CARE HOMES FOR OLDER PEOPLE
Victoria Lodge 11 Victoria Road Acocks Green Birmingham West Midlands B27 7XZ Lead Inspector
Jill Brown Key Unannounced Inspection 28th November 2006 09:20 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.V321665.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 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.V321665.R01.S.doc Version 5.2 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 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 27th October 2005 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 24 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 two floors. There are 22 single rooms all with en-suite facilities (toilet and wash hand basin); there are also two 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 has just completed an extension to the building and the extra bedrooms are finished to a high standard. The full fees for the home were between £368.00 and £385.00 per week. Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The home was visited unannounced in November and the inspector carried a key inspection looking at most of the National Minimum Standards. This inspection took about 9 and a half hours. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. During the inspection the inspector spoke with three residents, one relative, three staff members and a district nurse as well as the owner and the manager of the home. The inspector received 11 comment cards from relatives and 13 comment cards that had completed with residents and one comment card from a GP. Records for three residents were looked at as well as for two staff. Medication records and records of residents money were sampled. Records of maintenance and inspection of some of the building services were sampled. A tour of parts of the building was undertaken earlier in the year as part of checking the new building and also on this inspection parts of the building were sampled. The Commission had received no complaints or comments since the last inspection. What the service does well:
The home has available detailed information for residents and their representatives in the Statement of Purpose and Service User Guide. The Service User Guide is left in residents’ rooms for them or their representative to pick up and check at any time. This guide is on the homes computer and the print size can be changed to help residents with sight impairments. The home has put some computer pictures on to help residents know what each section is about. A number of residents at the home were unable to remember that this information was in their rooms. However comment cards suggested that relatives were aware of this information. Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 6 All resident files contained a contract informing them about the terms and conditions of their stay. Residents were not always aware of these however comment cards suggested that relatives were. One resident sad that the home assisted them when they first came into the home to get everything sorted. Residents have an assessment before being admitted to the home and these assessments were detailed and reflected the individual residents needs and preferences in how care is delivered. Residents spoken to said that the home had got to know them before they got admitted and made arrangements for staff they know to be on duty when they came in. The home ensured that every resident has a care plan that tells staff how the care should be given. This information is summarised so staff to remind them of the help needed can use it quickly. The residents Health Care needs were met. The home showed that were quick to identify and deterioration in health and ensure that appropriate health professionals were informed. A district nurse spoke of ‘sharing the care ‘ with the home. A GP stated that the home provided ‘exemplary care’ and that they had ‘no concerns for any of their patients.’ One relative stated that the improvement in their relatives health was ‘measurable’ after admission. The manner in which staff help residents with personal care was appropriate and kind. Relatives spoke of the ‘very pleasant and happy atmosphere of the home’, a resident said it was ‘better than I thought a care home could be.’ The home provides activities on a daily basis and has the benefit of a minibus, which allows those residents that wish the opportunity of visits out. Residents are encouraged with assistance to go out to the local shops if able and to maintain good contacts with relatives and friends. There was no restriction of residents walking around the building or going to their rooms if they wished. Residents spoken to were happy with the food. The home offers a choice of food at each meal time and residents were monitored for changes in appetite as part of overall health monitoring. The homeowner has meeting s with relatives and residents routinely to talk about concerns, and improvements the home can make and this openness tends to prevent concerns being complaints. The home was clean and fresh, well furnished and decorated. The levels of staffing were good. The home had ensured that 65 of care staff had an NVQ2 in care and further care staff were receiving this training and this is commended. Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 7 The home is managed by an experienced and qualified manager that showed an eagerness to improve the wellbeing of residents. The homeowner was involved and visited the home almost on a daily basis. The home has an independent quality assurance assessment but also the homeowner checks the home’s performance against the National Minimum Standards and this is commended. The home assists residents to manage their finances and assists relatives and residents manage small floats of money for hairdressing and so on. All sampled maintenance and inspection records for services such as gas and electric were in place and in date. What has improved since the last inspection? What they could do better:
Whilst the home has good care plans they need to show what ‘triggers’ or indicators staff should be aware to show that a resident with a mental health condition is becoming unwell. The home needs to ensure that reviews of a resident’s ability to safely undertake self medication is done in a timely way. Whilst the home provides activities they are not always showing in records that this is happening. The home need to be clear about the start date of staff so that supervised induction does not appear to show that staff have not had necessary checks before starting work. Whilst staff have good basic training, update training needed to be recorded in a way that showed when the last update training happened. Records of staff that have had adult protection training as part of their NVQ2 needed to be kept and the trainer of moving and handling and so on had to have their training certificate in date.
Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 8 Whilst the manager oversees staffs performance whilst on shift some changes to formal supervision could assist in the key working and reviewing of residents needs. 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 DS0000017040.V321665.R01.S.doc Version 5.2 Page 9 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.V321665.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 &5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home supplies the level of information required by legislation and tries to make this as accessible to residents that are admitted to the home. Residents have their needs assessed by the home and the home keeps this under review. Staff are aware of and are able to meet the needs of the residents in the home. EVIDENCE: The home supplied to the inspector updated copies of the home’s Statement of Purpose and Service User Guide at the inspection visit. Copies of the Service User Guide were visible in the resident bedrooms that were looked at. All comment cards received from residents and their families said they had enough information before coming into the home. The inspector spoke to two
Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 11 residents and a relative about the information they received before admission. The residents spoke to could not remember whether they had received information, the relative believed they had. Three more recent residents in the home had short-term memory difficulties and could not comment on this information. The Statement of Purpose had useful information and also some useful service contact details that those residents that are able and relatives can make use of. Both the Statement of Purpose and the Service User Guide are kept on computer and this means that it can be up dated quickly and that the size of the print can be adjusted to the needs of the resident. The Service User Guide contains a list of residents rights and clearly showed that the home has considered the range of ability, cultural experience, sexuality, religion and so on that may influence what the residents expect from the home. The home does not record that the Service user guide has been given at enquiry stage. Staff knew about the service user guide and its availability in residents’ rooms but were unsure if these were given on enquiry. The home has contracts on individual residents files. Residents spoken to said that they had signed something. One resident expressed the opinion that on coming into the home they were very ill and wasn’t aware what was happening but the homeowner discussed it with them and helped them ort out standing orders with the bank. The relative was aware of a contract in part with social services and was aware that this would change once a property was sold. The homeowner stated that fees were discussed with the relatives and residents when Social Services advised them of the contract changes in price. A copy of the contract was given to the inspector. This contract included much of the information given to potential residents and their representatives prior to admission. The home charged a fee for activities of £3.50 a month and this was included in the contract. The homeowner stated that this fee was not charged if the resident did not partake of activities. Residents spoken to were not interested in changes to the contract the home owner stated that the contract had not changed substantially but that they had been advised to put in the contract about care needs increasing and the possibility of increasing the fees. Residents that were not able were not asked to sign the contract, one resident was awaiting the Court of Protection taking over their financial affairs. Staff were aware that residents have a contract as the staff do. Staff interviewed thought the home provided residents with a new contract when the price changed. Residents had good assessments of need that were individual to them and clearly showed residents concerns about their health and personal care. One relative said that a social worker had asked them questions about their relative and was very good. Two residents said that the home had got to know them before admission. One resident came to the home for visits, then day care and then respite care before deciding to make a move into the home. One resident said that a staff member they had got to know helped them when they were
Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 12 admitted to the home. The three residents that had been admitted recently had good assessments on file. The information for the assessment was collected before admission and involved the care manager sometimes visiting the hospitals to gain the information. The information contained residents’ preferences for food and daily routines and this is important as it helps residents to feel comfortable if these preferences can be met. The assessments were in plain English and were easy to read and this makes them accessible for residents, their representatives and staff. A number of the residents admitted have short-term memory loss but are not under the care of a Consultant Psychiatrist for this condition. The care manager has experience in care of older people with dementia and was aware of where a potential residents dementia could not be managed by the home. Residents were asked about their religion and whether they practised this religion or not. Where a resident was unable to state a preference it was noted whether the resident had joined in a religious service at the home and enjoyed it. Staff spoken to were aware of sampled residents’ needs. Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning was individual to the resident and assisted staff to give good care. The health care needs of residents were monitored and met. Medication was administered safely with good checks in place to ensure that medication was accounted for. Residents and relatives were happy that they were treated appropriately and sensitively. EVIDENCE: Residents have care plans and these assist staff in delivering good care to residents. The care manager summarised the care plans so staff have an easy reference guide to the needs residents have and help that they need. Care
Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 14 plans included good information that explained a resident’s mood or behaviour where this was needed. The care plans included risk assessments where necessary for example on moving and handling and mobility. A resident that had a diagnosed condition of depression did not have recorded triggers or behaviour that may suggest that the resident is becoming unwell and this is useful to inform staff. The care plans are reviewed on a monthly basis for any changes however where changes have been seen care plans are amended quickly. Residents’ health concerns were recorded in daily records and acted upon where needed. Residents that had been recently admitted had appropriately increased in weight, one resident had a period of losing weight this was noticed and remedial action taken quickly. Residents that agreed had the flu injection organised for them. A district nurse spoken to was happy with the care the home provided. They spoke of the home ‘sharing the care’ with community district nurse service. They stated that the staff were very helpful and that always asked for advice if they were unsure about anything. A comment card from a GP stated ‘The care home provides exemplary care for residents I have no concerns about the care provided for any of my patients who reside at Victoria Lodge.’ One relatives comment card said ‘My mother was in a spiral of self-neglect prior to moving to Victoria Lodge. The improvement in her health is measurable.’ The home keeps good records of any accidents or injuries that residents have. The home were requested to inform the Commission of incidents where residents sustain an injury. The home advised that no residents are currently on a controlled drug. The home has its medication delivered in a monitored dosage system (NOMAD) and this has the medication for the individual separated out into sections according to the time of day it needed to be given. This medication on the ones sampled had been given correctly. A consultant supplies one medication and the home was managing the difficulty in tracking this three monthly prescription well. The home monitors medication that is not in the monitored dosage system well with an additional sheet to the Medication Administration Record counting down the number of tablets and the ones sampled were correct. One resident had a risk assessment to say that they were safe in selfadministering medication but this had not been reviewed in a timely way. The home has a medicines fridge and the record of the temperatures were not detailed enough. Observation and interviews with staff suggest that residents are treated with respect. Relatives said ‘Victoria Lodge is very pleasant and happy home.’ ‘ We have been very impressed with the whole atmosphere there staff are great and very friendly.’ One resident ‘s comment card said ‘I would be very unhappy to live alone now… this is wonderful for me,’ another said ‘still prefer to be at home but its better that thought it would have been.’ Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided activities for residents that wished on a daily basis but records did not always reflect this. The arrangements for food, visits and choice were good with residents and relatives expressing happiness with the service provided. EVIDENCE: The home ensures that there is a designated activity every day and in addition there is always a singsong at part of the day. During the inspection there was a bingo session and a singsong. Comment cards suggest that the majority of residents were happy with the activities the home provided. There was evidence that residents that had the majority of their care in their rooms were seen regularly and were checked to ensure they remained safe and well. The recording of activities needed to be more consistent. The home has a minibus with a tail lift and a number of residents have the benefit of being taken out in this. A resident was observed talking about wanting a newspaper the owner discussed with them going out with a member of staff to fetch it. However the
Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 16 resident wasn’t keen on going out that day and the newspaper was fetched for them. The homeowner stressed the importance of keeping the routine of going out whilst accepting that today they may not feel like it and this was good practice. Comment cards suggested that relatives and residents were happy with the visiting arrangements. Visiting arrangements were detailed in the Service User Guide and restrictions were only made around meal times. Residents were seen to have freedom of movement within the home. Care plans showed residents preferred routines of getting up and going to bed. During the visit in the summer a resident was seen to be out enjoying the garden. Comment cards suggested that the majority of residents thought that the meals were always good with a number thinking they were usually good. The menus provided showed that residents had a choice of food at meal times. Staff were seen asking residents what they wanted for a meal. The home had good stocks of food available. The cook was aware of what residents were not eating well and had a monitoring system in place to record the amount these residents had eaten and where needed supplements were started. One resident stated that they ‘appreciate the fruit and vegetables on the menu.’ One resident said that they would occasionally like a steak. Whilst this may be difficult for the majority of residents to eat perhaps a particular favourite could be added as part of a birthday treat. Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensured that relatives and residents could raise their concerns in different ways and be confident that these would be dealt with. The home ensured by good procedures, good communication and training that residents were protected. EVIDENCE: The home actively manages concerns and complaints. The homeowner and manager are available and make themselves known to relatives and check residents’ happiness with the service they provide. The homeowner has both resident and relatives meetings to discuss the running of the home and concerns are talked about and listened to. Resident and relative meetings were seen for September and October. The home has not had any formal complaints raised with them. The Commission has received no complaints. The service user guide has information about how to complain. Comment cards received stated that residents and relatives knew how to complain but had not needed to. One relative said that the meetings were very helpful. Two residents that were able said that they would speak to the homeowner or the manager if they were unhappy about anything. The home keeps a comment book although nothing has been written in this.
Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 18 The home has appropriate adult protection procedures. Staff spoken to were clear about the need to refer any concerns about the safety of residents within the home to the manager. A number of staff have attended a NVQ2 which may include training in adult protection where this is so this needs recording. Training for staff that have not got an NVQ 2 in care must be given on a staffs individual responsibility to report under Department of Heath guidance ‘No Secrets’. Residents spoken to had no concerns about their safety. The management of the home included the manager being involved in the care of residents on occasions and this makes her available to residents. Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,22 &26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The décor, facilities in the building were to a high standard and met the needs of the residents. Residents live in a safe well maintained home. EVIDENCE: The home had a variation to increase the number of places to available to 24. The new rooms provided are all single and en suite. The décor and finish of these rooms is very good. The home has also refurbished the older part of the building where it has been affected by the building works. At a previous visit these rooms were viewed to ensure they met the standard required and it was noted the garden had been improved and there was good garden furniture for residents to use. At this inspection the manager’s office was in the treatment
Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 20 room while the manager’s office was being refurbished. The inspector had no concerns about the building on this inspection. The room on the second floor was no longer in use and the plans to make this a guest room were a sensible option because of the steepness of the stairs. The home has two communal assisted bathing facilities of medi-baths one of which has a hydrotherapy facility on it and a number of bedrooms have their own showers. The home was clean and fresh at the time of the inspection. The home has domestics and housekeepers available that have undertaken NVQ training in cleaning and this helps to ensure that infections were kept under control. The home had adequate laundry and cooking facilities to meet the needs of the residents. Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 &30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home ensured that there was a good number of basic trained staff to meet the needs of residents. The home needed to show that their arrangements for employment of staff clearly met the risk checks needed. The home needed to improve on their recording of and provision of suitable up date on mandatory training to ensure that staff remain current on good care practices and meet the needs of residents appropriately. EVIDENCE: Residents and relatives were happy with the number of staff available to provide care. Rotas showed that the current staffing level was three care staff throughout the 24 hours with additional housekeeping, cooking and management support and this level of staffing is good. The home showed that they have 65 of the staff that have achieved an NVQ2 in care qualification and this above the required level the home has a further four staff registered to undertaken this course. A number of staff have achieved NVQ3 in care and this is excellent.
Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 22 The home undertakes a recruitment process and details of this were kept on the staff files for example the inspector found application forms, references, Criminal Record Bureau checks and checks against the Protection of Vulnerable Adults list. The home was on occasions employing staff for their supervised induction days before these checks were in place. Whilst this may not put residents at risk because of the supervision it may cause difficulties if the checks were subsequently to find any concerns. The home had an induction procedure and was aware of the Skills For Care organisations recommended training for new staff. The home kept a matrix of training that staff had undertaken this did not have dates of achievement so it was difficult to check that these had been up dated within the timescales. One staff member spoken to needed formal update training on first aid. The home manager trains the staff on moving and handling her Training for Trainers needed to be updated to ensure that moving techniques in the home remain current and safe. The home has some training that it undertakes by videos and must ensure that these remain current as practices change. Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33,35,36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well run and managed with residents best interests and health and safety being promoted and protected. EVIDENCE: The home manager had completed the Registered Managers award but was awaiting the certificate from the college. The home manager had many years experience of managing a care home. Staff, professionals and residents spoke about the good management of the home. One relative stated ‘I looked at 11 homes before placing my relative in Victoria Lodge I have absolutely no regrets. It is an extremely well run home.’
Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 24 The home has had an independent quality assurance where it scored extremely high and both the manager and homeowner are keen to improve. The home has an annual review of its service and the homeowner regularly assesses the home’s performance against the National Minimum Standards. Residents and relatives are invited to meetings to discuss the home. The homeowner is in day-to-day contact with the home. The home assists residents that cannot manage their financial affairs in several differing ways. A number of residents have small amounts of money kept in the safe to pay for hairdressing and so on. Checks on three residents money showed that this was accounted for appropriately. One resident spoken to spoke of how the homeowner helped them sort out their finances when in came into the home. The home manager ensures that the staff receive supervision. Whilst supervision is happening by the manager checking on performance routinely it was not always recorded and discussion was had about how this happen more efficiently and take in the key workers roles in the home. The home had appropriate records of maintenance testing and inspection of the building to ensure the safety of Gas and Electrical installations, Lifting equipment and Fire equipment. Victoria Lodge DS0000017040.V321665.R01.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 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 3 X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 3 X 3 Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 OP7 Regulation 15(1) Requirement Timescale for action 31/01/07 2. OP9 13(2) Relapse triggers must be placed in the care plan for those residents diagnosed with a mental health condition that fluctuates. Residents that are self31/01/07 administering medication must have a risk assessment that is routinely reviewed to ensure that the resident remains safe to so do. The temperature of the medicine fridge must have the maximum minimum and current through 24 hours recorded to ensure that medication remains within the product licence. Records must be routinely kept of all activities that residents have enjoyed. All staff must have adult protection awareness training. Staff must not be employed until there is at least a PoVA first check difficulties of cover for the home must be discussed with the Commission. A matrix of the staff teams
DS0000017040.V321665.R01.S.doc 3 4 5 OP12 OP18 OP29 16(2)(n) 13(6) 19 31/01/07 31/03/07 31/12/06 6 OP30 18(1)(c) 31/01/07
Page 27 Victoria Lodge Version 5.2 (i) performance against required training must be kept including the date of each staff member’s attendance. The trainer of moving and handling must have a current Training for trainers certificate. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP36 Good Practice Recommendations It is recommended that the supervision process is reviewed to include the staff members key-working responsibility. Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. Extracts may not be used or reproduced without the express permission of CSCI Victoria Lodge DS0000017040.V321665.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
