Inspection on 23/06/05 for Victoria Highgrove

This inspection was carried out on 23rd June 2005.

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

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

Other inspections for this house

Victoria Highgrove 26/02/09

Victoria Highgrove 29/09/08

Victoria Highgrove 04/03/08

Victoria Highgrove 11/12/06

Victoria Highgrove 07/12/05

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 Khot Unannounced 23 June 2005 10:00 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 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 H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Victoria Highgrove Address 59 Dyke Road Avenue Hove East Sussex BN3 6QD 01273 562739 01273 882818 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Victoria Nursing Homes Limited Teresa Kaczyk Care Home with nursing 23 Category(ies) of Old age, not falling within any other category registration, with number (OP) 23 of places Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for twenty-three (23) service users of both sexes who are older people with a physical disability or terminal illness. Date of last inspection 4 February 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. On the day of inspection there were fifteen service users in the home. All rooms have ensuite facilities. The home stands back from the main road and is set in very 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 H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and the Deputy Matron Mrs Seb Maleki assisted the Inspector answering questions and providing records and other administration required as part of the inspection process. The Inspector toured the premises and was able to have lunch with eight residents and one visitor in the dining room, as well as speak with a number of the residents in their rooms. The Registered Providers, Mrs Rowe and Mr Miles also visited the home to see the Inspector and discuss any requirements necessary arising from the inspection. The home was very clean and tidy with a calm atmosphere. Residents all spoke highly of the Registered Manager/Matron and the staff and all said they felt well cared for and that staff found time to chat with them and always made their visitors welcome. Mrs Teresa Kaczyk has recently become the Registered Manager/Matron of Victoria Highgrove following her interview with the Commission for Social Care Inspection. She was in the post as Matron for a few months before becoming registered and has previous experience in the Victoria Group, as Deputy Matron for over two years. Feedback from the inspection was given to the Deputy Matron. The inspection was completed in four hours. What the service does well: What has improved since the last inspection? Training has improved since the last inspection and both training and maintenance records are more organised and easily accessible. The outside of the home has been re-decorated. Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 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 standard(s) 1,2,3,4,5 and 6 The home has a statement of purpose and service user guide in place that demonstrates all aspects of the service that residents and their relatives need to know. The home takes care in its assessment of new residents to ensure that it is suitable for them and visits to the home before admission are invited. EVIDENCE: The Director of Nursing Services (Mrs Lorna Waltho) undertakes all preadmission assessments for Victoria Highgrove as well as the other homes in the Victoria Group. The pre-admission assessment that forms the basis for future care plans was seen by the Inspector and found to be comprehensive and very informative. All care and social needs of the prospective resident were outlined. During the inspection the Director of Nursing Services did show some relatives around the home with a view to placing someone in the future. The home has access to all specialist services to enable them to meet the needs of their residents and provide a sound nursing service. There is general basic nursing equipment on site and residents frequently use the home for short spells to convalesce or have respite care. Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 9 The home is not specifically registered for intermediate care but does have links to the Intermediate Care Team in Brighton and Hove who do assess residents for continuing care when they go home. One such assessment took place whilst the Inspector was in the home. Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 and 11. The home delivers a good quality of care that is well documented. All residents’ appear to be cared for very well and the home involves other specialist services for advice where necessary. Procedures for the administration of medicines are undertaken in a manner that safeguards the residents. EVIDENCE: Care plans were looked at by the Inspector and showed that they are regularly reviewed. Content was informative and comprehensive paying attention to both medical and social needs of each resident. Residents spoke highly of the care given and the support and help given them by staff in the home. Staff receive training on pressure relief and tissue viability, assessments and treatment are undertaken by RGN’s for pressure area care with support from the specialist nurse in the community if necessary. The home has pressurerelieving equipment in place. The continence advisor for the community provides additional support for any resident who suffers from continence problems. The home has access to all specialist services, which include the dietician, optician, dentist, chiropodist and the local hospice team. The home has a death and dying policy in place that is regularly reviewed and relatives are invited to be involved and to share the home’s facilities if they so wish. Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 11 The home is in the process of adopting the Liverpool Pathway Tool in conjunction with terminally ill residents to help ensure that all their needs can be fully met. Medicines are administered to residents by trained staff only and the Victoria Group has its own resident prescription sheets and uses bottle storage for medicines. All prescription sheets have a photograph of each resident in place to help with easy recognition. All stock is checked weekly to ensure that amounts are correct and in-date. The home’s Residents Charter of Rights that is part of the statement of purpose refers to observing the privacy, dignity and respect of the residents. Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and 15. The staff encourage residents to make choices in their daily life and try to support them in making decisions and join in with activities. The standard of food is good and the presentation ensures that those residents with poor appetites are encouraged to eat. EVIDENCE: Activities are provided in the home and the Inspector was able to meet the new Activities Co-ordinator for the Victoria Group who had recently come into post following the retirement of the longstanding Activities Co-ordinator. Activities are encouraged in the home but residents have a choice of whether or not they join in. One resident spoken with by the Inspector enjoyed games of scrabble and on a tour of the premises the Inspector noted that residents had books, card games, binoculars and plants and flowers in their rooms as well as radios and televisions. One resident had a bird feeder attached to the outside of their room. On the day of Inspection most of the residents were looking forward to watching Wimbledon. All residents spoken with said that their visitors were made welcome. The home does have a visitors’ book in place. The residents said they enjoyed the food and the Inspector was invited to join eight residents in the dining room. Food was enjoyable and well presented in a relaxed and homely atmosphere and the residents all chatted and seemed to get on very well. Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 13 The main kitchen is at Victoria 39 Dyke Road Avenue and food is delivered twice daily for lunch and supper. Menus are faxed to the home on the previous day for residents to make their choice. Records of meals eaten are kept for six weeks. The kitchen was very clean and well organised with staff wearing appropriate protective clothing. Food in the store cupboard was in-date. There were rotas in place for cleaning and re-filling of sugar bowls and changing table linen which are reviewed by the Registered manager/matron three monthly. Orders for milk were also on view and easily accessible. The home has a policy statement for kitchen cleanliness and fried and freezer temperatures are taken daily with records kept. There will be a recommendation in this report that marmite and Bovril plastic tubs are wiped after use as these were found by the Inspector to be sticky. Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17 and 18. Residents in the home are protected by the home’s attitude towards complaints and the staff have an awareness of protecting staff from potential abuse. EVIDENCE: The home has a complaints policy in place and a book for recording. Complaints are initially dealt with by the registered Manager/Matron or Deputy Matron; if they cannot solve the problem the Registered Providers are informed. The Deputy Matron said that residents use the postal voting service but one resident preferred to go to the polling station recently and was taken by a member of staff. The home provides in-house training for the Protection of Vulnerable Adults that is supported by a policy and procedure shared by each of the Victoria Homes. The Deputy Matron was aware of the procedure and discussed it with the Inspector. Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 23, 24 and 26. The home is maintained to a good standard and is decorated to meet residents’ needs. The garden is also well maintained and also arranged to meet the needs of the residents. EVIDENCE: The Inspector toured the premises and saw that the home is focussed on providing a comfortable and homely environment for the residents. Residents’ rooms, in many cases and through the choice of each individual resident were like a sitting room in their own home, with all the comforts, furnishings and ornaments they liked. Some said they had brought with them small items of furniture and pictures. There were a few things that the Inspector noticed that were in need of attention. One resident had been waiting for a long while for a new curtain rail, however the Registered Providers did have the matter in hand and were waiting for a company to fit the rail. Another room had wires trailing across the doorway, which caused a trip hazard. The door to one of the downstairs lavatories on the ground floor near to the sitting room did not open easily and required adjustment due to the height of the carpet. Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 16 The home was very clean with no noticed offensive smells. The home has a professional washing machine and drier for residents’ personal washing and the heavy laundry is sent to another home in the Victoria Group that has a larger purpose built laundry. Each resident has his/her own laundry basket for easy identification of clothing. The kitchen was also very clean and well organised. Throughout the kitchen and laundry room there are health and safety and hygiene notices to refresh staff memories on control of infection. There will be requirements made on the points mentioned above however the Inspector feels that the home should be scored as 3, meeting the standard in view of the quality of the environment as a whole. Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30. The home provides staff with relevant training and in sufficient numbers to meet the needs of the residents. EVIDENCE: Staff rotas show that there are sufficient members of staff on duty during a 24-hour span to meet the needs of the residents. The Deputy Matron said that the home has its own holiday relief staff and can access bank staff through the Victoria Goup. There is always an RGN (Registered General Nurse) on duty with the support of at least two and as many as four care staff depending on the time of day and needs of the residents. Extra staff are called in as required. The Victoria Group have an in-house trainer who addresses all statutory and induction training. The Inspector looked at training records of staff in the Victoria Highgrove that showed a rolling programme of training is available. Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,37 and 38. The home is well managed and the outcomes for residents’ are good. Staff and residents enjoy good relationships. There are no deep based concerns about the health and safety aspects of the home and the Deputy Manager has been made aware of issues that arose during the inspection. EVIDENCE: The Registered Manager/Matron has worked within the Victoria Group for over two years and has a wealth of experience as an RGN with the Health Authority. Both the Registered Providers visit the homes regularly and are known to both the staff and residents. The Deputy Matron said that they are very supportive of all the care staff and are always available if needed. Residents meetings do not take place in the home and when asked by the Inspector if they thought such meetings would be a good idea a group said they did not think so. Supervision takes place and is organised by the Registered Manager/Matron. Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 19 Policies and procedures are reviewed by the Director of Nursing Services with the assistance of senior staff; since the last inspection records in the home relating to staff training and maintenance have improved. Fire equipment was last checked on 10/10/04 and the fire alarm system was checked by staff on 15/06/05 and on the 27/02/05 by a commercial company. Emergency lighting is also checked professionally. The Deputy matron said that fire drills take place monthly and residents are escorted to the local fire- points allocated around the home. The last fire inspection report that was available in the home on file was dated 11/9/03, it was noted that some staff require updating in fire safety. The records relating to the checking of fire doors also showed that they had not been tested since November 2004 therefore requirements will be made in this report to request these tests are reviewed. Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x 3 x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x x 3 3 2 Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 21 NO Are there any outstanding requirements from the last inspection? 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 19 Regulation 16(1)c 23(2)p 13(4)ac Requirement Residents who do not already have a fan provided in their room to refresh them, to be given one if they so request it. The wires trailing across the doorway in room in room 4 to be made safe as they present a trip hazard. The door to the downstairs lavatory adjacent to the ground floor sitting/dining room to be adjusted so that it opens easily. The Registered Matron to request an up-to-date fire inspection report on the home. All staff who have not recently attended a fire safety training session to do so. All fire doors to be tested. Timescale for action 15 July 2005 1 July 2005 2. 19 3. 19 13(4)abc 15 July 2005 1 August 2005 1 August 2005 1 August 2005 4. 5. 6. 38 38 38 23(4) 23(4)d 23(4)c Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 15 Good Practice Recommendations The staff to ensure that containers for marmite and bovril are wiped after use. Victoria Highgrove H59-H10 s14071 Victoria v227093 230605 stage4.doc Version 1.30 Page 23 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. 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