Inspection on 01/07/05 for Victoria House Care Home

This inspection was carried out on 1st July 2005.

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

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

Other inspections for this house

Victoria House Care Home 14/08/08

Victoria House Care Home 15/08/07

Victoria House Care Home 06/06/06

Victoria House Care Home 25/01/06

Victoria House Care Home 17/02/05

Victoria House Care Home 28/04/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Victoria House 71 - 73 Victoria Road Polegate East Sussex BN26 6BX Lead Inspector Gwyneth Bryant Unannounced 1 July 2005 08.00 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 House H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Victoria House Address 71 - 73 Victoria Road Polegate East Sussex BN26 6BX 01323 487178 01323 487178 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) Supreme Care UK Ltd Vacant Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (OP) 20 of places Victoria House H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is twenty (20). 2. Service users must be older people aged sixty-five (65) years and over on admission. 3. To admit one service user out of category. Date of last inspection 17 February 2005 Brief Description of the Service: Victoria House is registered to care and accommodation for up to twenty older people. The home is a three-storey detached property situated in a residential area of Polegate. It is located in close proximity to local amenities including bus and rail links. Service users accommodation consists of twenty single rooms, eleven of which have en-suite facilities. All bedrooms have a least wash hand basin. The home has a range of communal areas including a large lounge and dining area. There a two communal bathrooms, both of which are assisted, and four communal toilets. There are toilet riser seats and handrails fitted as required. The external grounds offer an attractive garden and patio area. Car parking is available at the front of the property. The home has a passenger lift and a series of ramps that enable service users to access all parts of the home, however there are some internal steps so service users on the upper floors need to be mobile. Victoria House H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over six hours. There were nineteen service users in residence on the day of which five were spoken with. The purpose of the inspection was to check compliance with the requirements made during the last inspection and to inspect other standards. The Registered Manager and one members of care staff and the cook were spoken with. Fourteen key and seven of the other standards were inspected. A range of documentation was viewed including service users care plans, personnel files and medication records. A tour of the premises was carried out What the service does well: What has improved since the last inspection? What they could do better: The Manager has worked hard to meet the requirements from the last inspection and is aware of where shortfalls remain, several of which require financial input from the provider. Prospective service users need to be provided with detailed information about the services provided by the home, including how fees are calculated. Service users health, social, and personal care needs must be identified, recorded and planned for. Staffing levels need to be increased to enable the manager to fulfil her management duties. The requirements relating to health and safety need to be addressed without delay, especially the use of door wedges for which an Immediate Requirement was issued. Formal quality monitoring systems need to be introduced. Systems Victoria House H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 Page 6 need to be put in place to notify the CSCI of any outbreak in the home of an infectious disease. Staff training needs to be undertaken as required. 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 House H59-H10 s21277 Victoria v229588 030805 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 House H59-H10 s21277 Victoria v229588 030805 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 and 5 Service users are not supplied with sufficient information about the services provided by the home. Pre-admission documentation is satisfactory therefore the home is able to demonstrate it can meet service users needs. EVIDENCE: Documents intended to provide service users with information on the services provided were viewed and it was found that information about how fees are calculated and increased is unclear and is not accurately detailed in documentation provided to potential and existing service users. Pre-admission documentation for the last two admissions were viewed and found to be detailed and complete. One service user was in the process of the trial period. The Manager stated she is not sure the home can meet this person’s needs that appear to be more complex than was found during the pre-admission process. This was also evident in the daily log records. Service users spoken with said that they were given able to visit the home prior to admission and were given copies of the homes brochure. Victoria House H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 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 standard(s) 7, 8 and 9 Care planning systems need to ensure staff are guided in most aspects of service users care. The systems for the recording, handling and storing of medication are satisfactory. EVIDENCE: Five care plans were viewed and most showed that all care needs were identified and planned for. However, some plans were not complete and had not been reviewed monthly. Risk assessment are carried out to ensure the safety of service users both within and outside the home but these need to be reviewed more regularly to reflect changing needs. Not all service users or their representatives were given the opportunity to be involved in compiling and reviewing the plans. It is considered good practice to ensure all care planning documentation is signed and dated by the recorder and this was omitted in some records. In addition to care plans there is a daily log that is used as a communication tool for staff. Service users spoken with said they believed staff were aware of their care needs and were happy to ensure they are properly looked after. A chiropodist visits the home regularly, as does a hairdresser. All service users need to be weighed monthly and action taken based on weight lost or gained. Victoria House H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 Page 10 Medication records were viewed and found to be satisfactory. administer medication have received adequate training. All staff who Victoria House H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 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 standard(s) 12, 13 and 15 Social activities and meals are both well managed, creative and provide daily variation for people living in the home. Visitors are welcome to the home at all reasonable times to ensure service users maintain links with family and friends. EVIDENCE: The home has a weekly programme of suitable activities, including cards, board games, music and exercise. On the day of the inspection staff and service users were preparing for the home’s summer fete to be held the following day. The Manager said the event was to raise funds to buy new garden furniture and to encourage links with the local community. Service users care plans showed that they are encouraged to go out to local shops and service users spoken with confirmed they enjoy being able to visit shops or just go out for a walk. There were two visitors on the day of the inspection and they said they visit as often as possible and were made welcome. All service users spoken with said that the food was excellent and they were offered a choice at all mealtimes. Menus were viewed and they were varied and well balanced. Discussion with the cook found that she is aware of service users dietary preferences and has undertaken training in providing meals to diabetics. She is knowledgeable about nutrition and menus are seasonal. She Victoria House H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 Page 12 said that service users consulted on the menu content, discussion with service users and inspection of the minutes of service users meetings confirmed this. Victoria House H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 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 standard(s) 16 and 18 The home has a satisfactory complaints procedure with evidence that complaints are recorded and actions taken to resolve any issues. Although there are systems are in place to protect service users from abuse, staff would benefit from training to improve their understanding of adult protection issues EVIDENCE: The complaints book was inspected and it was seen that all complaints are recorded and include actions taken and outcomes. No complaints had been received since the last inspection. The home has policies and procedures on adult protection. The Manager provided evidence to demonstrate training in adult protection for staff has been booked, to ensure they are familiar with this issue. Victoria House H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 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 standard(s) 19, 21, 22, 24, 25 and 26 The standard of décor is good, providing service users with a homely and comfortable place in which to live. Improvements are required in respect of the provision of bathing facilities; adaptations and equipment to ensure the needs of all service users are met. EVIDENCE: A tour of the premises was carried out and most parts of the home are well maintained and décor is good throughout. The ground floor bathroom was used for storage and this needs to be rectified to ensure sufficient bathing facilities are available to service users. A suitably qualified person needs to make an assessment of the premises and grounds to ensure the needs of all service users are met. Additional grab and handrails would ensure the needs of all service users are met. Not all communal toilet facilities had wash hand basins fitted and this needs to be addressed to reduce the risk of infection. Service users individual accommodation is furnished according to the required standard, providing both comfort and privacy. Victoria House H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 Page 15 Laundry facilities are clean and hygienic. Systems are in place for to control infection. Victoria House H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 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 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 29 The deployment and number of staff at key times is insufficient to meet service users care needs. Recruitment practices are robust and provide safeguards to protect service users. EVIDENCE: Staff rotas were viewed and found that a total of 312.9 care hours per week are provided. Staff are also required to serve meals, make drinks and breakfast for service users. The Residential Forum staffing tool recommends a minimum of 440.26 care hours be provided for the nineteen service users taking into consideration the layout of the home. Cooks and domestic staff are also employed. Discussion with the Manager established that she undertakes ‘hands on’ care tasks and this impinges on her management time. This needs to be addressed to ensure she has sufficient time to undertake all management tasks. Recruitment records were viewed and found that no need staff had been recruited since the last inspection. The last inspection found that not all staff had provided the required documentation prior to appointment but the Manager now has a checklist of required documents that staff must provide prior to appointment. The effectiveness of these checks will be verified at the next inspection. Victoria House H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 Page 17 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) 32, 33, 36 and 38 The Manager provides good leadership and direction to staff to ensure service users receive consistent care, thus service users benefit from a supported and appropriately supervised staff team. Some practices do not safeguard the health, safety and welfare of service users. EVIDENCE: The Manager is in the process of becoming the Registered Manager and has extensive experience in the care industry. She is aware of the shortfalls in the service and is clear on the actions to be taken to address them. Staff were observed to work as a team and they confirmed that the Manager is open and approachable. Service users also stated that should they have a problem they could speak to staff or the Manager and would be listened to. Victoria House H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 Page 18 Minutes of staff and service users meetings were viewed and from these it is evident that both groups are given the opportunity to comment on and influence how the home is run. Service users surveys are carried out and this quality monitoring system needs to be extended to families and friends of service users. The introduction of formal quality assurance and quality monitoring systems would enable to the provider to critically evaluate the service and ensure it is run in the service users best interests. Staff supervision records were examined and from these it is clear that these sessions identify training needs and good practice issues. The staff member spoken with confirmed she receives satisfactory supervision and was able to outline the areas covered during these sessions. Door wedges were still in use in some parts of the home and this practice must cease. An immediate requirement was issued in respect of this. Service users care plans and the daily log showed that there had been an outbreak of diarrhoea and vomiting. While satisfactory containment had been put in place the Manager should have informed the CSCI. Systems need to be put in place to inform the CSCI of such incidences. Documents relating to safe working practices and Health and Safety were available and found to be satisfactory as were accident records. There were records showing the regular testing of call bells, emergency lighting and fire alarms and that fire equipment and systems are regularly serviced. Staff training in fire safety, moving and handling, infection control and Control of Substances Hazardous to Health have been booked and the Manager needs to ensure that all staff receive this training. Victoria House H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 Page 19 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 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x 2 x 3 3 3 STAFFING Standard No Score 27 2 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 3 2 x x 3 x 2 Victoria House H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 Page 20 yes 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 1 Regulation 4 (1) (ac) (2) and 5 (1) (a-f) (2) and Schedule 1 of the Regulation s 5 (1) (b) Requirement The homes statement of purpose needs to be reviewed to accurately reflect services provided. Timescale for action 01.10.05 2. 2 3. 7 4. 7 5. 8 The the service users guide, contracts and terms and conditions need to be reveiwed to accurately reflect services provided. 15 (1) (2) Risk assessments to be (b) (c) undertaken for all service users, and 12 including those risks related to (1) (a) (b) smoking and manual handling. and 13 Risk assessments undertaken for (1) (b) users both within and outside the home need to be reveiwed regularly. 15 (2) (b) All parts of service users care (c) plans must be completed, regularly reveiwed and evidence provided to show service users or their representatives are invloved in the reveiws. 14 (1) (a) Appropriate action needs to be (2) (a&b) taken where service users are and noted to have lost or gained Regulation weight H59-H10 s21277 Victoria v229588 030805 stage4.doc 01.10.05 01.10.05 01.10.05 01.10.05 Victoria House Version 1.30 Page 21 6. 7. 18 21 and 26 17 (1)(a) Schedule 3 (o) 13 (6) (7) (8) 23 (2) (j) 8. 22 9. 10. 11. 12. 27 31 33 38 13. 14. 38 38.7 Staff need to receive training in adult protection. The ground floor bathroom needs to be made available for use and wash handbasins fitted to all communal toilet facilities that require them. 16 (1) (2) An assessment of the premises (c) and 23 needs to be undertaken by a (2) (n) suitably qualified person to ensure the needs of all service users are met. 18 (1) (a) Staffing levels need to be increased to ensure service users needs are met. 9 (1) (2) That the Managers management (b) (i) and hours be increased to enable her 12 (1) (b) to fulfil her management duties. 24 (1)(a) That formal quality monitoring (b) (2) (3) and quality assurance systems be created and implemented. 13 (3) (4) That all staff be trained in (5) and manual handling, infection 16 (2) (J) control, fire safety and control of and 23 substances hazardous to health. (4) (a-e) (5) 23 (4) (a) That the use of door wedges (c) (i) (v) ceases and appropriate door closing devices provided. 37 (1) (a- That systems are created for g) (2) notifying the CSCI of incidents of disease. 01.10.05 01.10.05 01.10.05 01.10.05 01.10.05 01.10.05 01.10.05 01.07.05 01.10.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 7 Good Practice Recommendations All care planning documentation should be signed and dated. H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 Page 22 Victoria House 2. 3. 12 22 That training on the provision of activities is sought for care staff. That consideration is given to providing additional equipment to safely lift service users. Victoria House H59-H10 s21277 Victoria v229588 030805 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. Extracts may not be used or reproduced without the express permission of CSCI Victoria House H59-H10 s21277 Victoria v229588 030805 stage4.doc Version 1.30 Page 24 - 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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