Inspection on 30/07/07 for Victoria Lodge

This inspection was carried out on 30th July 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Victoria Lodge 16/10/08

Victoria Lodge 17/04/08

Victoria Lodge 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 Val Sevier Unannounced Inspection 30th July 2007 10:30 Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Lodge Address 59 Victoria Drive Bognor Regis West Sussex PO21 2TQ 01491 579270 01491 579738 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Victoria Lodge Ltd Miss Jade Michelle Elizabeth Weston Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 2006 Brief Description of the Service: Victoria Lodge is a care home for younger adults (18-65) who have learning disabilities. The home is registered for six service users. The home has four residents at the present time. The home is in a residential area in Bognor Regis it is a large house with surrounding gardens. There is an annex to the house that is currently used as an activities room. The service has an ethos that is geared very much towards promoting independence and strives for its residents to lead full lives within the community. The fees for the home are dependent on assessed need and on the day of the inspection visit ranged between £1333.75 and £1950. Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards and Regulations. The findings of this report are based on several different sources of evidence. These included: the Annual Quality Assurance Assessment (AQAA) completed by the home, and an unannounced visit to the home, which was carried out on the 30th July 2007, during which the inspector was able to have discussions with staff and have interaction with the residents at the home. During the visit the inspector looked around the inside and outside of the home, which included a sample of bedrooms and bathrooms. Staff and care records were sampled and in addition to speaking with staff and residents, their day-to-day interaction was observed. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. There is no manager currently working at the home, a senior team leader, support staff and a manager from another home belonging to the company, assisted the inspector with the visit. This manager is supporting the team leader in managing the home at the present time. What the service does well: Every potential resident for the home is visited and assessed to ensure that the home is able to offer a service to meet the needs of the individual. The assessment contains a lot of information about the needs and how staff can support them. There was written evidence about how staff support needs, promote choice and diversity, and the inspector was able to observe this in the interaction and relationship between the residents and staff at the home. Residents appeared to be engaged in activities that they like and this is varied and can be changed on the day. There is access to health care such as dentists, opticians and chiropody as well as ‘feel good’ therapies such as hairdressing. There is a choice of meals and individuals were observed to have foods that they liked and that also met dietary needs and requirements. Staff seem to be aware of the safeguarding of the people they care for and the majority have undertaken appropriate training. There is a complaints procedure and relatives and representatives have commented that the staff are approachable should they have any concerns or worries. Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 6 Victoria Lodge is a pleasant environment that is well maintained and homely; there is a lounge and dining room, all rooms are single and the residents have full use of the garden. Until recently staff received regular supervision from the manager and training was up to date. The home seeks the opinions of others in the management of the home and how it provides the service to the people that live at Victoria Lodge. What has improved since the last inspection? What they could do better: The manner in which some individuals communicate their needs, wishes and choices must be recorded on the care plans, so that individuals will always be supported appropriately. There are concerns of the potential outcomes and risks for people who live at the home and staff, with no manager at the home. It was seen that training, supervision, induction and fire safety checks have not been carried out since the manger left. Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 7 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.V343335.R01.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.V343335.R01.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can feel assured that their needs will be assessed and that the home has an understanding of their needs using the assessment process. EVIDENCE: It was seen that each individual that lives at the home, had been given a statement of purpose, which included the service users guide. This document included information on: the company, staff structures / support, aims and objectives, room sizes, leisure and how to make a complaint. The service users guide is also offered in a pictorial format. There is a trial period for anyone considering moving into the home, which includes a meeting. The service user guide describes this as: “a meeting with you and anyone else you want to be there. At this meeting you can tell us how you like things and the way you want to do them. Your family, friends and social worker can also tell us about the things you like to do and perhaps the things you might want to do in the future”. Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 10 The inspector sampled three care plans, which also contained the pre admission assessment. The assessments contain information about the needs of the individuals. It was observed that the information gained through the assessment had been used to complete the care plans. The information gathered at the assessment included areas such as: Health needs Psychological support, mental health needs, managing emotions Communication skills Daily living skills Self care skills Relationships and sexuality Community presence and participation Employment and education Recreation and relaxation Cultural and spiritual Financial skills/support. Relatives who have commented, explained what had happened in the decisionmaking process regarding the home and how they had been involved. Residents who were able also commented that they had been to the home and had been asked if they would like to live there. The relatives commented that the admission process had worked, that they had been given adequate information to assist with the decision, making process. The relatives felt that the needs could be met at the home; in some cases the relatives appreciated being part of the process as they had cared for the individual and could continue to do so. Victoria Lodge DS0000040980.V343335.R01.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 & 9 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Practices within the home demonstrate that people who use the service are encouraged to make decisions about their lives and to take risks as part of an independent lifestyle. However this could be improved for the people who use the service if more detailed information is recoded on the care plans. EVIDENCE: The inspector read three care plans, which included: risk assessments on areas such as accessing the community, front door and personal issues that may require specific support for example ‘I am to have female staff only to help with personal care’. The care plans seen also contained a timetable of the week’s activities for the individual, and they seemed to be based on individual’s wishes and abilities. The care plans had information on assessed need and the support needed to be given by staff and how that support could be offered. For example one individual becomes noisy when agitated, staff support was: ‘noise level Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 12 increases when agitated staff need to calm them and lead them away from what is upsetting them’. Another individual has no verbal communication at all. When looking at the care plan there was some information on how the staff support decision making and choices for this individual as the individual leads staff to what they want. However when the inspector spoke with staff they had a lot more knowledge on how the individual used facial expressions and other non verbal methods of saying what they wanted, this was not recorded. There were minutes from meetings that included the individual and their representatives, in addition to home staff and other professionals; these seem to happen yearly, or if there are concerns. Relatives have commented that they are involved with the reviews of the care plans and are informed of any concerns about the well being of the people who live at the home. Victoria Lodge DS0000040980.V343335.R01.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): 12, 13, 15,16 & 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service participate in activities appropriate to their age, peer group and cultural beliefs as part of the local community. Dietary needs are well catered for with a balance and varied selection of food available that meets individual dietary requirements and choices. EVIDENCE: Staff explained that residents are encouraged, to participate in social activities, both within the home and in the community. Records of activities are recorded in the individuals care plan and daily records, these include daily activities such as art, games, clubs, college and bowling as well as visits to the cinema and shopping. Staff confirmed they often support service users in going to the pub, or to local areas of interest. Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 14 Individual likes and dislikes were seen to be recorded on care plans for food and leisure. It was also seen that individuals have a weekly planner of their individual activities such as college, house activity, independent living skills which can be community or house based and included support to cook or shop. Two residents are going on holiday in September for a long weekend at a holiday camp and two staff will be going to support them. There was some evidence that care plans reflect the individual’s cultural beliefs and individuals sexual preferences. There was evidence that where there have been issues identified such as inappropriate behaviour towards the opposite sex that support and action to be taken by staff is in place. There was also evidence that individual’s religious beliefs are supported by staff. The inspector witnessed the visitors book that detailed family and friends visits to the home. Staff reported there are no restrictions on visiting, unless stated in an individuals care plan. The inspector saw the menus, which had a variety of nutritious meals, which included an alternative. Food storage areas and fridges were well stocked with fresh and tinned produce. Meals are seen as a social occasion that staff also join in, it was noted that staff support residents appropriately and with dignity, where needed. Residents are supported to prepare meals and snacks for themselves and for others. They were seen to access the kitchen for snacks and drinks whenever they wanted and staff were seen to be available to support them. Meals and snacks are dependent on choice and dietary requirements. The residents have their main meal in the evening, which is prepared by the staff and people who live at the home. This is because residents attend clubs and activities throughout the day and again the evening meal is a social occasion where the residents can catch up on what they have been doing, with others. Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service receive personal support in the way they prefer and require and have their emotional and health needs met. EVIDENCE: The inspector was able to speak with two of the three residents who were at home on the day of the inspection. They were able to indicate to the inspector that they feel that they are supported well and that staff listen to them, they do not always get to do what they want but feel they have a ‘good time’. Looking at the care plans it would seem the ‘not getting what they want’, is not an issue as the individuals through their learning difficulties sometimes have an unrealistic view on life and what life involves and staff were observed in supporting the individuals to make choices and express themselves to make real choices. The staff make comments daily on individuals daily activities, physical and emotional health and behaviour, records of visits to outside agencies, such as doctor, dentist, optician are kept on the individuals file, this enables the home to monitor and track the information recorded. Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 16 The home has a medication policy and procedure that was seen to be available for staff. The home uses a Medicine Administration Record Sheets (MARS) system, for recording the administration of medication. The records kept in conjunction with medication received and returned to the pharmacist were sampled and were found to be correct. Records of all staff trained to administer medication were found to be in order. Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are protected through the open complaints process and the staff’s knowledge and understanding of Adult protection issues. EVIDENCE: The inspector spoke with the staff, who confirmed the way they ensure service users views are listened to is to communicate in the style and pace appropriate to the individual, spend one to one time with residents, arrange regular review meetings, form positive relationships with families, friends and outside agencies. The staff confirmed they use a variety of ways to enable residents to make choices, for example, when choosing which clothes to wear, the staff member will arranging the options in front of the individual and prompt them to look and point to their choice. The same system is used when choosing to redecorate/ refurbish of areas within the home and where to go on holiday. The home has a clear complaints procedure, which is available in written or pictorial form. No complaints have been received at the home or the commission since the last inspection visit. The inspector observed staff listening to the residents, and responding appropriately to meet the individuals needs. Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 18 The inspector received six comment cards, all were completed on behalf of residents by their relatives, and all stated they were aware of who to speak to if they were unhappy about anything. The inspector saw the homes safeguarding adults procedure, which includes the Department of Health “No Secrets” guidelines. The home has a copy of the Sussex guidelines for the Protection Of Vulnerable Adults. Staff confirmed they have attended abuse awareness training, and that abuse was covered during their induction, the inspector sampled staff files which included records of training and certificates. This was confirmed in the training records with the exception of one new member of staff. Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have a pleasant and homely environment to live in which also has had adaptations to meet individual needs. EVIDENCE: The staff explained that they support residents to decide on the colours of the lounges/dinning areas, all were very different in colour and furniture, suggesting that thought has been given to individuals needs and wishes. All of the bedrooms were brightly decorated and had evidence of individual personalities with posters and the service users photographs on the walls, and other personal effects. The staff explained residents are encouraged to furnish the room with personal belongings, furniture and pictures to help it feel homely. The home appeared clean, warm and with no offensive odours. The home’s radiators and pipe work are safe ensuring that all potential hot surfaces are Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 20 kept to low temperature. The garden is well maintained and is accessible to residents. The rooms were all single occupancy. The communal areas were pleasant and individuals were seen to use them as ‘their own’. Victoria Lodge DS0000040980.V343335.R01.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, 34 & 35 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the services have their needs met by staff who are trained, supportive and sufficient in numbers. People who use the services are protected by robust recruitment procedures. EVIDENCE: There is currently no manager working at the home and there are several staff vacancies with a team leader and the manager having left recently. There are seven staff remaining three of whom have withdrawn their notice and are now staying at the home. The senior team leader is over seeing the day-to-day management tasks and arranging the rota, she was being supported by a manager from another home. The home’s staff are being supported by one agency and the manager from the other home has staff profiles including CRB checks, training and qualifications sent to her of the staff that Victoria Lodge are using. There are three staff on duty at the home throughout the day and two staff awake at night, there are two drivers working at the home at present and the team leader tries to ensure that one is available each day to support residents to go out. Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 22 Staff spoken with on the day of inspection indicated that they were aware of the needs of the residents who live at Victoria Lodge, they also seemed enthusiastic about working at the home despite recent issues. There was evidence that staff have received training in all mandatory areas such as food hygiene, first aid and manual handling, with the exception of one new member of staff. Two night staff attended training in medication in June 2007 and two more staff were due to go on the same training in 31st July 2007. The inspector was able to sample two staff files of individuals who had begun work at the home since the last inspection visit. Records indicated that they were detailed with the necessary checks taken to ensure staff are fit to work at the home. Induction for these two staff had begun but unfortunately has stopped with no manger being available at the present time. The inspector was able to see the induction pack and what the staff would cover. Day one at the home the new staff member looks at the layout of the home, fire procedures, meets residents, looks at medical procedures, aims of the home and becomes familiar with basic expectations and responsibilities. Week one includes: essential record keeping, daily reports, getting to know residents. Week two includes: overall service provided at the home, outside professionals used and why. Week three includes: being familiar with resident’s needs, likes and dislikes and daily support requirements and have spent time with residents at day services and / or college. Week four includes: showing knowledge and understanding of individual residents daily support requirements and identify own training needs to fulfil role in unit. Staff are also expected to look at and read policy and procedure of the home and sign and date they have read and understood. Victoria Lodge DS0000040980.V343335.R01.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 & 42 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. With no manager working at the home there is potential that the people who use the service are at risk. EVIDENCE: Staff have received adequate training on health and safety issues, as evident from the staff training plan, the inspector saw certificates for staff attending moving and handling training, first aid, food hygiene and Control Of Substances Harmful to Health. One new member of staff whilst they have certificates related to mandatory training such as moving and handling and fire, which were gained at another care home, the individual had not received fire training as related to Victoria Lodge, it was also not clear that the individual could relate the moving and handling training to the needs of the individuals living at Victoria Lodge. The induction for working at Victoria Lodge Victoria Lodge DS0000040980.V343335.R01.S.doc Version 5.2 Page 24 has also not been continued since the manager left and the last signed competency was 19th July 2007. The home has carried out quality assurance surveys, the last surveys were sent out on the 4th July 2007 to relatives and professionals involved with the home. There is no one at the home at present to coordinate a response or to analyse the returned forms. The home has risk assessments in place for the building and safe working practices for staff. Certificates showed the maintenance of services within the home were up to date. Fire training has taken place regularly. The fire equipment and safety checks were last carried out at the home on the 20th July 2007, the member of staff who was responsible for this and the manager having since left. Victoria Lodge DS0000040980.V343335.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 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 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 2 X X 2 X Victoria Lodge DS0000040980.V343335.R01.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 YA7 Regulation 15 (1) Requirement Care plans must show how people who use the service are supported in making decisions about their daily lives and how they as individuals communicate those wishes and choices. Staff must receive training in all mandatory areas and any training that is needed to help them support and protect people who use the service. Regular checks on the fire equipment must take place and a record kept to ensure that people who use the service and staff are protected. Timescale for action 30/09/07 2 YA32 13 (4) (5) (6) 18(1)(a) (2)(c) 23 (4) 30/09/07 3 YA42 31/08/07 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.V343335.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000040980.V343335.R01.S.doc Version 5.2 Page 28 - 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!