Inspection on 06/05/05 for Victoria Lodge

This inspection was carried out on 6th May 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 27/10/05

Victoria Lodge 20/10/04

Victoria Lodge 08/06/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

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 B27 7XZ Lead Inspector Kath Strong Unannounced 06th May 2005 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 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 E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Victoria Lodge Address 11 Victoria Road, Acocks Green, Birmingham B27 7XZ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0121 707 7921 0121 707 7626 Susan Howard Mrs Gillian Rea Care Home 18 Category(ies) of Old Age (18) registration, with number of places Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 20th October 2004 Brief Description of the Service: Victoria Lodge is a large, double fronted mid Vitorian 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. Residents 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 ownere is planning to extend the home to increase the number of bedrooms and to improve the layout of others. It is anticipated that works may commence shortly. Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection; this took place over a period of 4.5 hours. In order for the judgements to be determined evidence was obtained from a variety of methods. Documentation was examined; two care plans were reviewed including case tracking of one resident to determine if the total care needs were being provided. Discussions were held individually with the homeowner, the registered manager and four residents as well as a group discussion with residents in the small lounge. Relatives of a resident also provided their views on the service provision. A partial tour of the premises was carried out, all communal areas were visited and a sample number of bedrooms were inspected. What the service does well: The home provides a consistently high standard of care utilising the assistance and skills of external multi-disciplinary professionals. The home develops and maintains excellent relationships with resident’s families and carers and encourages their involvement with the day-to-day operations of the home. Care plans and policies and procedures are comprehensive and regularly reviewed. As with previous inspections it was identified that in consultation with residents the home provides a varied and interesting activities programme. There is a well motivated team of staff who strive to raise the standards of care. The home has a cheerful and relaxed atmosphere whilst maintaining a professional approach. Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 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 standard(s) 1, 2 and 3 Prior to a placement being offered the home provides comprehensive information and a statement of terms and conditions. Appropriate preadmission assessments are carried out to ensure that all care needs can be met. EVIDENCE: The registered manager advised that the content of the statement of purpose had not changed since the last inspection. The document included all relevant information over and above those items listed within Schedule 1. The service user guide was comprehensive, presented in a ‘user friendly’ format and a copy had been supplied to each resident. Irrespective of the funding arrangements contracts of terms and conditions are supplied to each person residing at the home. The content of the document is sufficient to comply with the National Minimum Standards. Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 9 The home generates an enquiry form for prospective residents. The inspector was advised that assessments are carried out either at the home or a venue convenient to the prospective resident. The pre-admission tool utilised was examined and noted to be satisfactory, the document then forms the basis for the in depth care plan upon admission. Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 10 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 standard(s) 7, 8, 9 and 10 The health needs of residents are being well met with evidence of a proactive approach to the input of multi-agency professionals. The systems for the administration of medication are well managed promoting good health. Residents are treated with dignity and respect. EVIDENCE: Care plans were found to be detailed and included physical and mental health aspects of care. They also contained detailed information in respect of the individuals family history, background, hobbies, preferred routines of daily living as well as likes and dislikes. The files included relevant risk assessments, monthly and six monthly formal reviews. Where possible the resident or a family member had agreed and signed the care plan. Carers also had daily care plans for each person with entries being made during each day and night shift. The records indicated that external multi-agency professionals are invited into the home in order to assess, advise staff and provide treatment as required. Discussions revealed that family members or if not available a carer escort residents in attending external appointments. Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 11 The written policies and procedures in place for all aspects of the administration of medications were determined to be satisfactory. Only those staff that had undergone relevant training were permitted to administer medications. The registered manager has recently successfully completed a course in advanced medication in order to continue the training of staff. Observations indicated that staff interactions with residents were respectful and appropriate including the preferred term of address. Two visitors spoken with provided positive feedback commenting that “Auntie looks much better since her admission and is well looked after and we are always made to feel welcome”. Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 12 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 standard(s) 12, 13 and 14 In-house and external social activities are both varied and well managed, with resident’s links with the community being maintained. The processes for consultation in this home are good; a clear means of obtaining residents views and acting upon them was evident. EVIDENCE: As with previous inspections the home provides a varied leisure programme. The quarterly residents meetings agenda always includes resident’s activities, the two visitors spoken with confirmed that they attend the meetings. The activities organiser reviews the programme monthly. Minutes were seen on display in the reception area and other communal areas. Information was given regarding future plans for a trip to West Midlands Safari Park and a singer has been invited to attend the home. Birthdays are celebrated with a present, cake and activities of choice. The registered individual was observed requesting feedback from the recent ‘fish and chip supper outing’. Enthusiasm was displayed for the suggestion of the outing being a monthly event. A resident who was a keen gardener also agreed to assist with the planting of hanging baskets for the home. The visitors informed the inspector that they felt involved and “a lot of decisions are made by the residents”. During the visit residents were being individually asked what they wished to have for their evening meal. The home regularly carries out a quality assurance audit when residents and relatives are requested to complete questionnaires. Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 13 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 standard(s) 16, 17 and 18 The home has a satisfactory complaints procedure with evidence that the opinions of residents and others are listened to and acted upon. Arrangements for the protection of residents are satisfactory in providing a safe environment. EVIDENCE: The written complaints procedure was noted to be satisfactory and included a logging, investigation and outcome system. The home had not received any formal complaints since the last inspection. The inspector observed that post is handed direct to residents. During the recent general election an official had attended the home to provide advice in respect of how to make postal votes. The registered individual reported that a number of residents had completed postal votes. The home was seen to have written policies and procedures in place regarding Adult Protection, Whistle Blowing, Restraint and Missing Persons. All staff had received training in this aspect of care. Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 14 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 standard(s) 19, 20, 21, 22, 24 and 26. The home provides a comfortable and safe environment for those persons living there and visitors. Full compliance with the National Minimum Standards has not yet been achieved. EVIDENCE: The location and layout of the home appeared to be fit for its stated purpose. There is a ramped access to the front and rear of the premises. The home is decorated and furnished to a high standard throughout whilst being well maintained. There was safe access to the attractive rear garden. Some requirements remain outstanding from the previous inspection; these have been incorporated into the planned building works for the planned extension of the home. Communal areas are bright and airy and appeared to be adequate for the number of residents. Further assisted bathing facilities will be increased from one to two with the extension of the premises. The proposed plans will also increase the en-suite facilities. The current call system does not extend to communal areas but will do so upon completion of the works. The Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 15 home has acceptable aids including grab rails, raised toilet seats, mobile hoists and various pressure relieving devices. Bedrooms vary in size and layout. Those visited had been personalised to the degree preferred by the occupant. All rooms had private lockable facility but suited door locks had not been fitted. One bedroom does not meet the spatial requirement s and is currently being utilised for short term respite care only. All areas of the home visited were noted to be hygienic and tidy. The systems in place within the kitchen and laundry rooms were noted to be satisfactory with health and safety being paramount. Radiator and water temperatures are checked on a daily basis. Radiator guards have not been fitted. Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 30 Staffing levels were adequate to meet the needs of residents. Staff training was good resulting in an enthusiastic workforce that strives towards improving resident’s quality of life. EVIDENCE: From examination of the duty rota it was evident that staffing levels during daytime hours are high. There are dedicated cooks, housekeeping and laundry staff. The home enjoys a low staff turnover thus ensuring continuity of care. Gaps are filled by bank staff or permanent staff, agency staff are utilised only as a last resort. Information was provided that 72 of staff have been trained to NVQ level 2 or above. The home provided evidence that it continues to meet all mandatory and refresher training requirements. Updates are regularly provided in topics such as Adult Protection and further training in dementia care was being arranged for the near future. The home has recently introduced distance leaning for staff with the assessor visiting the home. Other training includes healthy eating and infection control. The content of the induction programme reflects those topics identified within the TOPSS programme. Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35 and 36 The registered manager is qualified and fit to carry out her duties. The home regularly reviews aspects of its performance through a system of self audit and consultation with all who are involved in receiving and delivering the service. Satisfactory processes are in place for the safe handling of residents personal monies and formal staff supervision. EVIDENCE: The registered manager has successfully completed the registered managers award and NVQ level 4 in care and management. The home has recently been awarded 100 achievement from the Bettal Consultancy in respect of the quality assurance system. The home has also displayed all of the National Minimum Standards in the main office and staff regularly carries out risk assessments against various standards. Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 18 The system in place for the transactions and safe keeping of resident’s personal monies was determined to be satisfactory. The documentation for formal staff supervisory meetings has been improved and was noted to be comprehensive. The registered manager showed the inspector the matrix of established timings in respect of supervisory meetings. Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 2 2 2 2 2 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x 3 x 3 3 x x Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 20 YES 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 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 1st September 2005 1st September 2005 1st September 2005 1st September 2005 1st September 2005 2. OP22 23(2)n 3. 4. 5. OP23 OP24 OP25 23(2)e 12(4)a 13(4)c 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 Good Practice Recommendations Victoria Lodge E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Birmingham and Solihull Local 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 E54_S17040_Victoria Road_V226420_ 06.05.05 stage 4.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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