Inspection on 27/10/05 for Victoria Lodge

This inspection was carried out on 27th October 2005.

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

The inspector 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 Lodge 31/01/08

Victoria Lodge 28/11/06

Victoria Lodge 06/05/05

Victoria Lodge 20/10/04

Victoria Lodge 08/06/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

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Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Victoria Lodge 11 Victoria Road Acocks Green Birmingham West Midlands B27 7XZ Lead Inspector Kath Strong Unannounced Inspection 27th October 2005 10:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Victoria Lodge DS0000017040.V262340.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Victoria Lodge DS0000017040.V262340.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Victoria Lodge Address 11 Victoria Road Acocks Green Birmingham West Midlands B27 7XZ 0121 707 7921 0121 707 7626 care@victoria-lodge.co.uk 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) Ms Susan Howard Ms Gillian Rea Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Victoria Lodge DS0000017040.V262340.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 06/05/05 Brief Description of the Service: Victoria Lodge is a large, double fronted mid Victorian residence. It stands back from the road within its own grounds. The building has been adapted and extended to provide accommodation for 18 elderly persons. There is off road parking situated at the front of the premises. There is a large lawned area and patio situated to the rear of the building, which is accessible from the main lounge. The home is located within a residential area of Acocks Green and a short walking distance from all local amenities. Public transport is available close by providing access to Birmingham City centre approximately five miles to the north and Solihull six miles south. Resident’s accommodation is located on three floors. There are single rooms some with en-suite facilities (toilet and wash hand basin); there are also three comfortable shared rooms. The home does provide respite facilities. There are communal toilets and bathing facilities including assisted bathing located throughout the home. The ground floor provides a quiet front lounge and a dining area leading onto the large lounge, which overlooks the pleasant rear garden. There are dedicated kitchen, laundry facilities and a main staff office. The home owner is planning to extend the home to increase the number of bedrooms and to improve the layout of others. It is anticipated that works will be completed Spring 2006. Victoria Lodge DS0000017040.V262340.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to conduct an unannounced inspection. The outcome was determined by a number of means. In depth discussions were held with the registered provider and four residents were spoken with individually. Relevant documentation was examined including two care plans, which included cases tracking in order to ensure that all of the respective residents needs were being met. A tour of the premises was carried out and an overview of the arrangements in place for the onsite contractors to ensure that residents privacy was not being compromised. At the conclusion verbal feedback was provided to the registered provider. Previous inspections of this home have been without exception positive; standards of care have been consistently good. This inspection is restricted to the few outstanding requirements, the few key standard not assessed at the previous visit and the means deployed for the extension works currently in progress. In order to gain a full overview of the home it is recommended that this report should be read in conjunction with the report from the inspection carried out 6th May 2005. What the service does well: What has improved since the last inspection? Victoria Lodge DS0000017040.V262340.R01.S.doc Version 5.0 Page 6 Although the home provides a safe system of the administration of medications regular checks by the pharmacist have been implemented as well as spot checks of staff practices. The quality assurance programme has been reviewed and a new system of auditing introduced which provides clear guidelines and rationale regarding quality assurance. The tool for annual staff appraisals has been extended; staff now complete a pre-meeting questionnaire, which forms an integral element of the process. Building works were in progress with the least possible disruption, there was evidence that the comfort and privacy of residents was being maintained. Residents talked freely about the works, no negative comments were made. 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 DS0000017040.V262340.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria Lodge DS0000017040.V262340.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4 and 5 The home carries out an extensive pre-admission assessment in order to ensure that it is able to meet the identified needs. EVIDENCE: The tool utilised for pre-admission assessments complies with all items listed within standard 3.3 and the Bettal quality assurance system. Reports from other health care professionals are also acquired prior to a placement being offered. Visits to the home are encouraged and prospective residents can use the opportunity to talk with permanent residents and to sample the food. If the home determines that nursing care is required external professionals are consulted and subsequent assessments are carried out in order to identify the appropriate needs. Relatives are consulted and kept fully informed. It was determined that standards 1, 2 and 3 were fully met at the previous inspection. Victoria Lodge DS0000017040.V262340.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 and 11 Health care needs of residents are being fully met with evidence of a proactive approach to the involvement of external professionals. Staff practices revealed that residents are treated with dignity and respect. EVIDENCE: As with previous inspections care plans were found to be detailed, all information in respect of physical and mental health needs were well documented. Emphasis is placed upon the safety of residents and regular reviews were being carried out with the input of the respective resident and/or the relatives. Files included information about the family history, background, likes and dislikes, hobbies and preferred routines of daily living. Care staff compile their own files for each resident, which are updated during each day and night shift. The advice provided by multi-agency professionals was well documented and adhered to. Family members or a carer provide escort duties for health care appointments. Victoria Lodge DS0000017040.V262340.R01.S.doc Version 5.0 Page 10 The registered provider described the processes established for the current building works in order to ensure that resident’s comfort and privacy is not compromised. Residents reported that they were unconcerned about the works being carried out. Very ill residents are given a choice regarding admission to hospital or to remain at the home. The decision reached is following consultation with relatives, the GP and others involved in the care. It was determined that standard 9 was fully met at the previous inspection, subsequently further auditing processes have been introduced. Victoria Lodge DS0000017040.V262340.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 15 Emphasis is placed upon the involvement of residents with the recreational programme. There is provision of a varied menu to enable residents to exercise choice and control over the food they eat. EVIDENCE: The registered provider advised of the planned meeting to be held with relatives to discuss and agree the Christmas festivities. Normal practice is for relatives to participate with some of the festive activities. A carol service has been arranged and the charity theme for the year. Regular outings are arranged such as fish and chip supper, which was actioned as a result of requests from residents. One resident who is a keen gardener assists with light gardening tasks such as making up hanging baskets. Staff were observed asking each resident what they would prefer for their evening meal. The registered provider advised that snacks available at suppertime had recently been reviewed. The menu indicated that cooked food was offered at breakfast time and two choices given for lunch, which constitutes the main meal of the day. It was determined that the meals provided a nutritious and varied diet and that dietary needs were catered for. Lunch was observed being served. The procedure was carried out discreetly with assistance offered where appropriate. The meal was well presented. Victoria Lodge DS0000017040.V262340.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No standards were assessed. EVIDENCE: It was determined that standards 16, 17 and 18 were fully met at the previous inspection. Victoria Lodge DS0000017040.V262340.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 and 26 The home provides a comfortable and pleasing environment for those persons living there. Full compliance with the National Minimum Standards has not yet been fully achieved. EVIDENCE: The location and layout of the home appeared fit for its stated purpose. Ramped access is available at the front and rear of the premises. The home is well decorated and furnished to a high standard throughout whilst being well maintained. Due to the building works access to the rear garden is restricted. Upon completion of the works this will result in up grading of some of the current bedrooms, additional bedrooms and improved bathing facilities. It is anticipated that the outstanding requirements will be addressed with the current works schedule, which is due for completion Spring of next year. The protracted time has been agreed in order to stage the works thus ensuring minimal disruption for residents. Victoria Lodge DS0000017040.V262340.R01.S.doc Version 5.0 Page 14 Communal areas are bright and cheery and appeared acceptable for the current client group. The call system does not extend to communal areas; therefore the requirement in respect of this will be carried forward. Bedrooms vary in size and layout; those visited were noted to be very personalised. The systems in place regarding the kitchen and laundry were found to be satisfactory with health and safety being paramount. Rooms did not have an adequate supply of electrical sockets and suited door locks, however these issues are included within the works schedule. The registered provider also advised that radiator guards would also be fitted but in the meantime radiator and water temperatures were being checked daily. Good hygiene levels were being maintained irrespective of the building works. Victoria Lodge DS0000017040.V262340.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 Recruitment practices are sufficiently robust to protect residents from harm. EVIDENCE: Two staff files were examined including the latest recruit. They were found to be satisfactory with all relevant checks being carried out prior to a post being offered. It was determined that standards 27, 28 and 30 were fully met at the previous inspection. Victoria Lodge DS0000017040.V262340.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 Health and safety practices carried out ensure the protection of residents and staff. EVIDENCE: All respective checks and servicing have been carried out including risk assessments for the premises and the presence of the contractors on site. Regular fire alarm and emergency lighting checks are carried out and documented. Staff participate in the six monthly fire drills. No concerns were noted during the inspection. It was determined that standards 31, 33, 35 and 36 were fully met at the previous inspection. Victoria Lodge DS0000017040.V262340.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 3 3 2 2 2 2 2 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 Victoria Lodge DS0000017040.V262340.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? YES 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 OP21 Regulation 23(2)j Requirement The registered person must ensure that there are a sufficient number of adapted bathing facilities in the home. The registered person must ensure that all areas of the home used by residents have an accessible call system. The registered person must ensure that bedrooms provide two double electrical sockets. The registered person must ensure that bedroom doors have suited locks in place. Radiators throughout the home must be guarded. Timescale for action 30/04/06 2. OP22 23(2)n 30/04/06 3. 4. 5. OP23 OP24 OP25 23(2)e 12(4)a 13(4)c 30/04/06 30/04/06 30/04/06 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 DS0000017040.V262340.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Lodge DS0000017040.V262340.R01.S.doc Version 5.0 Page 20 - 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. 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