Inspection on 07/12/05 for Victoria Highgrove

This inspection was carried out on 7th December 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 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 Unannounced Inspection 7 December 02:00 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.V254530.R01.S.doc Version 5.0 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.V254530.R01.S.doc Version 5.0 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) 012 73-562739 01273-882818 Victoria Nursing Homes Limited Teresa Kaczyk 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.V254530.R01.S.doc Version 5.0 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. 23rd June 2005 Date of last inspection 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 the home had three empty beds. 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 DS0000014071.V254530.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the afternoon over a period of three and a half hours. Mrs Teresa Kaczyk the Registered Manager facilitated the inspection. During the inspection the Inspector was able to look at the home’s administration processes, tour the premises, visit residents and speak to visitors. The Inspector found the home to be warm, comfortable and calm, staff were welcoming and the inspection was positive and enjoyable. Feedback was given to the Registered Manager at the end of the inspection and any issues raised during that time were discussed fully. The Inspector would like to thank all the staff for their helpfulness and hospitality. What the service does well: What has improved since the last inspection? All requirements made at the last inspection have been addressed and attention paid to ensuring staff training is up to date. Victoria Highgrove DS0000014071.V254530.R01.S.doc Version 5.0 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 DS0000014071.V254530.R01.S.doc Version 5.0 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 Highgrove DS0000014071.V254530.R01.S.doc Version 5.0 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): These standards were all assessed in June 2005, all were fully met. EVIDENCE: The Inspector noted that the home has a statement of purpose and service user guide, the registration certificate and insurance certificates are on view in the main entrance and the latest inspection report is available should anyone wish to see it. Victoria Highgrove DS0000014071.V254530.R01.S.doc Version 5.0 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): 7,9 and 10. The home delivers a good quality of care that is well documented. All residents’ have an individual plan of care that is well maintained. Procedures for the administration of medicines are undertaken in a manner that safeguards the residents. EVIDENCE: The Inspector was able to look at residents care plans and found them to be well-maintained and up-to-date with dates and signatures. The Inspector read through care plans and found them to provide clear indication of the nursing and general care needs of each resident. Flu vaccines have been arranged for residents who require them. All residents are assessed for taking risks in their everyday life in the home. Records are kept separately for each review of care and changes are made in the care plans as appropriate. One visitor told the Inspector that staff always communicate to him any proposed changes to his relative’s care, another resident said that the staff and she always planned her care together. On the day of inspection only one resident self medicated and the Inspector saw that this had been risk assessed by staff and a consent form signed by the Victoria Highgrove DS0000014071.V254530.R01.S.doc Version 5.0 Page 10 resident. The Inspector looked at the clinical room used for storage of medication and found it to be clean, tidy and well organised. Equipment is checked regularly, syringe drivers well maintained and fridge temperatures recorded. Medication is stored in a safe manner and those looked at by the Inspector were in-date; this included dressings. There was no evidence of stockpiling. The Registered Manager told the Inspector that only trained nurses dispose of medication using the new system involving dupe containers, controlled drugs are disposed of in the appropriate solution. Victoria Highgrove DS0000014071.V254530.R01.S.doc Version 5.0 Page 11 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 and 13, all standards were assessed and fully met in June 2005. 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. EVIDENCE: The Activities Co-ordinator for the Victoria group of homes visits the home twice weekly and residents told the Inspector that they are offered the chance to join in, if they choose not to the Co-ordinator will chat to them individually. The Inspector spoke with a group of residents who always eat their lunch and afternoon tea together to provide a social focus to each day. They appeared to communicate well with each other and with staff. There is evidence in the home of group- activities; a large jigsaw puzzle is being completed by a group of residents in the dining/sitting room. Residents have their own televisions in their individual rooms. One resident told the Inspector about trips he makes outside the home; another said her visitors to the home are always made welcome and offered refreshment. At Christmas relatives and friends are able to stay for lunch or tea by prior arrangement and residents are looking forward to this. Although the standard relating to meals was not inspected the Inspector noted that the kitchen was clean and tidy and the afternoon tea was well presented Victoria Highgrove DS0000014071.V254530.R01.S.doc Version 5.0 Page 12 to the residents with sufficient portions, one resident told the Inspector that the food is always good and that staff always offer a change if she doesn’t like the food prepared for her. Victoria Highgrove DS0000014071.V254530.R01.S.doc Version 5.0 Page 13 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 and 18. Residents in the home are protected by the home’s attitude towards complaints and staff have an awareness of protecting staff from potential abuse. EVIDENCE: The home has a complaints policy in place that is part of the information given to residents and relatives on admission to the home. The Inspector and Registered Manager discussed the recording of complaints and none had been brought to her attention since the last inspection. Residents spoken with by the Inspector all said they had never made a complaint and all felt that should a situation arise they would consult the Registered Manager. This was apparent in the case of one resident who had communicated a concern earlier to the Registered Manager who had dealt with it accordingly. A visitor said he has always felt very comfortable about consulting the Registered Manager with any issues he is concerned about. All staff receive training in the protection of vulnerable adults and a flow chart is on view to ensure the process is clear. The Inspector saw records of staff meetings where adult protection had been discussed and staff training files sampled showed that staff have received training. Staff files showed that staff have been Criminal Records Bureau checked before commencing employment. Victoria Highgrove DS0000014071.V254530.R01.S.doc Version 5.0 Page 14 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): 20,21,22and 25. The home is safe and comfortable with sufficient lavatories and washing facilities. 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. 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. 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, Victoria Highgrove DS0000014071.V254530.R01.S.doc Version 5.0 Page 15 adequate moving and handling equipment and a lift are all in place. The home also has a passenger lift. Victoria Highgrove DS0000014071.V254530.R01.S.doc Version 5.0 Page 16 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 and 30. 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 home has a thorough recruitment procedure in place. The Inspector was able to look at staff recruitment and training files and found that each member of staff had been employed with two references and a new Criminal Records Bureau check. Other information showed that staff receive job descriptions, induction training and terms and conditions of employment. All staff have a probationary period to complete before becoming permanent members of staff. The home has an in-house trainer who is pro-active in ensuring that staff do attend training sessions. Records are kept of all staff training undertaken and reminders sent to those who miss mandatory training e.g. fire safety and moving and handling. During discussion with the Registered Manager the Inspector learned that more staff have commenced NVQ 2 training and by the summer 2006 it is hoped that 50 of staff in the home will have achieved the qualification. The Registered Manager is pro-active in supporting staff with training and organises regular clinical updates from the OlderPeople’s Nursing Team to ensure they are up-to-date with the latest nursing and care methods. Victoria Highgrove DS0000014071.V254530.R01.S.doc Version 5.0 Page 17 All staff receive certificates copies of which are kept in their training file. Files sampled by the Inspector showed that staff receive induction training and that moving and handling, food hygiene and adult protection training is up to date. Victoria Highgrove DS0000014071.V254530.R01.S.doc Version 5.0 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 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): 32,34,35 and 38. 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: The home is well managed and the Registered Providers and Registered Manager ensure that staff are supported in the work they undertake with meeting the needs of the residents a priority. Staff meetings take place regularly and although meetings are not formerly organised for residents a group spoken with by the Inspector said they did not feel such meetings to be necessary as staff always responded to their wants and needs. They confirmed Victoria Highgrove DS0000014071.V254530.R01.S.doc Version 5.0 Page 19 that their opinions had been asked about prospective Christmas activities. The Registered Manager supported this by saying that she always made sure that residents are consulted about any changes or wishes when she visited them during the day. The Inspector saw records of staff meetings that take place monthly. The Registered Manager confirmed that the home does not keep any valuables belonging to residents; these are kept in a central office. The home has a petty cash float for any immediate finances required however the Registered Manager reported that any new equipment or furnishings are supplied by the Registered Providers on request. Training records are kept of all moving and handling, health and safety, food hygiene, first aid, infection control, and fire safety training that care staff undertake. Staff are aware of the need to use protective clothing and were seen on the day of inspection suitably clothed to provide safe care. The home has a new fire alarm system in place that pinpoints rooms rather than zones. Fire drills are undertaken but the Inspector could not find evidence of the names of the staff taking part and suggested to the Registered Manager that this be addressed. The last fire inspection took place on 10.10.04. Looking through maintenance records it was not clear when some tests to services and equipment had last taken place. It appeared that the nurse call alarm system had not been checked since 12/09/04. Hoist and lift servicing needed to be updated. The home has a health and safety policy, adequate signage and a COSHH cupboard. All residents are risk assessed for their safety within the home and the accident book is in line with current legislation and maintained. Records showed that the next PAT (portable appliance test) to electrical equipment is due on 26/01/06. The Inspector discussed the importance of keeping maintenance/testing and servicing records within the home with the Registered Manager during feedback. Victoria Highgrove DS0000014071.V254530.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X 3 3 3 X X 3 X STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X 3 3 X X 2 Victoria Highgrove DS0000014071.V254530.R01.S.doc Version 5.0 Page 21 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 2 Standard OP38 OP38 Regulation Sch 4 & 23(4)c Schedule 4 and 17 Requirement The home to keep a record of all named staff taking part in fire drills The home to ensure that all records of maintenance and servicing are kept up-to-date for easy reference. Timescale for action 20/12/05 20/12/05 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.V254530.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection East Sussex Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Victoria Highgrove DS0000014071.V254530.R01.S.doc Version 5.0 Page 23 - 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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