Inspection on 13/09/06 for Victoria Lodge

This inspection was carried out on 13th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Victoria Lodge 16/10/08

Victoria Lodge 17/04/08

Victoria Lodge 30/07/07

Victoria Lodge 15/11/05

Victoria Lodge 10/05/05

Victoria Lodge 13/12/04

Victoria Lodge 14/06/04

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

CARE HOME ADULTS 18-65 Victoria Lodge 59 Victoria Drive Bognor Regis West Sussex PO21 2TQ Lead Inspector Mr D Bannier Key Unannounced Inspection 13th September 2006 09:30 Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 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 Lodge DS0000040980.V307907.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 Adults 18-65. 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 Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Lodge Address 59 Victoria Drive Bognor Regis West Sussex PO21 2TQ 01491 579270 01491 579738 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) Victoria Lodge Ltd Miss Jade Michelle Elizabeth Weston Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 Brief Description of the Service: Victoria Lodge is a care home for younger adults (18-65) who have learning disabilities. The home is registered for six service users. The home has four residents at the present time. The home is in a residential area in Bognor Regis it is a large house with surrounding gardens. There is an annex to the house that is currently used as an activities room. The service has an ethos that is geared very much towards promoting independence and strives for its residents to lead full lives within the community. Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report has been written using new methods introduced on 1st April 2006. Some evidence used to assess standards has been gathered before this visit took place. For example, information has been used from information provided by the manager in a questionnaire; information has also been used from written reports of visits to the care home made by representatives of the registered provider. This visit was unannounced and started at 9.30am. It took place over six hours. Due to severe learning disabilities it was not possible to have meaningful discussions with residents. However, the inspector met and spent time with four of the five residents who are currently living at Victoria Lodge. The other resident was at college. The inspector also observed care practices. This gave the inspector a picture of how it is to live at this care home. The inspector also spoke to three staff who were on duty. This helped the inspector to gain a sense of the work staff are expected to do. The inspector saw the communal areas and some of the private accommodation. Some records were also examined. The inspector looked at those standards that are about how new residents are admitted to the care home; how residents are cared for; the daily life and social activities provided for residents; how the care home deals with complaints and how they protect residents from abuse; the environment in which residents live; how staff are recruited and trained; and how the care home is managed. Jade Weston, the registered manager, was not available. However, the deputy manager was present throughout the inspection and kindly assisted the inspector with his enquiries. What the service does well: Staff are very caring and considerate and the atmosphere at Victoria Lodge is very homely. Residents are encouraged to play a part in the day to day running of the care home as far as they are able. They are also encouraged by the staff to take a part in the local community. Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 , 3 and 4 Residents have been provided with information about the care home. The registered provider has ensured all prospective residents’ needs and aspirations have been fully assessed. The registered provider needs to ensure all prospective residents know the home will meet their needs and aspirations. The registered provider has ensured all prospective residents have an opportunity to visit the care home before they decide to move in. Quality in this outcome area is considered adequate. EVIDENCE: The inspector looked at the records of two residents who had been admitted since the last inspection. A copy of the Service User’s Guide and Contract, each of which were in pictorial format, were on each resident’s file. However, it was not clear if the resident was able to understand the information they contained. One resident has been readmitted from another care home owned by the registered provider. The resident had been discharged due to violent and Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 9 aggressive behaviour to other residents and staff. The resident has already been issued with a written notice requiring them to leave the care home within a period of 20 days. The reason for the notice is that the resident continues to exhibit violent and aggressive behaviour, putting other residents and staff at risk. It is not clear, if this is the case, why the resident was readmitted in the first place. Records seen showed that each resident’s needs had been thoroughly assessed prior to admission. This means that the manager at the care home knows what the needs are of each resident before they are admitted. This will help them to make a decision whether they are able to meet them. However, there was no evidence to demonstrate that the registered provider had written to each resident, or their representative before admission, to confirm the care home was able to meet their identified needs. The registered provider was informed that this is required by current legislation and has, therefore, been made a requirement. There was evidence to demonstrate that residents had been provided with several overnight stays in preparation for admission to the care home. This means that residents are able to try the care home out before they are admitted. Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Due to their disabilities, which affects their ability to communicate, it was not possible to determine if residents know about their care plans. Some work is necessary to ensure care plans are reviewed regularly and reflect the changing needs of residents. The registered person has ensured residents are able to make decisions about their lives with assistance as necessary. The registered person has ensured residents are supported in taking risks as part of their daily lives. However, some work is necessary to ensure risk assessments are reviewed regularly, as with care plans, to ensure they reflect the changing needs of residents. Quality in this outcome area is considered good. EVIDENCE: Due to the severity of their learning disability the inspector was not able to determine if residents know about their care plans. The inspector examined in detail the care plans of two residents who have been admitted since the last Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 11 inspection. Care plans seen provided clear information about the needs of each resident. Whilst care plans do not include information about how the needs of each resident are to be met, guidelines have been drawn up for staff to follow to ensure residents’ needs have been met. They are stored in a folder in kitchen, which is locked when not attended. It is recommended that some work should take place to marry up care plans with the guidance notes. This will mean staff will have access to all information regarding the needs of residents and how they should be met. It will also mean that the manager will know that there are guidance notes for all assessed needs for each resident. Whilst there was evidence to demonstrate that care plans are reviewed, from the information available it was not clear how often this takes place. It is recommended that a system is implemented to ensure all care plans are reviewed regularly and a record made when such a review takes place. This will enable the manager to monitor frequency of reviews to ensure information within care plans is up to date. The inspector also advised the deputy manager to ensure care plans also include clear instructions or directions to staff with regard to how residents’ needs are to be met. This will ensure consistency and continuity of care. For example, records included phrases such as staff should “support” a resident. The deputy manager was advised that care plans should include information to staff about how each individual should be supported, including frequency and the level of support required. Due to the severity of their disabilities residents need a large amount of support from staff when making decisions about their lives. A weekly planner has been drawn up for each resident, which identifies the activities each resident will be involved in throughout each day. During each day there are also opportunities for each resident to make their own choice about the activity they wish to participate in. One resident enjoys a ride in the car and also walks down to the seafront for a cup of coffee. Another resident likes to complete word searches in a puzzle book. The inspector observed staff helping residents with activities they had chosen to do. Records seen showed that risk assessments were in place and were comprehensive. This was clearly necessary due to the severity of residents’ disabilities. Some risk assessments were generic and included general issues and the environment, whilst other were clearly tailored to the needs of individual residents. Again, it was not clear how often risk assessments had been reviewed. For example, one resident had recently moved into another bedroom. The bedroom is on the first floor, however, there were no window restrictors. The deputy manager assured the inspector that the resident was in no danger as a result of this. However, a risk assessment had not been completed to support this statement. It is recommended that, in line with reviews of care plans, risk assessments are also reviewed on a regular basis to ensure the safety of residents. Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 The registered person has ensured residents are enabled to take part in appropriate activities. Appropriate steps have been taken to ensure residents are encouraged to be part of the local community. The registered person has ensured residents have appropriate personal and family relationships. It was not clear if appropriate steps have been taken to ensure residents’ rights are respected and responsibilities recognised in their daily lives. The registered person has ensured residents are offered a healthy diet and enjoy their meals and mealtimes. Quality in this outcome area is considered good. Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 13 EVIDENCE: A weekly planner has been drawn up for each resident, which identifies the activities each resident will be involved in throughout each day. They include activities based in the community such as college, swimming, and lunches out. They also include activities to improve residents’ independent living skills. These are based in the house and include tidying bedroom, washing, ironing and putting away clothes and cake making. Residents also pursue leisure activities including going out for walks, going out for rides in the car. Residents can also be involved with house based activities such as listening to music and watching television, art and crafts, and doing puzzles. The inspector noted that residents were participating in a variety of activities during his visit. The inspector also spoke to staff on duty who explained that they aim to keep the residents occupied as much as possible. The inspector noted that one resident was attending a local college during his visit. The inspector was also informed that another resident had recently commenced college at the start of the academic year. Staff were seen accompanying residents in order to visit the local shops. One resident attends a local church on Sundays. The inspector was also informed residents enjoy walking down to the seafront, which is nearby, for a cup of coffee and going out for lunch. The inspector noted that the care home has a vehicle for residents to use when they need to go to college or to church. The deputy manager informed the inspector that there is always a nominated driver amongst the staff team on each shift. Where possible residents are helped to keep in touch with family and friends. According to a weekly planner, one resident visits their parents every week. The deputy manager informed the inspector that one resident, who has been admitted since the last inspection, came to live at Victoria Lodge in order to be near their family so that they may visit. The deputy manager was able to confirm that the resident’s family does visit as they had completed a comment card and had returned it to the inspector. They confirmed that they were pleased how well the resident had settled into Victoria Lodge. According to the Statement of Purpose, the aims and objectives include a statement about independence as follows, “To allow individuals to make choices, decisions in regard to all aspects of their own lives.” The inspector looked at residents’ individual weekly planners, which showed that all residents participate, as far as they are able, in daily chores and housework duties. From Monday to Friday residents’ days have been well structured with appropriate activities and also includes some free time for them to choose their activities. It was not clear from the evidence available if residents have chosen to participate in such tasks and activities, or it is the expectation of the care home that they will help with the chores and take part in routines of the house. The inspector noted that a contract is in place, including one in a picture format. However, it was unclear if it had been discussed and agreed Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 14 with the resident or their relative or representative. It is recommended that this does take place and the outcome of discussions recorded. If residents do take part in household chores it should be with their agreement, or a representative acting on their behalf, and there should be clear evidence that this part of their agreed care plan. The inspector was provided with copies of a four week menu which included meals for breakfast, lunch and dinner. The main meal of the day is taken after 5pm when all the residents are back from the day’s activity. The meals described on the menu appeared to be varied nutritious and healthy and were appropriate to the age range and needs of residents. An alternative dish is provided for those residents who do not like the main meal. One resident told the inspector how much he enjoyed the chicken wrap they had eaten for their lunch. According to information seen on the menu, several residents had been consulted when the menu was drawn up. The inspector observed some residents needed assistance with eating their meal. Staff provided this in an appropriate way which maintained the dignity of the resident who needed help. Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 There was no evidence to confirm that residents receive personal support in the way they prefer and require. The registered person has taken appropriate action to ensure residents’ physical and emotional health needs have been met. Residents are not capable of retaining, administering and controlling their own medication. Appropriate steps have been taken to ensure residents are protected by the home’s policies and procedures for dealing with medicines. Quality in this outcome area is adequate. EVIDENCE: There was no evidence to confirm that residents receive personal support in the way they prefer and require. Due to their severe disabilities residents seen by the inspector were unable to have meaningful discussions. As mentioned previously, care plans need to be reviewed to ensure there is clear instructions to staff with regard to they way in which residents should be supported. The registered provider is also advised to ensure, wherever possible, this includes the choices and wishes of individual residents. For example, confirming that staff should encourage residents to choose the colour and style of their clothes. Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 16 The inspector was very concerned that a resident’s re admission into Victoria Lodge had taken place without staff who have appropriate training and experience in behaviour management techniques. The resident was discharged from the care home due to their aggressive behaviour. It is possible this will put other residents and staff at risk. This was made clear to the deputy manager before the inspector left the care home. The deputy manager could provide no evidence to confirm that Victoria Lodge could provide the care and support the resident required. Records seen showed that, when necessary, residents have been provided with access to community health care resources to ensure their physical and mental health care needs have been met. Residents are escorted to appointments to GPs, community nurse, dentists, opticians and psychiatrists as necessary. Currently no residents are considered to be able to administer their own medication. The care home has, therefore, established systems for staff to administer medicines in a safe manner. Medication is administered from containers that have been marked with instructions by the dispensing chemist. Records of medications received in the home, administered and disposed of were up to date and in accordance with the requirements of current legislation. Records of PRN (or when required) medication administered were also seen and were up to date. Guidance notes for staff for the administering of PRN medication was also in place. Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Due to their severe disabilities, it was not possible to determine if residents feel their views are listened to and acted upon. However, the registered provider has developed a complaint procedure and appropriate documents to investigate any complaints received. The registered provider has taken appropriate steps to ensure residents are protected from abuse, neglect and self harm. Quality in this outcome area is considered good. EVIDENCE: The registered provider has developed a written complaint procedure, which is included in the Statement of Purpose as required. This document has been provided to each service user in a pictorial format. However, as mentioned before, it is not clear if the residents can understand this format. The registered provider has also developed a system for recording and investigating any complaints about the care home. No complaints have been received since the last inspection. According to records seen, staff have been provided with training in identifying different forms of abuse and neglect. Staff have also been provided with training for reporting any allegations or instances of abuse. The deputy manager is also aware of her role in the procedure for dealing any allegations of abuse. However, it is recommended that this person does make themselves familiar with the West Sussex Adult Protection procedures and, if possible, the Department of Health guidance entitled “No Secrets.” This will ensure the they will know how to respond to any allegations of abuse. In turn this will mean Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 18 that residents will be protected from abuse, or neglect. One resident has a history of self harm. Guidance notes have been developed for staff to follow to ensure the resident has been appropriately protected. Again, these guidance notes should also be included in the review of care plans recommended earlier. This will ensure guidance is up to date and meets the current needs of the resident. Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The registered provider has ensured residents’ accommodation is comfortable and safe. Appropriate steps has been taken to ensure the premises is clean and hygienic. Quality in this outcome area is good. EVIDENCE: The inspector visited several bedrooms, toilets, bathrooms, the lounge and dining room, the utility room and the kitchen. Those areas of the home seen were presented in a homely and comfortable manner. The decoration and furnishings provided ensured residents live in a comfortable and safe environment. Information supplied by the registered provider prior to the inspection confirmed that the premises and equipment had been checked and maintained regularly to ensure the safety of residents and staff. The inspector noted that all areas of the premises were clean and hygienic. Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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 and 35 The registered provider has provided mandatory training and NVQ training for staff. Some improvements are necessary to the home’s recruitment policy and practices to ensure supported and protected. The registered provider must ensure appropriate training is required to ensure staff able to meet the complex needs of residents who have been admitted. Quality in this outcome area is considered adequate. EVIDENCE: Currently there are five residents living at this care home. The inspector saw copies of the staff rota covering a period of four weeks from 21/08/06 to 17/09/06. Rotas seen showed there are adequate numbers of staff to provide care and support to residents. According to information supplied by the registered provider, there is evidence to demonstrate the care home has made a commitment to ensuring staff provided with opportunities to enrol on courses leading to the National Vocational Qualification (NVQ) in Care at Level 2 and above. Staff have also received mandatory training in Health and Safety; Food Hygiene; First Aid; Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 21 Fire Safety; Medication and Manual Handling. In addition staff have also received training in Conflict Management; Adult Abuse and Epilepsy Awareness. Three members of staff have been appointed since the last inspection, one of whom is no longer working at the care home. According to records seen one member of staff had started work before a criminal records check had been obtained. The deputy manager advised the inspector that it was thought the POVA check was sufficient to enable to member of staff to start work. The acting manager was advised of the requirements of current legislation should a member of staff commence work without a criminal records check. This will ensure residents are protected from the possible risk of abuse. The inspector expressed concern regarding the lack of training and skills within the staff team with regard to the specific needs of residents accommodated. This was in particular regard to the resident who was readmitted to the care home despite displaying violent and aggressive behaviour. Details of the resident’s care needs were included in records seen at the time of the visit. Records seen included a document with a list of do’s and don’ts for staff to follow. This includes, “do use a person centred approach”; “do not offer open ended choices”; “do try to understand the complexities surrounding your client group”; “do use a young approach, ensuring your verbal and body language is open and friendly.” There was no evidence to confirm that staff at Victoria Lodge had received training to provide them with the necessary skills, knowledge and understanding to successfully follow any of this guidance. In addition, the inspector saw a document written by a Locum Consultant in Psychiatry, who recommended the resident be placed in a home with carers trained in breakaway techniques. Only five of the eleven staff had completed training in breakaway techniques. The issue of staff training, to ensure they can do the work required of them, is a regulatory issue. This has, therefore been made a requirement. Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The registered provider has taken appropriate action to ensure residents’ benefit from a well run home. A representative of the registered provider visits the care home regularly and speaks to residents and their relatives to ensure their views underpin all self monitoring, review and development of the home. The registered provider has taken appropriate steps to ensure the health, safety and welfare of service users are promoted and protected. Quality in this outcome area is considered good. EVIDENCE: Currently the registered manager is on maternity leave. The registered provider has appointed the deputy manager to act as manager during this period. The registered provider has also ensured this person receives support from a more senior person to ensure they are able to fulfil the tasks required of them. Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 23 The inspection has identified some requirements to ensure Victoria Lodge is being run in accordance with the requirements of current legislation. This includes improvements to the practices/procedures for admitting new residents; improvements to recruitment practices and provision of further training to ensure staff have the necessary skills to meet the complex needs of residents. The registered provider has continued to ensure a representative visits the home regularly to monitor the management of the home. Copies of reports of such visits have been made available to the Commission. Reports seen indicate that, where possible the visiting representative will speak to residents, or their relatives to ensure their views underpin self monitoring development by this care home. Information supplied by the registered provider prior to the inspection confirmed that the premises and equipment had been checked and maintained regularly to ensure the safety of residents and staff. According to the same information, the inspector noted that, on seven separate occasions incidents and accidents to residents have resulted in residents being taken to hospital for treatment. However, the Commission has not received notification of such incidents. Following discussion, the deputy manager was not aware that this was an expectation under current legislation. The deputy manager was unable to confirm that it was the practice to regularly review accidents to find out if there was a pattern of such incidents and if anything could be done to reduce their occurrence. It is recommended, as a matter of good practice, that such a system is developed. Victoria Lodge DS0000040980.V307907.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 Adults 18-65 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 2 3 3 2 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 3 x 3 x x 3 x Victoria Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 25 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 YA3 Regulation 14 (1) (d) Requirement Timescale for action 30/10/06 2. YA6 15 (2) (b) and (c ) 3. YA18 12(1) (b) 4. YA35 18 (1)(a) The registered person shall not provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so, the registered person has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare. The registered person shall keep 30/10/06 the service user’s plan under review; where appropriate and, unless it is impracticable to carry out such consultation, after consultation with the service user or a representative, revise the service user’s plan. The registered person shall 30/10/06 ensure that the care home is conducted so as to make proper provision for the care and, where appropriate, treatment, education and supervision of service users. The registered person shall, 30/10/06 having regard to the size of the care home, the statement of DS0000040980.V307907.R01.S.doc Version 5.2 Victoria Lodge Page 26 5. YA35 18(1) (c )(i) purpose and the number and needs of service users- ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users- ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform, including induction training. 30/10/06 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 Lodge DS0000040980.V307907.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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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