Inspection on 25/06/08 for Victoria Lodge Care Home

This inspection was carried out on 25th June 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Victoria Lodge Care Home 10/02/10

Victoria Lodge Care Home 07/12/09

Victoria Lodge Care Home 18/11/09

Victoria Lodge Care Home 04/08/09

Victoria Lodge Care Home 03/12/07

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Victoria Lodge Care Home Bent Street Brierley Hill West Midlands DY5 1RB Lead Inspector Lisa Evitts Unannounced Inspection 25th June 2008 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 Care Home DS0000070198.V367235.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 Care Home DS0000070198.V367235.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Lodge Care Home Address Bent Street Brierley Hill West Midlands DY5 1RB 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) 01384 572567 01384 79658 Select Health Care Limited Post Vacant Care Home 61 Category(ies) of Dementia (61), Old age, not falling within any registration, with number other category (61) of places Victoria Lodge Care Home DS0000070198.V367235.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care (with nursing) and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: - Old age, not falling within any other category (OP 61) - Dementia (DE 61) The maximum number of service users to be accommodated is 61. 2. Date of last inspection 3rd December 2007 Brief Description of the Service: Victoria Lodge is registered to provide personal and nursing care to people who have dementia and people who have personal care needs associated with old age. It can accommodate a maximum of 61 people at any one time. The home is located not far from Brierley Hill High Street giving easy access to main bus routes from Dudley and Stourbridge. There are a range of shops and other amenities along Brierley Hill High Street and Merry Hill Shopping Centre. Victoria Lodge is a purpose built home and was opened in the summer of 2007. The premises consist of three separate floors with nursing care being provided on the top floor. Each floor has its own communal areas, dining room and lounge, bathrooms and toilets. All bedrooms are single occupancy with en-suite facilities. The home has hoists and pressure relieving equipment for use with people who are assessed as requiring this assistance. There is a passenger lift to all floors, which would assist people with limited mobility. The home has a main kitchen and separate laundry. There are small garden areas which are accessible to people using wheelchairs. Inside the home there are various notice boards, which display information about forthcoming events and other articles, which may be of interest. The last inspection report was not on display but was available from the manager so that people could access this information if they chose to read it. The service user guide and statement of purpose were displayed in the reception area of the home. These did not include details of the fees for the home and this information should be available for people. Top up fees are charged and additional costs include chiropody, physiotherapy, hairdressing and toiletries. Victoria Lodge Care Home DS0000070198.V367235.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The focus of our inspections is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. The visit to the home was undertaken by two inspectors over ten hours and was assisted throughout the day by the Acting Manager. The home did not know that we were visiting. There were 40 people living at the home and one person was receiving hospital care. Since the last key inspection of the home in December 2007, we, the Commission had undertaken two additional visits to the home. The first visit was undertaken on the 25th February 2008 and was undertaken to monitor the progress of the home following concerns found at the key inspection. This visit resulted in a Statutory Requirement Notice being served regarding medication management. The notice was served as part of the enforcement process to make the home improve the practice and to ensure that the people who live at the home are safe. A second visit was undertaken in April 2008, and this was to check that the home had made the improvements required regarding the management of medication. The home had made the improvements required regarding management of medication however; concerns were raised regarding the care plans. Care plans did not provide sufficient information for staff to follow or to ensure that people’s needs were being managed appropriately. This resulted in a Statutory Requirement Notice being issued in respect of care planning. The notice was served as part of the enforcement process to make the home improve the practice and to ensure that the needs of the people who live at the home are met. Due to the enforcement action Dudley Commissioners had placed a suspension on the contract for the home, which meant that they would not place any new people into the home until the improvements had been made. The home did continue to take new privately funded people into the home. This visit was a key inspection and was undertaken to monitor progress and check that the home had made the improvements required to the care plans. It was pleasing that care plans had improved and that previous improvements had been sustained. Information was gathered from speaking to five people who live at the home and observing them, as it was not possible to speak with a number of residents due to communication difficulties. Six people were “case Victoria Lodge Care Home DS0000070198.V367235.R01.S.doc Version 5.2 Page 6 tracked” and two files were partly reviewed. Case tracking involves discovering individual experiences of living at the home by meeting or observing them, discussing their care with staff, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files and health and safety records were reviewed. Three relatives and three staff were spoken to and staff were observed performing their duties. No immediate requirements were made at the time of this visit. This means that there was nothing urgent that needed to be done to make sure people stayed safe and well. What the service does well: What has improved since the last inspection? Care plans have improved so that they provide staff with information about how to meet individual’s needs and preferences. Staff knowledge of peoples Victoria Lodge Care Home DS0000070198.V367235.R01.S.doc Version 5.2 Page 7 needs has improved and this means that people’s needs should be met in a way that they prefer. The management of medication has improved so that people receive their medication safely. A second activities coordinator has been employed so that people with one to one needs also receive stimulation. Meals are provided for individuals that meet dietary and cultural needs so that people receive food of their choice. Improvements have been made concerning the handling of complaints, which gives people better assurance that their complaints will be listened to and addressed. The number of complaints received has reduced significantly. Sluice machines are in working order and this should help to minimise the potential risk of cross infection. Corridors are in the process of having muriels painted on them so that people have something of interest to look at. The recruitment of staff is robust so that people are safeguarded from harm. A new manager has been appointed who appears to be committed to making improvements to the home so that it is run in the best interests of the people who live there. Senior managers undertake monthly visits to the home to monitor the quality of service being provided. What they could do better: Service users guides should be available in alternative formats and should include the fee rates for the home so that all people can access this information. Staff should not mix together pureed food, as this does not enable the person eating the meal to experience different tastes. Consideration should be given to the complaints procedure and menus being available in alternative formats so that all people can understand them. The quality assurance system should be fully implemented so that people’s opinions are sought about the service provided. The acting manager has implemented a number of changes, which have improved the home in the short time that she has been in post. It is Victoria Lodge Care Home DS0000070198.V367235.R01.S.doc Version 5.2 Page 8 anticipated that further improvements will be made in order to enhance the lives of people living in the home. 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 Care Home DS0000070198.V367235.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 Care Home DS0000070198.V367235.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): 1,3, 4 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People have some information to enable them to make an informed decision about whether they would like to live at the home. Pre admission assessments ensure that people know their needs can be met prior to moving in. EVIDENCE: The home has produced a statement of purpose and service user guide, which is displayed in the reception area of the home. The service user guide was seen in some people’s bedrooms. This is available in large print but not in any other formats. It is recommended that consideration is given to producing these documents in alternative formats so that all people can access this information. The fee rates were not included in the service users guide and this should be included so that people know what they will have to pay for if they choose to live at the home. Victoria Lodge Care Home DS0000070198.V367235.R01.S.doc Version 5.2 Page 11 The certificate of registration and public liability insurance are on display in the reception area of the home, which enables anyone to view these when visiting. A copy of the previous inspection report is not displayed so that people can read this if they choose to. The service user guide informs people that they can ask for a copy should they wish to read it, however it is recommended that it is on display. Comprehensive pre admission assessments are undertaken prior to people coming to live at the home and this ensures that people are confident that their individual assessed needs can be met upon admission to the home. Some documents were not signed and dated by the person completing these and staff should complete this to show that people’s needs were assessed prior to coming into the home. People who would like to come and live at the home and their relatives are able to visit the home. This means that people have the opportunity to sample what it would be like to live at the home, helping them to make an informed decision. 30 staff had received training in Dementia care and external courses had been sourced for further raining. The acting manager was planning to introduce the Yesterday, Today, Tomorrow training which will increase staff knowledge about how to meet the needs of people who have dementia. One person said “Its alright here” and a relative said, “Its very good here, we are happy with the care”. Victoria Lodge Care Home DS0000070198.V367235.R01.S.doc Version 5.2 Page 12 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 plans provide good information for staff to assist people to meet their individual needs and preferences. People’s health and personal care needs are well met so they are supported to maintain good health. EVIDENCE: At the additional visit in April 2008 concerns had been raised about the standard of care planning and a Statutory Enforcement Notice had been issued to bring about the changes required in order to improve the standard of care delivery. It was pleasing that the staff have worked hard to meet the requirement regarding care planning. Each person had a written care plan. This is an individualised plan about what the person is able to do independently and states what assistance is required from staff in order for the person to maintain their needs. We looked at six peoples care files in detail and two files were partly reviewed. Victoria Lodge Care Home DS0000070198.V367235.R01.S.doc Version 5.2 Page 13 There was some good information about individuals’ personal care needs and preferences so that people should receive care in a manner they need and like. Care plans for difficult to manage behaviour gave details of how staff could avoid this behaviour and what they should do if this behaviour occurred. At lunchtime we saw that one person became agitated by the noise and was upset by another person wandering around. Staff asked him if he would like to move and he moved into the lounge were he sat quietly as was not interrupted by other people. Detailed plans were available for wound dressings so that staff knew how often to change them and what to dress them with. Care plans for specific problems such as diabetes gave good instructions for staff to follow. There were lots of personal choices recorded for example “prefers a daily strip wash but wants an occasional soak in the bath”. Care plans described people’s skills so that they remain as independent as possible, for example,” can select own clothes but needs prompts to ensure they are put on correctly. It is recommended that the manager review documentation, which states if people can vote, self medicate or manage their personal allowance as it read as if the home had made these decisions rather than the individual people. Food records were detailed with the amount of food taken and people were weighed as they had been assessed so that staff could monitor their nutritional intake. Daily records provided some information but these could be more detailed and the manager said that she was aware that this was also a training issue for staff. She planned to do training with staff about how to evaluate care plans and write daily records. This will be reviewed at the next inspection. There was evidence that external healthcare professionals such as General Practitioner, district nurse and social workers see people as required. People can keep their own GP (If the GP is in agreement) or people can be registered with a local GP. It was pleasing when talking to staff that they knew individual peoples needs and were able to state how there needs should be met as the care plans stated. One person said, “We get some choice, there are no specific times for getting up or going to bed”. At the additional visit in February 2008 concerns were raised about the management of medication. A Statutory Enforcement Notice had been issued to bring about the changes required in order to improve the standard of medication management. At the visit In April 2008 it was pleasing that the home had met this requirement. During this visit we reviewed the medication of the people we case tracked and found that the medication generally Victoria Lodge Care Home DS0000070198.V367235.R01.S.doc Version 5.2 Page 14 continued to be managed well and that people were receiving their medication as prescribed. The exceptions were that fridge temperatures were not being accurately recorded in all cases and this meant that the home could not be sure that they were storing medication in line with its product license. Medication, which was to be returned, was not stored in a locked cupboard on two of the floors and this was brought to the attention of the manager on the day of the visit. On the ground floor there was some discrepancies in the audits of medication for two new people admitted into the home and this meant that we could not be sure if people had received their medication or not. People appeared to be well supported by staff to choose clothing appropriate for the time of year, which reflected individual cultural, gender and personal preferences. There is a payphone available in the home for people to use and people can have their own telephone line installed at an additional cost so that they can make and receive calls in private. There is a post box in reception for people to post their mail. Victoria Lodge Care Home DS0000070198.V367235.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. People are able to exercise choice regarding the activities they participate in which promotes their individuality and independence. People are offered a choice of meals, which meet any dietary or cultural needs and preferences. EVIDENCE: The home has employed a second activities coordinator at the home since our last visit and this means that people who require one to one activities now also receive some stimulation. There is a monthly activities programme and this consisted of games, crafts, one to one, exercises, quizzes, music and cookery. External people visit the home and these include a hairdresser once a week, a yoga therapist once a week and a weekly entertainer. A jewellery party had been held and a clothes show was planned. Every third Thursday a church service is held where people can receive Holy Communion if they choose. One person who is a Jehovah Witness attends a local meeting group and this means that people can continue to follow their chosen religion. Newspapers can be delivered for individual people should they want them so that they can continue to read articles of interest to them. Victoria Lodge Care Home DS0000070198.V367235.R01.S.doc Version 5.2 Page 16 People are encouraged to go out of the home and the activity coordinators take people out to local shops and libraries. We saw one person going out to the chemist with the activity coordinator and we saw other people going out with their relatives. The organisation has a mini bus and they were in the process of organising trips to Cosford air museum and the Lavender gardens. The home has an open visiting policy, which means that people can maintain the relationships that are important to them. Relatives spoken to confirmed that they could visit at anytime. During the day we observed people joining in activities with staff such as colouring and dominoes. One person was seen walking around with a doll, which she appeared to be very happy to be looking after. There is a four-week menu in place and this offers an option of a full breakfast or cereals, two hot choices at lunchtime and soup and a buffet tea at teatime. All meals are served with potatoes and two seasonal vegetables unless stated otherwise. Yoghurts, cheese and biscuits and fruit platters are available when requested. The lunchtime meal was observed and tables were nicely presented with napkins, cloths, condiments and flowers. Cold drinks were on the table. Staff were observed to sit down and help people with their meals and cut up food where required. Food was platted up by staff and served, gravy and butter was offered. Plate guards were used where these helped people to be able to maintain their independence. We saw that some people chose to have their meals in their room or to stay in their armchairs. Some people said that the food was very nice but some people were not able to comment. The meal was gammon and leak pie but the sauce was runny and didn’t look very appetising and one person commented on this. Pureed meals were served in separate portions however staff mixed it all together before assisting people to eat. This does not promote peoples dignity and enable them to experience the texture and flavour of the different foods. This was brought to the manager’s attention at the time of the visit. One person required a Caribbean meal and this was now being provided by an external company. A copy of the menu was seen and this was in a standard format. It is recommended that menus are available in alternative formats so that people understand them. Victoria Lodge Care Home DS0000070198.V367235.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. People can be confident that their complaints are listened to and acted upon. The home has policies, procedures and staff training, which should safeguard people from harm. EVIDENCE: The complaints procedure is displayed in the home and is included in the service user guide so that people know how to make a complaint if they need to. The procedure is not available in any other formats and consideration should be given to this so that all people can access this information. Previously there had been a high number of complaints about the home and it is pleasing that the number of complaints has reduced, as this indicates that people are more satisfied with the service being provided. We have received four complaints since the last key inspection, two of which were reviewed as part of the additional visits. One was referred back to the providers to investigate under their own procedure and one was regarding breakdown of the lift, which was resolved once the part had been delivered. The home had recorded nine complaints since December 2007. The home has not received any complaints since the acting manager came to work at the home in March 2008. A relative told us “We have no complaints”. Victoria Lodge Care Home DS0000070198.V367235.R01.S.doc Version 5.2 Page 18 The home had an adult protection policy in place however this should be made clear as to who staff should inform and who should investigate any allegations. The home has a copy of the local multi agency guidelines so that staff have guidance to follow in order to safeguard people from harm. There has been one adult protection raised since our last visit to the home, however this has now been resolved and the case closed. Staff spoken to were able to give satisfactory responses to questions about how they would safeguard people from harm in the event of an allegation being made. The home has a whistle blowing policy so that staff will raise any concerns without the fear of reprisals. It is recommended that contact numbers for external agencies are included in the policy so that staff know who they can contact. The training matrix showed that the majority of staff have received training in the Protection Of Vulnerable Adults and the acting manager was aware that further training sessions were required in order to ensure that all staff had received this training. Victoria Lodge Care Home DS0000070198.V367235.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): 19,21,24,25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with a clean and comfortable environment, in which to live, which meets their individual needs. EVIDENCE: The home is purpose built and opened in 2007. It is a three-storey building and each floor has its own living and dining spaces. There are additional smaller lounges for people to see their visitors or join in activities as they choose. All of the bedrooms are single occupancy with en suite facilities. It was pleasing that there were two married couples living at the home and their beds had been placed in one room and the other room was turned into a sitting room so that they could maintain their privacy. Communal areas are comfortable and attractive and there is an activity room and a themed ‘pub’, which can be used by people at the home and their Victoria Lodge Care Home DS0000070198.V367235.R01.S.doc Version 5.2 Page 20 relatives. There is a separate hairdressing room at the home so that people can have their hair tended to as an activity. The room had magazines and pictures so would promote a social occasion. During the additional visits to the home, it was found that the home was difficult to find your way around as everywhere was painted in the same colour. It was pleasing that some muriel’s had been painted on the walls of local places of interest and work was continuing on these on the day of the visit. The manager plans to further improve the environment by improving the signage and adding more things that may be of interest to people in the corridors. All of the bedrooms have ensuite facilities but there are also larger assisted bathing facilities if people prefer to use these. Each floor has a sluice room and all of these machines were now in working order. This should help to minimise the risk of any infection in the home. It is recommended that racks are provided to hold commode pots so that they are not stored on the floor. Waste and clinical waste bins were securely stored behind fencing at the front of the home. We looked at the bedrooms of the people we case tracked and these were found to be personalised and reflected individual tastes, gender and cultural preferences. People are encouraged to bring in their own possessions in order to have familiar items around them to make their rooms as homely as possible. People are able to have keys to their rooms and this promotes their privacy and dignity. One person was pleased to show us his room, he had his own key and the room was very personalised and included a small fridge. We looked at the room of one person who had visual impairments and this room had been set up differently to the others so that the person knew where all their things were and so could maintain as much independence as possible and this is positive. One of the extractor fans was not working in the ensuite and the manager asked for the maintenance person to complete an audit of all rooms. The laundry area was tidy and measures were in place to minimise the potential risk of cross infection from soiled linen. We did not review the kitchen area on this visit as the home had received a visit from the Environmental Health Officers as part of the routine inspections undertaken by them. Each floor has a small kitchenette area and we noted that there was a lot of spillage down the walls, which had not been cleaned. It was recommended that this was cleaned and that ways to reduce this occurring were looked at as it did not promote the cleanliness found throughout the rest of the home. The atmosphere in the home was friendly, calm and relaxed. People living at the home were engaging in conversation with each other and with staff, other people were wandering around the home as they chose. Victoria Lodge Care Home DS0000070198.V367235.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 good. This judgement has been made using available evidence including a visit to this service. People are supported by a suitable number of staff who have received some training to ensure that they have the knowledge and skills to meet individual needs. The recruitment procedure is robust and should protect people from harm. EVIDENCE: During the day there are three carers on the ground floor until 17:30 when this is reduced to two, and two carers overnight. On the middle floor there are three carers throughout the day and two carers at night. On the top floor there is one qualified nurse and four carers in the morning, three carers and one nurse in the afternoon and one nurse and two carers throughout the night. In addition to care staff the home has domestic, laundry, administrative, maintenance and kitchen staff to meet all the needs of the people living at the home. The manager stated that there were no vacancies for staff as they had all been recruited to which means that people know who will be assisting them to meet their needs. The staff rotas were reviewed and these showed minimum use of agency staff. The manager told us that she had worked with the staff out on the floor so that she could see how they were organising things and make changes where required in order to benefit the people living at the home. Staffing levels had been an on going concern since the home opened. During this visit people’s Victoria Lodge Care Home DS0000070198.V367235.R01.S.doc Version 5.2 Page 22 needs were being met and we did not observe people waiting for care to be delivered. We saw good staff interactions and people were walking around the home as they chose to. The manager had further ideas regarding staffing levels as was aware that the numbers of staff would need to be reviewed as more people came to live at the home. We will continue to monitor staffing levels at the next visit to the home. People told us: “The staff are alright” “Staff are friendly and helpful” We spoke to one person who lived at the home. This person told us that they were only a visitor to the home but that staff were always very pleasant and made him welcome. Whilst this person believed themselves to be a visitor to the home, the comments made indicate that this person has a positive state of well-being and were happy at the home. There are currently 90 of staff who have completed a National Vocational Qualification (NVQ) Level 2 in care and the remaining staff are working towards achieving this. This should ensure that the staff have the knowledge and skills to care for people individually and collectively. Three staff files were reviewed and these were found to contain all the required information to ensure that people employed were deemed safe to work with vulnerable adults. These files were well-organised making information easy to retrieve. The home has a training matrix and this showed some staff have received training in health and safety, moving and handling, first aid, food hygiene, infection control, protection of vulnerable adults, fire, dementia, risk taking and care planning. Some of this training was in house and some was external courses. Some staff had received training in the Mental Capacity Act and safe handling of medicines. Further training was booked for moving and handling and health and safety. We could not see any evidence of induction training on the staff files. The manager confirmed that staff were supernumery until they had completed an induction, however it is recommended that there is some written evidence of this being undertaken on the files. Victoria Lodge Care Home DS0000070198.V367235.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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager needs time to sustain the improvements made so that the home continues to be run in the best interests of the people who live there. EVIDENCE: The previous home manager left employment at the home in February 2008; the current acting manager is now the third manager of the home since it opened in the summer of 2007. The acting manager has been employed at the home for 3 months and it was clear that she had made significant improvements resulting in better outcomes for the people living at the home. The manager is a Registered Mental Nurse and has a number of years experience within management roles and has been Victoria Lodge Care Home DS0000070198.V367235.R01.S.doc Version 5.2 Page 24 the Registered manager of another home within the group. The manager was receptive to suggestions and was honest about what work still needed to be done to improve the home further. It is recommended that she submit an application to become the Registered manager with us. It was clear while walking around the home that the people who lived there knew who she was, and the manager knew about the people and was able to engage in meaningful conversations with them. Staff told us: “The management is much better now, its fantastic” “There have been many improvements and people work as a team” The manager told us that there were systems in place to monitor the quality of service provided although these were not being utilised at present. This may mean that the views of people living in the home and their relatives are not reflected. There are resident satisfaction questionnaires that are to be sent out every three months and information will be collated into a report. Progress on this will be reviewed at the next visit to the home. The manager completes monthly care plan, medication and accident audits so that she can monitor situations. Senior managers visit the home and complete Regulation 26 visit reports which report on the quality of service being offered at the home. The June report noted that ‘the home was more settled and there was good staff morale’. We looked at the money of four people, which the home hold for safekeeping and the balances were found to be correct. There are individual records kept and two signatures recorded for all transactions. Receipts were kept as proof of any expenditure. This should mean that people’s money is kept safely. Health and safety and maintenance checks had been undertaken in the home to ensure that the equipment was in safe and full working order. We did not see any records for the maintenance of the hoists in the home and these should be available for inspection. During lunchtime we observed people being brought into the lounge in wheelchairs without footplates on one floor. This was brought to the attention of the manager at the time of the visit as may cause an injury to the person using the chair. Victoria Lodge Care Home DS0000070198.V367235.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 2 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X 3 X X 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Victoria Lodge Care Home DS0000070198.V367235.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 OP9 Regulation 13 (2) Requirement All medication must be correctly accounted for so that people receive their medication as prescribed. Timescale for action 20/08/08 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 OP1 Good Practice Recommendations The service users guide and statement of purpose should be made available in alternative formats and should include the homes fee rates so that all people can access this information. The last report should be displayed so people can read this information if they chose to. Daily records and care plan evaluations should provide more details so that evidence of peoples needs being met is provided. Fridge temperatures should be monitored so that medicines are stored correctly. Medication for return should be kept in a locked cupboard to safeguard people from harm. People should receive their pureed meals in a way that DS0000070198.V367235.R01.S.doc Version 5.2 Page 27 2. 3. 4. OP1 OP7 OP9 5. OP15 Victoria Lodge Care Home 6. 7. OP16 OP18 8. 9. 10. 11. 12. OP26 OP26 OP30 OP31 OP38 enables them to experience the taste. The complaints procedure should be available in alternative formats so that all people can access the information. The whistle blowing policy should contain contact details so that staff know who they can contact. The adult protection policy should give staff clear guidance how to safeguard people from harm. Racks should be provided in sluice rooms to reduce the risk of cross infection. The walls by the kitchenettes should be clean so that the home promotes a homely and clean environment. Induction of staff should be documented so that people know what is expected of them. The manager should submit an application to us to become the registered manager of the home. Evidence of hoist servicing should be available for inspection so we know that equipment is safe to use. Victoria Lodge Care Home DS0000070198.V367235.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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