose and Service User Guide are in the process of being updated and they need to include more information on the proprietor, the manager and staff; the complaints procedure needs to be incorporated into both documents. All prospective residents are assessed by the manager or the deputy manager prior to admission and the information gathered at this assessment recorded on the residents’ personal record. Prospective residents and their relatives have the opportunity to visit the home prior to admission to ensure that it is suitable and meets their needs. Victoria Court DS0000015479.V283483.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 11 The care plans have improved however still require further development. Residents’ health needs are fully met by the home and their wishes on death are sought and recorded. EVIDENCE: The care plans examined had good instructions, however some did not always detail the level of assistance required; the guidelines for care need to be more specific on the extent of any assistance that is required. Each care file included all the relevant documents and the care notes were thorough and detailed. All care files included a record of healthcare visits and risk assessments for pressure areas, falls and nutritional screening. A dependency profile is also completed and regularly reviewed. Residents’ wishes on death and terminal illness are recorded in their personal record on most of the files examined; the manager said that where this was not recorded she was awaiting instructions from the residents’ family. Victoria Court DS0000015479.V283483.R01.S.doc Version 5.1 Page 10 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, 14, 15 The home offers a good range of activities to suit individual’s needs and preferences. Residents are assisted to exercise choice and control over their lives. Residents receive a wholesome balanced diet in pleasant surroundings. EVIDENCE: A range of activities is offered by the home, residents spoken with commented on the different activities that they enjoyed; one resident said that she enjoyed following the plots on the soaps on television. The home has a flexible approach to routines; this enables residents to choose when they want activities to be carried out. Residents’ bedrooms included many personal possessions that had been brought from their homes; residents spoken with said that they were able to choose what to bring with them. The home offers a choice of four different options at lunchtimes; the meals served on the day of the inspection were well presented and appetizing and served in sufficient quantities. Residents spoken with said that the food at the home is excellent and that they are always offered different choices at each meal. The atmosphere in the dining area was pleasant and relaxed. Victoria Court DS0000015479.V283483.R01.S.doc Version 5.1 Page 11 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 Complaints are taken seriously and acted upon, although the procedure does need further development. Staff are well trained in abuse awareness and the home protects residents from abuse. EVIDENCE: There is a complaints procedure that is being updated to include clear timescales and the new details of the CSCI. The home has a record of complaints in its complaints book but does not show a date of action taken and by whom. The complaints procedure must have clear timescales and the complaints records must show the date and the name of the person taking any action. There is a policy and procedure for the protection of vulnerable adults and it works in conjunction with the Southend Borough Council procedure, a copy is available in the office. Staff spoken with had a good awareness of this procedure and said that the manager provides in house training on the protection of vulnerable adults prior to them having the training through Southend Borough Council. Victoria Court DS0000015479.V283483.R01.S.doc Version 5.1 Page 12 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, 22, 26 Residents live in a safe, well-maintained environment and have the specialist equipment to maximise their independence. The home is clean, pleasant and hygienic. EVIDENCE: The home is well decorated and has good quality furniture and fittings. The kitchen units are quite old and in need of repair, the manager said they will be replaced in summer 2006. Repairs are carried out as and when required, any defects are recorded in the maintenance book and the manager checks that they have been carried out and signs to confirm this. The home has three multi-used hoists that are regularly serviced; each resident that has been assessed to use the hoist has their own individual sling. The deputy manager is a moving and handling trainer and is continually assessing the use of any equipment. Most walking aids are brought in with the resident, however should it become necessary for a resident to need alternative or new specialist equipment the manager said she would refer them to the physiotherapist. Victoria Court DS0000015479.V283483.R01.S.doc Version 5.1 Page 13 The home employs two cleaners and one domestic supervisor and on the day of the inspection the home was clean, tidy, fresh and free from any odours. Victoria Court DS0000015479.V283483.R01.S.doc Version 5.1 Page 14 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): 28, 29 Residents are in safe hands at all times and they are protected by the homes recruitment policy and practices. EVIDENCE: The home provides a high level of NVQ training and has three NVQ assessors available. Eight care staff has attained NVQ, eight care staff are within one unit of achieving NVQ and six care staff are enrolled to begin their NVQ in April 2006. The home has an identified training budget. Of the staff files examined the two most recently employed included the relevant documents required under Schedule 2 with the exception of evidence of the physical and mental fitness of each employee. There were discussions with the manager and deputy manager on ways of rectifying this. All documents required under Schedule 2 must be in place. A new interview pack has been developed and will include a declaration of fitness by the employee. The new pack includes evidence of induction and the outcome of the interview process. Staff employed by the home is on a sixweek probationary period and receive their contract of employment at the end of this. Victoria Court DS0000015479.V283483.R01.S.doc Version 5.1 Page 15 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, 34, 33, 35, 36 The home is well managed by a very experienced manager. Residents are safeguarded by the homes accounting procedures. The registered provider visits the home regularly but does not comply with Regulation 26. Residents financial interests are safeguarded however, more frequent checks on cash balances need to be carried out. Staff have informal supervision on a regular basis, a more formal structure must be implemented. EVIDENCE: The manager has been in post for more than nine years and has sixteen years experience in the care of older people; she hold the City & Guilds 325-3 Advanced Management for Care qualification and is a qualified NVQ assessor. Both the manager and the deputy manager will be enrolling on the Registered Managers Award NVQ level 4 in September 2006. The manager regularly updates her skills and knowledge by undertaking relevant training courses. Victoria Court DS0000015479.V283483.R01.S.doc Version 5.1 Page 16 The home has sufficient insurance cover. The proprietor pays all the bills and fees associated with the home and the records of these transactions are kept at his home address. The home has achieved the Investors in People award and is due for a review in summer 2006. There is an annual business plan prepared but this could not be located at the inspection; the manager will send a copy to the CSCI when located. The owner visits the home frequently and examines the building; he talks to staff and residents, however he does not record the outcome of these visits. The owner must document the outcome of visits on a monthly basis and send copies of his report to the registered manager and the CSCI. Five residents’ cash and transaction records were inspected and four were found correct. One resident’s cash did not agree with what was in the transaction record, however on further checking the missing amount was found in another resident’s cash wallet. All monies held by the home must be regularly checked against their transaction records to ensure they agree. Staff say that the manager has an open door policy and they are able to deal with any issues daily and do spend time on a one to one basis with the manager. Formal recorded supervision sessions have not yet been arranged; the manager said that she plans to undertake these formal sessions from April 2006 and she will be recording the outcomes of these meetings. All staff must receive formal supervision at least six times a year. Victoria Court DS0000015479.V283483.R01.S.doc Version 5.1 Page 17 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 2 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 X 28 4 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 2 2 X X Victoria Court DS0000015479.V283483.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 5 Requirement The home must complete the development of its Statement of Purpose and Service Users Guide. This refers to the requirement to include the complaints procedure and information on the proprietor and staff. 2. OP29 19 (b) (i) Sch 2 This is a repeat requirement All information and documents required to ensure robust recruitment procedures are in place. This refers to the evidence of workers physical and mental fitness. 3. OP33 26(1)(3) (4)(5) The registered provider shall make an unannounced visit to the home once a month to inspect the premises and interview staff and residents and send a written report to the registered manager and the CSCI. DS0000015479.V283483.R01.S.doc Timescale for action 01/05/06 01/05/06 01/05/06 Victoria Court Version 5.1 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP7 OP16 OP36 OP35 Good Practice Recommendations The home should continue to develop its care planning process to ensure greater clarity. The complaints procedure should include clear timescales and the new details of the CSCI. That care staff receive formal supervision at least 6 times a year. All monies held by the home are regularly checked against their transaction records to ensure they agree. Victoria Court DS0000015479.V283483.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Court DS0000015479.V283483.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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