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Inspection on 01/11/05 for Victoria Lodge Nursing Home

Also see our care home review for Victoria Lodge Nursing Home for more information

This inspection was carried out on 1st November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Home is well managed with constant support from the Manager and deputy and residents spoke of the staff giving a good standard of care, and support with their social and leisure activities. The Home has welcoming surroundings and a friendly atmosphere, which residents and visiting relatives said was always the same. All visitors to the home are made welcome and treated with courtesy and respect by the staff. Residents and visiting relatives spoke well of the staff. Some made such comments as "I`m very happy with the home, and the staff are lovely, I`ve no complaints", "I`ve only got to press the buzzer for assistance and they come", I have everything I need here, lots of my own things".

What has improved since the last inspection?

The decoration and refurbishment of the Home has continued. A number of residents` bedrooms have been decorated. The corridors, lounge and dining rooms on the first floor have been decorated and are waiting for some new furniture and furnishings. This gives fresh uplift to these areas, making them more homely, bright and comfortable for the residentsThe plans to make the ground floor a single unit for people with physical disabilities continue to make some progress. Some residents on the ground floor have begun moving upstairs to help with the planning, to different rooms of their choice, which they say they find better. People in the Home with physical disabilities said they were looking forward to the plans being completed.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Victoria Lodge Nursing Home Leechmere Road Sunderland SR2 9DJ Lead Inspector Mrs P A Worley Unannounced Inspection 1st November 2005 10:30 X10029.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 Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and 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 Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Victoria Lodge Nursing Home Address Leechmere Road Sunderland SR2 9DJ 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) 0191 523 7530 0191 523 7524 victoria.lodge@fshc.co.uk Tamaris Healthcare (England) Ltd (wholly owned subsidiary of Four Seasons Health Care Limited) Ms Marjorie Condacos Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (38), Physical disability (12) of places Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2005 Brief Description of the Service: Victoria Lodge Nursing Home is a purpose built, two-storey home. It is registered to provide nursing and personal care for up to 38 older people, and 12 physically disabled people between the ages of 18-60 years. All rooms are single occupancy and have en-suite toilet facilities. Corridors and door widths are wide to allow easy access for wheelchair users throughout the Home. A passenger lift provides access between floors. Baths and showers are provided in sufficient numbers on both floors, and have with adaptations and equipment to assist those who need it. A number of lounges of varying sizes and decor are available between both floors and dining facilities are provided on each floor. A separate smoking lounge is also provided. The Home shares the location site with another Home and has access via a car park, which is at the front of the building. There is a garden and secluded area at the rear of the home that service users can use for recreational purposes. The home is set in a residential area but has transport, shops and other amenities close by. Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out by one Inspector over one day. The Manager has been working at another Home owned by the Company for some weeks and the Deputy Manager was managing the Home and present at the time of the inspection. Eighteen residents, the Deputy Manager, a number of staff and two visiting relatives were spoken to. A sample of records were inspected that included care assessments, care plans and resident’s finance records of personal allowances, and staff files. The building was checked to see the facilities and equipment available for residents, and the general maintenance and safety of the property. The one requirement from the last inspection has been acted on. Not all standards were looked at this inspection and of those that were; only one requirement was made. What the service does well: What has improved since the last inspection? The decoration and refurbishment of the Home has continued. A number of residents’ bedrooms have been decorated. The corridors, lounge and dining rooms on the first floor have been decorated and are waiting for some new furniture and furnishings. This gives fresh uplift to these areas, making them more homely, bright and comfortable for the residents. Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 6 The plans to make the ground floor a single unit for people with physical disabilities continue to make some progress. Some residents on the ground floor have begun moving upstairs to help with the planning, to different rooms of their choice, which they say they find better. People in the Home with physical disabilities said they were looking forward to the plans being completed. 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 Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards in this section were not assessed on this occasion. Intermediate care is not provided by the Home (standard 6). EVIDENCE: Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7 & 10 (Older People) and 6, 16 & 18 (Adults 18-65). Social care plans are being developed and care plans generally have made some good progress. However, some aspects of personal care are still not detailed enough to provide sufficient guidance to staff and ensure a consistent approach is adopted. Personal care and support by staff is offered to residents in a way that respects, promotes and protects their privacy and dignity. EVIDENCE: Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 10 Staff indicated a good knowledge and awareness of individual residents’ needs. Some care plans were examined and contained good assessment information. Social care plans are now documented and have input from care staff, health related risk assessments are completed and have associated care plans, which detail the actions to be taken with reference to falls, nutrition and pressure damage. The care plans contain information of the input by GP’s and other relevant professionals. Specific information relating to specific needs for some residents was recorded for example, the planning for ‘life back in the community’ for one resident and the preference of another resident to have a male carer for personal care. However, such detail as how to provide assistance for men with facial shaving, where help is required, should also be included in the personal care plans. An improvement in care planning documentation was evident, but and this needs to continue to make certain that documentation is detailed enough, to give more meaningful information about how the care is planned and delivered. Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 & 14 (Older People) and 7 & 13 (Adults 18-65). Service users are encouraged and supported to lead active lifestyles and to control how they spend their daily lives, based on their preferences and choices. Links with families, friends and the community are maintained and service users are supported by staff in doing this. EVIDENCE: Many of the younger adults and a number of older people living in the Home spoke of how they spend their daily lives and of outings and places they go to. Some residents go to various day centres two or three times week, two attend college and others go out with relatives or places of their choice. Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 12 Two residents spoke of their recent attendance at a Sunderland football game at the Stadium of Light with some of the staff. Others spoke of the party planned for the afternoon in the Home to celebrate a residents’ birthday, and of the entertainer who was to attend. One resident said she was looking forward to going out at the weekend to celebrate another residents’ birthday, with a relative and some staff, and another of planning a shopping trip out to the town. One resident said, “it’s great here, I get to do so much”. Other residents said they choose where their spend their time and what they do with it. All residents spoken with were consistent in their view that staff were very helpful in this area. Evidence was seen from observations, of staff asking residents what they wished to do, where they wished to go, and of generally offering choices to them on various matters throughout the day. Residents were also observed coming and going as they chose and generally doing things to suit their individual preferences. All residents confirmed that relatives and friends were able to visit at any time and one visiting relative confirmed this. Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 (Older People) and 23 (Adults 18-65). Appropriate policies and procedures are in place and together with staff training; this ensures that residents are protected from abuse. EVIDENCE: A Protection of Vulnerable Adults (POVA) procedure is available in the Home for staff guidance and includes whistle blowing. The Local Authority Multi Agency Procedure for the Protection of Vulnerable Adults (MAPPVA) is also available in the Home for staff guidance. Staff records and conversations with staff confirmed that they have received training on the protection of vulnerable adults. Staff were able to describe and give a good account of appropriate actions to be taken on suspicion of, or witnessing abuse. Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 (Older People) and 24 & 30 (Adults 18-65). The environment of the Home is clean, safe, well maintained and decorated offering residents a homely and attractive place to live. EVIDENCE: Since the last inspection a number of residents’ bedrooms have been decorated. The corridors and communal lounge and dining area on the first floor have also been decorated and are bright, fresh and attractive. Some new carpets, furnishings and furniture, including curtains, are also to be provided but will not to be delivered for some weeks. However, there are no curtain Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 15 tracks or curtains at the communal room windows and this gives a stark and cold appearance especially now that the winter season is here. The Manager is to provide some interim window dressings meanwhile. New lighting is also to be provided in the corridor and communal rooms on the first floor. A tour of the remainder of the Home showed it to be clean to a good standard, well maintained, and odour free. A number of bedrooms were visited and were homely in appearance, provided appropriate furnishings and equipment and contained many items of residents’ own possessions, which personalised the rooms. Doors to rooms and cupboards where there were potentially hazardous items were locked or closed as appropriate. At the last inspection the Manager spoke of plans to develop better facilities to improve the service for younger physically disabled residents within the Home. Some progress has been made with the planning to dedicate the ground floor for this service. No changes have yet been made but older residents living on the ground floor have been consulted about this and some have already moved to other rooms on the first floor, to help to accommodate the change. Some said they prefer their new rooms as some are bigger or have a better view from the window. Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 & 30 (Older People) and 34 & 35 (Adults 18-65). The recruitment policy and procedure for the employment of staff on this occasion were not fully complied with, therefore did not provide the safeguards and protection for the people living in the Home. Residents are supported by a well trained staff team as staff have, and continue to receive the appropriate training to enable them to competently carry out their work. EVIDENCE: The files of two recently appointed staff were examined. Both contained appropriate documentation and included requests for safety checks. However, one staff member had commenced work before the Criminal Records Bureau (CRB) check had returned. The other was in post and the CRB disclosure check was still not returned. This member of staff has only been in post for one week and was still doing induction training therefore was supervised at all times, which she confirmed. Both had had Protection of Vulnerable Adults Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 17 (POVA) register checks carried out and were in the files. In discussion with the Deputy Manager it was reinforced that the appropriate checks must be available before staff take up posts in order to ensure the safety of the vulnerable people living in the Home. A staff training and development programme is in place to cover induction training, statutory training and other training relevant to the care offered in the Home. Staff training files and conversations with staff confirmed that good levels of training opportunities are offered. Training includes specific conditions and care needs such as PEG feeding, palliative care, tissue viability, multiple sclerosis, Huntington’s chorea, dementia and epilepsy. Nursing staff also have the opportunity to up date knowledge and skills in such areas as ‘flu vaccines and Cardiac Pulmonary Resuscitation (CPR). The required statutory training is provided to include moving and handling, fire safety, food hygiene, infection control and Control of Substances Hazardous to Health (COSSH). A training matrix is available that identifies at a glance, specific training needs and statutory training requirements. Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35, & 38 (Older People) and 39, 23 and 42 (Adults 18-65). In the absence of the Manager, the Home has been managed by a person who is competent and qualified to take the responsibilities. Systems to are in place to determine the quality of the service provided by the Home, and ensure that it is run in the best interests of the residents. Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 19 Appropriate systems are in place and function well, to safeguard service user’s personal allowances. Records are clear and well documented. Staff follow appropriate safe working practices to promote and protect service users’ health, welfare and safety. EVIDENCE: The Manager has been seconded to another Home within the company for some weeks, but is to return in two weeks. The Deputy Manager has been responsible for the management of the Home during that time and residents said that the running of the Home had not changed, it had remained consistent and they were happy with the way things have been with the Deputy. One resident said, “ I miss the Manager but the deputy’s been OK, things have stayed stable”. Some Company quality assurance systems are in place and include anonymous service user questionnaires and random questionnaires issued by the Company to service user’s relatives. An annual audit of the Home takes place and the Regional Operations Manager, also the home’s Manager, carries out in-house audits on subjects such as care plans and falls and accident reports and complaints. The Regional Operations Manager submits monthly reports to the Commission as required by Regulation 26. Staff meetings are held two monthly and minutes are kept. Residents and relatives meetings are held evidence was seen of action taken following a request by residents six months ago to review the meals and menus. A follow up meeting is planned with them later in the week to review its success. Residents who were asked confirmed that they are consulted about matters affecting the Home and have an opportunity to state their views and influence some issues. Inspections are responded to appropriately, and policies and procedures and practices are reviewed as required. Service users are encouraged to maintain control of their own financial affairs where they are able to do so. A number of service users currently handle their own finances. The security arrangements and records of service users, whose monies are held in the home, are well organised and well maintained. The petty cash and personal allowance monies of some service users, the Home’s petty cash and the Residents’ fund are the accounts that are dealt with at the home, by the administrator. Individual records are kept in hard copy and on computer. Numbered receipts, with copies and two signatures for entries, back up the well-maintained records. Communal receipts are submitted by the hairdresser and the chiropodist and the administrator, following the suggestion, agreed to speak with them to request individual receipts. Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 20 The company have financial procedures to guide staff dealing with service user finances. Monthly personal allowance account balances are sent to the Company’s financial office and the Regional Administrator, and Regional Operations Manager carry out regular, random audit checks. In conversation staff confirmed that they receive training in all areas of health and safety. Throughout the day staff demonstrated awareness of good health and safety practice. Moving and handling procedures by staff with the residents, were observed to be good with appropriate practices carried out. A multi-disciplinary Health and Safety committee is established within the home and regular meetings take place regarding health and safety issues. No hazards were identified at this inspection. Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 21 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 x 2 x 3 x 4 x 5 x 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 ENVIRONMENT Standard No Score 19 3 20 x 21 x 22 x 23 x 24 3 25 x 26 3 STAFFING Standard No Score 27 x 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 x 33 3 34 x 35 3 36 x 37 x 38 3 Victoria Lodge Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 22 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 OP29 Regulation 19 (Schedule 2) Timescale for action Appropriate security checks must 01/11/05 be carried out before staff come into post to ensure the protection of service users. Requirement 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 Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Nursing Home DS0000018212.V269083.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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