Inspection on 11/12/06 for Victoria Highgrove

This inspection was carried out on 11th December 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 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 Highgrove 26/02/09

Victoria Highgrove 29/09/08

Victoria Highgrove 04/03/08

Victoria Highgrove 07/12/05

Victoria Highgrove 23/06/05

Victoria Highgrove 04/02/05

Victoria Highgrove 03/08/04

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 Highgrove 59 Dyke Road Avenue Hove East Sussex BN3 6QD Lead Inspector Linda Boereboom Key Unannounced Inspection 12th December 2006 15:00 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 Highgrove DS0000014071.V320554.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 Highgrove DS0000014071.V320554.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Highgrove Address 59 Dyke Road Avenue Hove East Sussex BN3 6QD 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) 01273-562739 01273-882818 Victoria Nursing Homes Limited Vacant Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23), Physical disability (23), Terminally ill (23) of places Victoria Highgrove DS0000014071.V320554.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-three (23) 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 7th December 2005 Brief Description of the Service: Victoria Highgrove is one of the Victoria group of homes and is situated in a residential area of Brighton and Hove in Dyke Road Avenue, not far from the A27, Brighton by-pass. The home is registered for twenty-three service users within the categories of the elderly, physically disabled and terminally ill. All rooms have ensuite facilities. The home stands away from the main road and is set in attractive gardens that are accessible to wheelchairs. There is parking available for approximately three cars in front of the home and five in the small car park just off Hill Brow, which runs to one side of the home. The No 27 bus stops outside twice hourly and operates from central Brighton near to the mainline station. The home comprises of four floors with a passenger lift servicing each floor. The kitchen, laundry, dining room/sitting room and staff room are on the lower ground floor. There are two bedrooms also on the lower ground floor with views to the garden. Victoria Highgrove along with the other four homes in the Victoria Group has the Quest for Quality Award. Victoria Highgrove DS0000014071.V320554.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 Victoria Highgrove will be referred to as ‘residents’. This unannounced inspection took place over one part day and one full day. On the first day the Inspector visited the Head Office of the Victoria Group and looked at staff files for all the homes in the Victoria Group as some staff work between each; the remaining day was spent at Victoria Highgrove where the Inspector interviewed three residents, chatted with others and interviewed two more care staff and the Acting Manager. Four qualified nurses who work day or night duties in each of the Victoria Homes were also interviewed. During the inspection the Inspector was also able to tour the premises, speak with the maintenance person and Director of Nursing Services and look at the homes administrative procedures including residents’ files. Ten resident and staff surveys were sent out at random by the Commission for Social Care Inspection and at the time of writing this report seven care staff and five residents had replied. The inspector also contacted three relatives by telephone and left a message for a fourth to ask their views on the home; comments have been reflected in this report. The cost of care in the home varies from £595 to £795 a week; items not covered by the fee include hairdressing, chiropody, incontinent products, toiletries and magazines. Mrs Linda Ayres who is the Acting Manager for Victoria Highgrove helped facilitate the inspection. The Inspector also spoke with Mr Paul Burns the Responsible Individual, Mrs J Rowe the Registered Provider and Mrs L Waltho the Director of Nursing Services. The Inspector would like to thank Mrs Ayres and the staff and residents for helping to make the inspection positive and enjoyable. What the service does well: Victoria Highgrove 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. Victoria Highgrove DS0000014071.V320554.R01.S.doc Version 5.2 Page 6 The management approach of the home is positive and supportive taking into account the wellbeing of residents and staff. One resident told the Inspector ‘I’m enjoying it here and am perfectly happy’, another said ‘my room is very homely with my own possessions and pictures on the wall’ whilst a third added ‘I trust Mrs Rowe (Registered Provider) completely’. Care staff told the Inspector that they thought the home was ‘first class’ and ‘residents have everything they need and we try to provide anything extra’. Two relatives spoken with on the telephone said they felt able to raise concerns with the Acting Manager if necessary and that they were always made welcome in the home. What has improved since the last inspection? What they could do better: One requirement from the last inspection report did not appear to have been maintained, although initially after the last inspection it had. This is in relation to a list of all maintenance to the equipment in the home being recorded. The requirement will appear again in this report. There is a requirement concerning the administration of medication, requesting the home ensure it is working within the latest Nursing and Midwifery Council and Department of Health Guidelines, and another following the request by a resident that she would like to attend a church service within the home if at all possible. All other issues that came up during the inspection were discussed and ways of solving them agreed thus avoiding extra requirements being made. These have been reflected throughout the report. There were concerns raised during telephone conversations with relatives that they had not been made aware that the home has an Acting Manager in place and her name was not known to them. In addition relatives had waited for ten minutes for someone to open the door to them and had eventually gone away. Food was also discussed and concerns raised that food delivered to a resident’s bedroom was often cold and afternoon tea was sometimes luke warm and stewed by the time it arrived. These issues were discussed on the telephone with the Acting Manager on 21 December prior to the draft report being sent to the home for her to address with the care and nursing staff. Victoria Highgrove DS0000014071.V320554.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 Highgrove DS0000014071.V320554.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 Highgrove DS0000014071.V320554.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. All residents are appropriately assessed before moving into the home and are given the opportunity to visit first to meet other residents and care staff. EVIDENCE: Whilst in the home the Inspector spoke with some of the residents and found that they could not remember having been given any information or receiving a contract. Later during conversation with the Director of Nursing Services it was revealed that she always takes information on a pre-admission assessment. The Inspector discussed the possibility of all residents having information about the home i.e. the statement of purpose, service user guide and complaints procedure readily available in each individual room as well as in the main entrance hall. This was undertaken and any information that had Victoria Highgrove DS0000014071.V320554.R01.S.doc Version 5.2 Page 10 gone astray was replaced. Two residents could not remember visiting the home prior to admission however, one said she moved initially to another home within the Victoria Group but felt the room was too small and was later offered a room at Victoria Highgrove with which she is very pleased. Residents were unsure about receiving a contract outlining the terms and conditions of residency but later conversation with the Acting Matron revealed they all had contracts, some having been signed and kept by relatives on resident’s behalf; some surveys received confirmed that resident’s had signed a contract. The pre-admission assessment undertaken by the Director of Nursing Services acts as the basis for the care needs assessment undertaken in the home once a resident has been admitted. Care staff receive training in the needs of the elderly and trained nursing staff provide any specialist care. The home is not registered for Intermediate Care however some residents are admitted to the home for respite and to gain confidence and strength between leaving hospital and going home either acting on their own initiative or suggestion from the hospital service. Victoria Highgrove DS0000014071.V320554.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. Risk assessments are undertaken and kept separately. Residents are monitored on a daily basis and any changes recorded by staff. 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 consults with the wound care specialist or pharmaceutical representative who are both qualified to advise on tissue viability. The home Victoria Highgrove DS0000014071.V320554.R01.S.doc Version 5.2 Page 12 also liaises with the continence nurse specialist and dietician for the community as appropriate and the Acting Manager confirmed that the home has access to all professionals within the Healthcare Trust e.g. physiotherapist, occupational therapist and the community psychiatric nurse. Residents confirmed having been weighed on a monthly basis. At the time of inspection residents did not self medicate and the Acting Manager confirmed that only trained staff are able to give medication. All residents spoken with said they received their medicines at the correct time. The Inspector looked at the procedures for the disposal of medication and found them to be appropriate with the Acting Manager keeping a list of medication returned and any controlled medication requiring de-naturing for safety. There is a controlled medication register and separate lockable facility for storage in place. The Inspector and Acting Manager discussed the administration and checking processes used by the home as there is only one trained Registered General Nurse on at any one time which might cause a problem with the checking of medication. It was later 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 Highgrove includes a potting up system for the administration of medication and following consultation with the CSCI pharmacist a requirement will be shown in this report requesting that this method follows current good practice and guidance in agreement with the Nursing and Midwifery Council and the Department of Health ‘Building a Safer NHS’. Fridge temperatures in the fridge used for storage of medication are checked weekly and the care of syringe drivers to ensure they are in good working order is organised by the Director of Nursing Services via the local Healthcare Trust. When a resident dies medication is kept for 7 days in case a coroner’s inquest is required. The home has privacy and dignity policy in place and the Inspector noted that staff were polite to residents and visitors, and knocked on doors before entering individual rooms. Residents spoken with by the Inspector told the Inspector that they felt they were treated respectfully, however one relative told the Inspector that she was concerned when the resident she visited complained that the night staff did not offer explanation to her prior to moving and handling her during the night. The Inspector discussed this with the Acting Manager and Director of Nursing Services for discussion with all staff. Residents said they were able to use the telephone in private and given their own post to open. All confirmed having their own clothes to wear and two said it sometimes takes staff a while to sort the clothes out to make sure they are returned to the rightful owner. Other comments included: ‘staff are very kind’ and ‘staff are respectful and all are very nice and cheerful’. One resident survey read - ‘the matron and staff are always most willing and friendly in carrying out any requests or requirements’. The Acting Manager told the Inspector that she always ensures that she reminds care staff about being respectful to residents who are nearing the end of life. The home works with a local hospice that provide some training on the Victoria Highgrove DS0000014071.V320554.R01.S.doc Version 5.2 Page 13 use of syringe drivers and palliative care, and also support the Victoria Highgrove staff when necessary. Victoria Highgrove DS0000014071.V320554.R01.S.doc Version 5.2 Page 14 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, inviting them to share meals in the home by arrangement. The Activities Co-ordinator 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: Residents in Victoria Highgrove are encouraged to maintain their social contacts and visitors are made welcome, however a relative did tell the Inspector on the telephone that staff take a long time to answer the door and on one occasion had given up waiting and gone home after a ten minute wait. Residents spoken with by the Inspector commented that their visitors are always made welcome and are able to share mealtimes by prior arrangements. All said their visitors are offered tea or coffee during their visit. The home has a visitor’s book in place to record visits to residents and the Inspector saw this was in use. One resident told the Inspector ‘my visitors are made very welcome, most certainly, and friends come in for lunch and the table always looks very nice’, another said that tea and coffee is always offered and biscuits for any children who visit. Victoria Highgrove DS0000014071.V320554.R01.S.doc Version 5.2 Page 15 The Victoria Group of homes has an Activities Co-ordinator who visits each home in turn, the Highgrove is visited weekly and at which time she provides quizzes and bingo or one to one chats. Not all residents however, take part through personal choice. Residents that are able are accompanied out each day after lunch for a short walk whilst others prefer to go out with family. During the day in the home the Inspector noted this happened. The home has a board on view with photographs of activities that have taken place. On the day of inspection a grand raffle was on show in the main entrance hall. For the Christmas period the home has musical entertainment organised and one resident told the Inspector she would like to be able to attend a church service within the home. A requirement will be made in this report that her wishes are considered. The Inspector saw that residents interests are recorded and when asked was told that the Activities Co-ordinator visits each resident in turn to advise them which activities are being provided. Residents make their own financial arrangements and the home does not have any involvement in resident’s finances, all are able to bring possessions into the home by prior arrangement. Trained staff told the Inspector on the first day of inspection ‘Compared to what we’ve seen these are real homes and people are treated individually’ Approximately eight residents eat regularly in the dining room whilst others choose to eat in their own rooms. The Acting Manager told the Inspector that some therapeutic diets are made on site, however all other meals are cooked at another of the Victoria homes nearby and sent to each individual kitchen prior to serving. Hot and cold drinks are available throughout the day with cake and biscuits available in the morning and afternoon. All residents are given a choice of food that is faxed through to the home each morning. Although the main meals are sent to the home, evening staff make afternoon teas and serve evening suppers. There were positive comments made by some of the residents about the food in the home that included ‘the food is par for the course, sometimes it is extra nice but always good’ and ‘I like the food, it’s lovely that it is cooked for me!’. One relative did raise concerns though about the temperature and presentation of the food, and said that cups of tea delivered to a resident’s room were often cold and stewed; the Inspector discussed this with the Acting Manager and Director of Nursing Services prior to the draft report being sent out. Victoria Highgrove DS0000014071.V320554.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 however senior staff require up-to-date information on managing protection of vulnerable adults should an incident occur. EVIDENCE: The home has a complaints procedure in place with a recording system that is common to each home within the group. The last complaint on the register at Victoria Highgrove was in January 2006. The Acting Manager, who is new in post had not been given specific instruction on handling complaints, this was discussed and it was agreed that she would consult the registered Provider and seek advice and read through the home’s complaints procedure, this being the case a requirement will not be included in this report. Residents did have information about the complaints procedure. In addition to the complaints procedure Victoria Highgrove has a comments book in the main entrance hall however, the last entry was in 2003. Residents spoken with by the Inspector all said they would feel confident in going to the Acting Manager or Registered Provider for the home with a concern or complaint. The home is registered for postal voting but residents are able to go to a local polling station if they wish to. Victoria Highgrove DS0000014071.V320554.R01.S.doc Version 5.2 Page 17 The Inspector spoke with senior staff who might be left in charge of a home within the Victoria Group, and also with care staff. Some of the senior staff revealed that they had not had up to date training and information on the protection of vulnerable adults and although they had a common sense approach did not fully understand the procedure whereas the care staff were all clear on their role and who to report to should an incident occur. The Inspector spoke with the Responsible Individual and the Registered Provider who agreed to address the matter as a matter of urgency when the new Trainer 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. All staff are Criminal records Bureau checked prior to commencing work within any home in the Victoria Group. Victoria Highgrove DS0000014071.V320554.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 ensure that attention is paid to any work, inside or out to maintain safety and comfort. 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. EVIDENCE: The Victoria Group of homes share a maintenance and gardening team who regularly visit to undertake any repairs or improvements, during the inspection the Inspector was able to speak with a maintenance person about the record keeping of tests and services to equipment. All residents have their own toilet and hand washbasin, some have a bathroom and toilet whilst others have a shower and toilet. On the first floor there is a bathroom with bath hoist and on the ground floor a separate shower room and toilet. The lower ground floor has two toilets adjacent to the dining/sitting room. Victoria Highgrove DS0000014071.V320554.R01.S.doc Version 5.2 Page 19 The home has appropriate equipment to meet the needs of the residents. Victoria Oaklands, another home in the group, has an equipment store with a supervisor who distributes aids and equipment to all the Victoria homes as the need arises. The Inspector noted that grab rails, sitting and standing hoists, adequate moving and handling equipment are all in place. The home also has a passenger lift. Since the last inspection some redecoration and the fitting of new carpets has been undertaken, one shower room has also been refurbished. The home does not have any CCTV cameras on site. Residents’ rooms seen by the Inspector were all centrally heated and radiators thermostatically controlled, one resident had been risk assessed to manage his own central heating whereas staff monitored all other radiators. Residents’ rooms had been personalised and appeared clean, tidy and comfortable, only one resident said she would have preferred brighter colours rather than the tones of cream currently used. A Resident told the Inspector that the rooms were cleaned each day and that the cleaner was very thorough. All residents had a call alarm system and those spoken with by the Inspector were able to reach their own call bells and said that staff came quickly should they ring for assistance. All said their rooms were warm enough and one resident mentioned a draught from her window, which the Responsible Individual looked at immediately and arranged for it to be mended. Towels and light laundry including personal laundry is undertaken in the home in a laundry room on the lower ground floor that is sited away from the kitchen area. Heavy laundry is sent to another home within the Victoria Group that has specialised industrial equipment. All substances hazardous to health, used for cleaning purposes are locked away. There are policies and procedures in place for the control of infection and staff are aware of the management of MRSA and Clostridium difficile although the Acting Manager told the Inspector that it was not currently the policy of the home to accept a resident with either condition. Victoria Highgrove DS0000014071.V320554.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 the day of inspection the home appeared to be well staffed. EVIDENCE: The staffing levels in Victoria Highgrove are kept consistent with extra staff brought in from the bank staff employed by the Victoria Group of homes as necessary i.e. if one resident requires extra care and attention or care staff are on annual leave or sick leave. Some staff work between the homes in the Group. Each morning there is one trained registered nurse on duty and four care assistants, followed by one trained registered nurse and three care staff on the afternoon/evening shift and one trained registered nurse on the night shift with two care staff. The server/cook is in the home from 10.30am until 1.30pm each day to serve the meals that are sent from another home within the Victoria Group. Each day there is a cleaner on duty with more on designated days. The in-house trainer for the Victoria Group has recently retired and her replacement, appointed from within the Victoria Group takes over in January 2007. All training is provided by the Victoria Group for staff, however some Victoria Highgrove DS0000014071.V320554.R01.S.doc Version 5.2 Page 21 are organised that staff contribute towards the cost, one example being Heartguard sessions, the Inspector found that few staff attended these sessions to support their existing knowledge despite being encouraged to do so. This was discussed with the trained staff and the Registered Provider. 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. The Inspector spent time at the Head Office of the Victoria Group looking at recruitment files for staff 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 shown a commitment for working for the Victoria Group of homes. Victoria Highgrove DS0000014071.V320554.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 records of maintenance and system checks have, in some cases, been overlooked. EVIDENCE: One requirement from the last inspection report pertaining to keeping maintenance records up to date has not been undertaken and will be repeated in this report. The Acting Manager has been working in the Victoria Highgrove for three months but only as Acting Manager for one month. She is a qualified Registered General Nurse and is aware of the need of completing a Victoria Highgrove DS0000014071.V320554.R01.S.doc Version 5.2 Page 23 management course if approved for registration at the end of her probationary period. She also has experience as a care manager in a sixty-four bedded nursing home in her previous employment. One resident survey returned to the Inspector said ‘The Matron (Acting Manager) is always accessible and is prepared to listen to complaints or suggestions’ and ‘One need only say that, as on a ship, the wellbeing of an establishment such as this depends on the Captain, there I think we are fortunate!’. There are clear lines of accountability within the home with the Registered Provider taking an active role and visiting the home regularly throughout the week. This was confirmed by both staff and residents who all said they found her to be understanding and supportive. The home also has a Director of Nursing Services who is responsible for the assessment of all prospective residents, providing them with sufficient information about the home and ensuring they have a contract of residency. Staff meetings take place regularly and although meetings are not formerly organised for residents a group spoken with by the Inspector at the last inspection said they did not feel such meetings to be necessary as staff always responded to their wants and needs, there did not appear to be any change to this at this inspection. The Inspector contacted the head office for the Victoria Group to confirm that quality questionnaires are sent to residents for their views on life in the Victoria Highgrove as they did not appear to have received any. During the inspection, the Inspector noted that the filing cabinets in the main office were not locked and discussed the importance of doing so with the Acting Manager. 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 Acting Manager. Care staff confirmed receiving supervision and a training needs analysis with individual records kept in the home, however trained staff working between the homes said they did not receive formal supervision or have a training needs analysis. This was discussed between the Inspector and Registered Provider on the first day of inspection and it was agreed that the issue would be resolved; therefore a requirement will not be made in this report. The Acting Manager and care staff also confirmed that she works with a different staff member each day to ensure good practice and working relationships. Staff are trained in moving and handling, fire safety, first aid, food hygiene and infection control. Regular checks for efficient working are undertaken on the fire alarm system, and all electrical and gas installations. All electrical equipment is regularly PAT tested (portable appliance tests) the last one having taken place on 6/2/06. The Inspector noted that some maintenance records were not up to date for some external company maintenance and servicing. The Inspector spoke with the Director of Nursing Services confirmed that a local company services wheelchairs, hoists, baths and other equipment. Victoria Highgrove DS0000014071.V320554.R01.S.doc Version 5.2 Page 24 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 N/A 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 2 3 3 3 3 3 Victoria Highgrove DS0000014071.V320554.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement Timescale for action 15/01/07 2. OP38 Schedule 4 and 17 3 OP12 16(3) 4 OP33 24(1)2 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. The home to ensure that all 15/01/07 records of maintenance and servicing are kept up-to-date for easy reference. Carried over from the last inspection report. The home to make enquiries 01/02/07 about the provision of a church service for residents who wish to attend but are unable to leave the home. The home to ensure that a 01/03/07 suitable quality assurance system is in place for residents to seek their views on life in the home. Victoria Highgrove DS0000014071.V320554.R01.S.doc Version 5.2 Page 26 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 Highgrove DS0000014071.V320554.R01.S.doc Version 5.2 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Victoria Highgrove DS0000014071.V320554.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!