Inspection on 17/04/08 for Victoria Lodge

This inspection was carried out on 17th April 2008.

CSCI found this care home to be providing an Poor service.

The inspector found no outstanding requirements from the previous inspection report, but made 9 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 30/07/07

Victoria Lodge 13/09/06

Victoria Lodge 15/11/05

Victoria Lodge 10/05/05

Victoria Lodge 13/12/04

Victoria Lodge 14/06/04

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Southfields

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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 Ian Craig Unannounced Inspection 17th April 2008 11:00 Victoria Lodge DS0000040980.V361173.R02.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.V361173.R02.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.V361173.R02.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.V361173.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th July 2007 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. At the time of the visit 5 residents were accommodated. The home is in a residential area in Bognor Regis. The building is detached and has surrounding gardens. There is an annex to the house that is currently used as an activities room. The service aims are to assist residents to develop independent living. The weekly fees range from £1378.00 to £2176.00. Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. The visit was unannounced and lasted for 6.5 hours. The acting manager and the area manager were involved in the inspection. Information was used for this report from the following sources: • The Commission’s records • Communications from relatives of people who use the service • Communications from care managers and other health and social care professionals • Discussions with 2 staff on the day of the visit • Discussion with a resident • Observation of staff working with residents • Documents, records and policies and procedures at the home • A tour of the building • The Annual Quality Assurance Assessment completed by the home Caretech Community Services acquired Victoria Lodge Ltd on 29th April 2008 which became a subsidiary of Caretech Community Services. This means that although the registered provider remains as Victoria Lodge Ltd, Caretech Community Services has taken over operational responsibility for the home and have already stated its commitment to addressing the requirements of this inspection and to improving the service. What the service does well: Comprehensive assessments are carried out by the home for those referred for possible admission. There are opportunities for potential residents to come and look round the home and to spend time with the staff and the other residents. This helps potential residents to decide if they wish to move in. There are recorded guidelines for supervising residents, although these need to be expanded in several instances. A resident described how he/she is supported in dealing with emotional needs and is aware of an action plan agreed with the home. Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 6 Residents are encouraged to develop independent living skills. Records show that residents’ daily personal care needs are addressed. A resident’s relative commented how the people who live at the home are kept clean and how well clothed the residents are. Health needs are monitored, including weight. Arrangements are made for health checks with opticians, dentists and general practitioners. There are opportunities for residents to attend a variety of activities, including attending college courses and social events. There are regular outings based on the needs and wishes of the individual residents. Each person is involved in devising his or her activity programme. The home has its own minibus for transporting residents to activities. There is no charge for the use of this transport. The home also has a budget for providing holidays for residents. There is a ‘craft room’ where residents can involve themselves in artwork and other creative hobbies. Newly appointed staff receive an induction. Staff have access to a variety of training courses including National Vocational Qualifications in care. A relative commented how the home takes account of the preferences of each person living at the home. For instance, individuals and their relatives are asked about colour schemes for bedroom redecoration. What has improved since the last inspection? What they could do better: Consistent and improved management of the service is needed to ensure that residents’ needs are met. Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 7 Improvements are needed to the supervision of residents to minimise the number of incidents resulting in injury to residents. Care plans and assessments should be improved so that care and behaviour needs are met. There is a lack of clarity about how the home deals with incidents affecting the safety of residents. Improvements are needed regarding liaison with social services, in order that residents receive adequate protection. Improvements are needed to ensure that staff who administer medication by injection have received the required training. Numerous repairs are needed to the home’s interior. At the time of the visit decorators were completing repairs and redecoration. The recruitment of staff needs to improve to ensure that newly recruited staff only commence work after 2 written references are obtained. Records need to be maintained of incidents referred to the Commission as required by Regulation 37. Routine testing of the fire alarms needs to take place. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 8 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.V361173.R02.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with information about the services provided by the home and there are opportunities for potential residents to have a look around the home to help them decide if they wish to move in. The home carries out its own assessments of need of those referred for possible admission, which includes liaison with health and social services. This ensures the home admits those whose needs it can meet. EVIDENCE: The home has a Statement of Purpose and a Service Users’ Guide, which contain information about the home. These are in pictorial format for easier understanding by the residents. A copy of each of these documents is contained in each resident’s file. The process of assessing the needs of those referred to the home for possible admission was looked at. This shows that the home carries out its own Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 10 comprehensive assessment, which includes an initial assessment plus a fuller assessment covering the following needs: pen portrait, health needs, psychological support and mental health needs, managing emotions, potential triggers, communication skills, daily living skills, self care skills, relationship and sexual needs, community presence and participation, employment and education, recreation/relaxation and finance. Records also show that the home liaises with relevant health and social services, obtaining needs assessments, reviews of multi agency reviews and guidelines for providing care. A resident described how he came to have a look round the home so that he was able to make a decision about whether or not to move in. This included having an evening meal with the staff and residents. Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments need to be in greater detail to show how staff are to deal with more specialist needs relating to behaviour and medical conditions. People who live in the home are able to participate in the decision making in the home and in making choices about how they lead their lives. EVIDENCE: Each person has a ‘Service User Day File,’ which contains details of health and personal care needs, as well as details of risk assessments as follows: • Weekly planner and overview of immediate goals to be met • Service user daily information Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 12 • • • • • • • • GP and psychiatric appointment record Chiropody and hospital appointment records Optician and dentist appointment records Weight chart Bowel chart Personal care chart Seizure chart Risk assessment and guidelines Care plans are completed each person with immediate, medium and long terms aims. Assessments are carried out when there is an identified risk for a resident. This includes travelling in the minibus, going out in the community, neurological conditions and behaviour. Each person has a Cultural Needs and Diversity Assessment Care Plan, detailing the person’s preferences in respect of music, language, food, sexuality and religion. Care plans and risk assessments need to be expanded in the following areas: • Greater detail of how staff are to intervene to minimise risks associated with neurological conditions • The risks associated with mobility needs and how staff should provide supervision to minimise the risks of injury • Assessment of the risks and care plans associated with residents receiving medical attention There is a format for the monthly review of care plans. The home has a keyworker system whereby each resident has an allocated staff member responsible for coordinating arrangements for care. The home’s management hold meetings with keyworkers to discuss residents’ needs. Residents are involved in devising aspects of their care plan, such as weekly and daily activity plans. A resident described his/her care plan acknowledging agreement to how staff help him/her with developing independent living skills and dealing with emotional needs. There is also evidence in the records that residents’ individual preferences are assessed and acknowledged in daily routines. There is choice for residents in the food they eat and in the activities they take part in. Each resident signs to acknowledge agreement to their activities programme. Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are opportunities for residents to develop independent living skills as well as attending activities for occupational, educational and social needs based on individual preferences. Residents are provided with a nutritious and varied diet. EVIDENCE: Each person has a weekly planner showing individual resident’s planned activities. Records show that individual preferences are assessed and there is a Cultural Needs and Diversity Assessment and Care Plan reflecting each person’s preferences and needs for language, food and relationships. Daily Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 14 running records show that residents are supported with a varied activity programme including shopping trips, meals at pubs and restaurants, and excursions to Brighton. A relative of a resident described how the residents are supported to have regular outings from the home. A resident described how he/she is encouraged to be independent and that staff offer support and guidance with cooking, cleaning and changing bed linen. Residents are able to develop cooking skills, which staff provide support with. One resident described how he/she attends cookery classes at a local college. Educational courses are also attended such as in performing arts. Residents sign a record acknowledging agreement to their individual activities plan. The home has a crafts room where residents can paint and take part in other creative activities. There is a holiday budget for each resident and the home facilitates residents having a holiday or day excursions as an alternative. Since the last inspection a relative has complained that a resident has not had a holiday for 2 years. It is understood that this has been addressed by the resident’s care manager at social services. The home has its own transport for taking residents out in the community. There is no charge for the use of the minibus by residents. Care plans include details of how residents access community facilities as well as family and personal relationships. A relative confirmed that there is contact between relatives and the home’s staff regarding the arrangement of suitable activities. Assessments of need include recreational, employment and educational needs. The home has a menu plan showing varied and nutritious meals based on the choices of the residents. Fresh fruit is available in the kitchen. Residents’ records include guidelines for diet. Victoria Lodge DS0000040980.V361173.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health and personal care needs are met with the exception that staff are administering medication by injection without the required training; this places residents at risk. EVIDENCE: Records detail daily care routines for each resident and include teeth cleaning, continence needs and personal hygiene. A relative confirmed that personal care needs are addressed. Each person has pro form for monitoring health care needs entitled, ‘Health Action Plan.’ These show that residents receive feet care from a podiatrist, have regular checks with opticians and dentists. Records also show that health checks are arranged regularly and when required at short notice. Weight is Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 16 monitored. There is liaison with specialist health professionals such as psychiatric services and speech and language therapy services. Staff have received training in working with residents who have neurological needs. Medication procedures were checked. Records are maintained when staff administer medication to residents. The home has a medication policy and staff are trained by the organisation and the supplying pharmacist in handling medication. There are specific procedures where staff receive training from the district nursing team in administering insulin by injection, which includes written confirmation that the individual staff member is competent in this task. It was identified that one staff member was carrying out this task without the required training. The area manager present at the time of the visit was unaware of this and expressed a commitment for this staff member to cease this practice immediately. A letter was sent to the home following the inspection, highlighting that only staff who have been trained and deemed competent by the district nurse in this practice are permitted to administer injections. Victoria Lodge DS0000040980.V361173.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home’s procedures for dealing with complaints and incidents involving the safety of residents are unclear with the potential for residents to be inadequately protected. EVIDENCE: The home’s complaints procedure is available in the home. The visit included confirmation that the home’s procedure is that any complaint made is recorded in a complaints log with details of how the complaint is investigated and any outcomes. It was noted that a recent complaint had not been logged and there were no details available to say how the matter was being dealt with. Following the inspection there was discussion with two people form Beacon Care, including the area manager, and it was not clear who should have dealt with the complaint. The complainant stated that he/she has a useful dialogue with a representative of Beacon Care who listens and deals with any concerns. Whilst the complainant stated that his/her complaint has been addressed there has been no written or verbal acknowledgement of the complaint, nor, written or verbal response regarding any action the home may be taking. Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 18 There is a copy of the local authority adult protection procedures. Discussions with staff and management, as well as training records, show that staff receive training in adult protection. Since the last inspection, a staff member has been dismissed for assaulting a resident. Records show that incidents have occurred where residents have received an injury, which should have prompted a referral to social services, for possible consideration under the safeguarding adults procedures. Records of these incidents are inconsistent. Incident forms could not be found for several events and others were found in piles of paper on top of desks and cabinets in the office. For 3 incidents there was no record to show that any contact had been made with social services for advice or consideration under safeguarding procedures. In one case there was a copy of an e mail that referred to an incident being referred to the social services’ care manager. A letter was sent to the home by Commission immediately following the visit highlighting that the home must notify social services of events where the safety of residents is affected so that social services can consider if the safeguarding adults procedures needs to be implemented. The Commission was notified of one incident affecting the safety of a resident, which the Commission referred to social services for consideration under the safeguarding adults procedures. At the inspection, further correspondence from a different person at Beacon Care was seen retracting the complaint. It appeared that the two people had a different interpretation of the event. The home has not fully reviewed the resident’s needs in this area. Clear guidelines for staff from the home to follow to reduce the risk of injury are not recorded. The letter retracting the allegation partially addresses this. Social services confirmed that the allegation has been referred to them but has since been retracted. Social services also confirmed that a multi agency decision will be made regarding the matter. The home’s procedures for supporting and handling residents’ finances were checked. Staff were observed recording any incoming and outgoing amounts including a balance. The home’s management showed an awareness of the protocols and issues involved in protecting vulnerable residents’ finances. Staff receive training in procedures for dealing with aggressive behaviour by residents. This involves identifying ‘triggers’ that may lead to aggression and procedures for deescalating situations with an emphasis on non-physical intervention. Guidelines are recorded for staff to follow in handling individual resident’s behaviour. In view of the number of incidents involving aggression between residents there is a need for these to be reviewed so that staff are following the correct procedures. Victoria Lodge DS0000040980.V361173.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is sound, spacious and has good facilities for the residents, but is in need of refurbishment and repair in many areas. EVIDENCE: Each bedroom has an en suite toilet with a wash hand basin. One en suite facility also has a bath. Bedrooms have been personalised with posters, hi fi, televisions and other personal items. A resident described how much he/she likes his/her bedroom. A relative confirmed that residents and their representatives are given a choice about colour schemes when their bedrooms are redecorated. Bedrooms are of a good size. Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 20 The home has a lounge/dining room on the ground floor and a second lounge on the first floor. In addition to this there is a craft room where residents can take part in arts and craft activities. There is a garden to the front, rear and side of the house. Residents look after a pet rabbit, which is kept in a hutch in the garden. As well as having the en suite facilities there is a communal ground floor bathroom with a hoist for those with mobility needs and a further bathroom on the first floor. At the time of the inspection decorators were making repairs and redecorating bedrooms. It was noted that the following are in need of attention: • Stained carpet outside the kitchen door. • Stained and damaged carpet in the living/dining room. • Damage to wall in living/dining room • Paintwork peeling on the wall and ceiling above the sink in the kitchen • Damaged work surface of a kitchen unit • Damage to the interior window frame in the ground floor bathroom • Paintwork peeling in en suite bathroom • Loose floor covering and shower curtain and rail on the floor in first floor bathroom In December 2007 the Commission received a complaint from social services about the state of the premises. A letter was sent to the home regarding this. Residents’ movement around the home is restricted for safety reasons. There is a door at the foot of the stairs, which has a coded lock to help prevent injury to residents. This is a longstanding arrangement. The kitchen is also locked when staff are not present. A care manager commented that there appears to no reason for this. This was discussed with the home’s management who stated that the arrangement is to prevent injury. There is no recorded assessment of why this restriction is needed. It was noted that there was a significant risk to a resident being able to access a mains electrical fuse box. This was addressed at the time of the inspection. Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides sufficient staff to met the needs of the people who live there. Staff have access to a variety of training courses but the practice of allowing staff to administer medication without proper training places residents at risk. Residents are not adequately protected by the home’s recruitment procedures. EVIDENCE: The home aims to provide at least 4 care staff on duty from 8am to 8 pm each day plus a manager. This includes one resident having one staff member allocated to meet his or her needs during these times. Observations, the staff rota and discussions with staff show that these staffing levels are being maintained. At night time there are 2 ‘waking’ staff on duty. Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 22 Newly appointed staff have an induction programme to introduce them to the home’s policies and procedures. This is a set format based on nationally recognised induction standards for residential services and includes training in the following: philosophy of care, health and safety, food hygiene, infection control and specialist care needs. A certificate is awarded when the induction is complete. A recently appointed staff member confirmed that he/she completed an induction. Discussions with staff and records show that staff receive supervision. A care manager, two relatives of residents and care staff commented on the high turnover of staff and managers, which has had a negative effect on the running of the home and the continuity of care for the residents. The home employs 10 care staff and the inspector was informed that 5 of these staff have started work in the last 12 months. Staff were observed to interact with the residents with affection and a rapport. Care staff demonstrated a commitment to promoting the welfare of the people they care for. One staff member stated that the management of the care staff could be improved saying that the staff do not always work as a team and that staff are often unsure of who is doing what. There is a training programme for the staff and 60 of the care staff have either attained, or are studying, the National Vocational Qualification in Care (NVQ)level 2 or above. Two staff members’ training records were randomly chosen to look at. Both are studying for the NVQ level 3 and one has NVQ level 2. In addition to this, the following training has been completed: medication, first aid, health and safety, moving and handling, infection control, adult abuse awareness, vulnerable adults risk assessment, dealing with aggression and violence, fire safety and epilepsy awareness. Recruitment procedures were examined for two staff who have recently started work at the home. These show that the required checks are completed prior to the staff starting work, with the exception that only one written reference had been obtained for each person. Records show that a second reference had been requested but not returned by the referee. Staff have an interview, which is recorded, and each person makes a declaration of health. Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Management of the home has been inconsistent. Records are poorly maintained and the home’s policies and procedures are not being followed to the extent that has the potential to adversely affect the welfare and safety of the residents. EVIDENCE: At the time of the last inspection, 30/07/07, the home did not have a manager. There have been two acting managers since the last inspection. The Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 24 acting manager at the time of the visit was an interim arrangement. Staff and two relatives comment that there have been numerous management changes and that there hasn’t been a permanent manager for the last 12 months. At this visit it was found that a number of records regarding incidents happening to residents were either not available or were found after looking in piles of paper in the office. Policies and procedures are not being followed for dealing with complaints and incidents that affect the welfare and safety of residents. There is a lack of evidence of records when referrals should have been made to social services. There is contradictory information given from differing people in Beacon Care regarding one incident. The home has procedures for checking and monitoring its own performance. At the time of the visit these were partially implemented. The home has an annual development plan covering medication procedures, health and safety, environment and staffing. There is a document entitled Annual Quality Management Cycle, which was last completed in July 2007. Surveys are sent to residents and their relatives and professionals. The findings from these surveys have not been collated or incorporated into any action plan. Health and safety procedures were looked at. Radiators are covered to prevent possible burns to residents. Temperature controls are installed on baths and shower taps to prevent possible scalding to residents. The water temperature is also checked each month and a record maintained of this. First floor windows are restricted to prevent the likelihood of falls. Appliances and equipment are tested and serviced by suitably qualified persons. This includes electrical appliances, gas heating, and electrical wiring. A recommendation was made in November 2007 by a heating engineer that the home’s gas boiler should be replaced. Fire safety records show that fire drills and instruction for staff in fire safety take place. Fire safety equipment is serviced. The fire alarms were not tested between the following dates: 21/01/08 and 10/04/08. This should take place on a weekly basis. The home has a fire safety risk assessment. Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 25 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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 1 X 2 1 1 2 X Victoria Lodge DS0000040980.V361173.R02.S.doc Version 5.2 Page 26 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 YA6 Regulation 15 Requirement Care plans must detail how specific care needs are to be dealt with so that there is sufficient information for staff to follow. This includes: • Dealing with emergency neurological conditions • Needs relating to mobility where there is a risk of injury • Dealing with routine medical appointments where there is an identified risk Risk assessments must be carried out for individual residents where there is identified risk, such as neurological conditions, mobility and behaviour when receiving medical treatment. Action must be taken to minimise identified risks and hazards to residents. 3 YA20 13(2) Where residents require that staff administer medication by injection each staff member carrying out this must be DS0000040980.V361173.R02.S.doc Timescale for action 30/05/08 2 YA9 13(4) 30/05/08 18/04/08 Victoria Lodge Version 5.2 Page 27 trained and deemed competent by the district nurse with verification of this by the district nursing service. 4 YA22 22(3)(4) The home’s complaints procedure must be followed. Any complaint must be logged, fully investigated and the complainant informed of the outcome of the investigation within 28 days. Where appropriate, incidents involving injury to residents must be notified under safeguarding protocols to social services. A record must be maintained of this. Where residents are restricted from accessing parts of the domestic environment this must be supported by an assessment highlighting the risks to residents and the reasons for the action being taken. 30/05/08 5 YA23 13(4)(6) 18/04/08 6 YA24 23 30/05/08 7 YA24 23(2)(b)(d) The home must be in good decorative order and following addressed: • Stained carpet outside the kitchen door. • Stained and damaged carpet in the living/dining room. • Damage to wall in living/dining room • Paintwork peeling on the wall and ceiling above the sink in the kitchen • Damaged work surface of a kitchen unit • Damage to window of the interior window frame in the ground floor bathroom • Paintwork peeling in en suite bathroom DS0000040980.V361173.R02.S.doc 17/07/08 Victoria Lodge Version 5.2 Page 28 • Loose floor covering and shower curtain and rail on the floor in first floor bathroom 8 YA37 8 The home must appoint a skilled 17/05/08 and experienced manager on a permanent basis. The manual fire alarm must be tested on a weekly basis and a record maintained. 17/05/08 9 YA42 23 (4) 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.V361173.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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