Inspection on 14/06/05 for Victoria Lodge Nursing Home

This inspection was carried out on 14th June 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.

Other inspections for this house

Victoria Lodge Nursing Home 18/04/07

Victoria Lodge Nursing Home 01/11/05

Victoria Lodge Nursing Home 15/11/04

Victoria Lodge Nursing Home 11/08/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Victoria Lodge Nursing Home Leechmere Road Sunderland SR2 9DJ Lead Inspector Mrs P A Worley Announced Inspection 14th June 2005 10:00 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.V254951.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.V254951.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) Limited (wholly owned subsidiary of Four Seasons) 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.V254951.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2004 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.V254951.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced, and was carried out by one Inspector over one day. Before the inspection a questionnaire had been completed by the Manager, which gave up to date information about the Home to allow more time to be spent with residents on the day. A tour around the home to check the cleanliness, health and safety matters, and maintenance and decoration was carried out and found it to be clean, tidy and well decorated. Fifteen residents, three visiting relatives, and eleven staff including the Manager, Deputy, Activities Co-ordinator, care staff and nurses were spoken with. Lunch was taken with some residents in one of the two dining rooms. A number of records and documents were examined including residents’ care plans and staff files. An action plan had been received from the Provider following the last inspection when only one recommendation was made, and has been dealt with. Not all standards were looked at this inspection and from those that were; one requirement was made. A number of CSCI comments cards were received before the inspection and were generally very complimentary about the Home and the staff. What the service does well: The Home delivers a good level of care to the residents, and a range of varied social and leisure activities are available and supported by a committed team of staff. Residents spoke well of the staff and the Manager stating that they are caring, friendly and kind. It is a well managed home with support offered to staff, residents and families. Some comments made by residents about the Manager were: “I think the manager is good, she makes sure we’re looked after” and “she’s so helpful and keeps the staff right”. Meals are varied and choices and alternative foods are available to suit individuals’ tastes. Residents were complimentary about the cook and the meals. Victoria Lodge Nursing Home DS0000018212.V254951.R01.S.doc Version 5.0 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 Nursing Home DS0000018212.V254951.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.V254951.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): 3 & 4(Older people) and 2 & 3 (Adults 18-65). The Home’s admission procedure is robust and ensures that appropriate assessments are carried out prior to, and following admission, to make certain that service users needs can be met by the Home. EVIDENCE: The files of two residents that had been recently admitted were looked at and evidence was available of assessments by Care Managers, the Home’s preadmission assessment, and further assessment by the Home’s staff at the time of admission. Evidence was also available of residents’, and relatives’ involvement in this process. Victoria Lodge Nursing Home DS0000018212.V254951.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, 8 & 9 (Older people) and 6, 19 & 20 (Adults 18-65). Residents individual care plans continue to show improvements, however, do not fully reflect and document their observed needs. This can limit the guidance available to staff regarding care practice and consistency. Residents spoke of their health care needs being met. Documentation was available to support this, and of good multi-disciplinary working taking place. The systems for the administration of medicines are good with clear and comprehensive arrangements in place to ensure residents’ medication needs are met. Victoria Lodge Nursing Home DS0000018212.V254951.R01.S.doc Version 5.0 Page 10 EVIDENCE: In conversation with the Manager, Deputy and other staff, they displayed a good knowledge of individual residents and their needs. They were able to say how those needs are met and how identified risks were managed. A sample of care plans were examined and contained good basic information but more and specific detail, about the care delivered, and addressing changing needs should be recorded. Health related risk assessments were carried out, with care plans, as to how they were to be acted upon with reference to falls, nutrition and pressure damage, but the information in these needed to be expanded upon. The care plans contain information of the input by GP’s and other relevant professionals. Residents who were spoken to described how their health care needs were met and of their satisfaction with this. One resident said, “they look after my health very well, I’m better than I’ve been in years”, and another said ”my health is good now, thanks to the staff”. Key workers and Senior Care staff contribute by completing social assessments but no care plans are developed from these. Since the last inspection there has been an improvement in care planning documentation, however further progress is needed to make certain that documentation is detailed enough, so as to give more meaningful information about how the care is assessed and delivered. Examination of the medications systems indicated that clear systems were in place for the safe practice of medicines control. The policies, procedures and practices for the ordering, receipt, and disposal of medicines were good and in line with relevant guidance and legislation. A policy is in place for residents who wish to control their own medicines however, none at present choose to do this, or are able to. The standard of medicine administration records (MAR) was good and an audit trail of some medicines carried out was correct. All other records associated with medicines were satisfactory. Victoria Lodge Nursing Home DS0000018212.V254951.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): 12 & 15 (Older people) and 14 & 17(Adults 18-65). Residents are offered the opportunity of participating in a range of leisure and social activities enabling them to lead active and fulfilled lives. Residents are consulted and involved in menu planning and receive varied, wholesome, nutritious and well-presented meals, which offers them choices and contributes to their general health and well being. Victoria Lodge Nursing Home DS0000018212.V254951.R01.S.doc Version 5.0 Page 12 EVIDENCE: Conversations with the Manager, Activities Co-ordinator and other staff, and a number of residents, and reference to the activities programme displayed, confirmed the range of various activities, events and outings available. An activities board is displayed giving details of daily activities and events, which is user-friendly and clear to see. Four of the younger adults and two older people who live in the Home were out for the day at various day centres, colleges and an outing with relatives. Residents spoke of opportunities to join in daily activities including craft and card making and some were actively involved with the raised gardens at the rear of the Home where residents had planted flowers and herbs. Residents spoke enthusiastically about this and a member of staff had set up a gardening ‘club’ which had membership of a number of residents. Some relatives and visitors had provided compost and other items to help develop this facility. One resident spoke of going out regularly to the ‘Bingo’ and to the ‘pub with a relative, and of other places of entertainment such as the Sage Music Centre and a Museum. One relative spoke of the “good level of activities and opportunities to go out” and two residents spoke of their visits to the shops and other places of interest. Two residents said they preferred to stay in their rooms and provide their own entertainment and commented that staff respected their choice not to participate in group activities. Lunch was taken with residents in one of the dining rooms, for lunch. The tables were pleasantly set with condiments, serviettes, sugar and milk, and were pleasantly decorated. Cold drinks were offered during the meal and the meal was tasty and well presented. A white board in the dining room indicated in a clear and legible way, what the meals of the day were. Alternative choices were served to those people who requested them. Residents confirmed that such facilities and choices were offered on a daily basis and that they always enjoyed their meals. Staff were attentive and offered assistance to those who needed it, in a discreet, courteous and unhurried manner. The environment and the atmosphere were sociable and pleasant with good interactions taking place between residents, staff and visitors. Victoria Lodge Nursing Home DS0000018212.V254951.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): 16 (Older people) and 22 (Adults 18-65). The Home has a satisfactory complaints procedure, which ensures that complaints are handled objectively, and residents indicated that their concerns are listened to, taken seriously and acted upon. EVIDENCE: The Home uses the Organisations’ corporate complaints procedure for staff guidance and a more user-friendly version is provided by the Home for service users and relatives. Information about complaints is available in the foyer of the Home. In the past year there has been one complaint made to the Home, which was managed and recorded appropriately. The Manager is diligent in keeping CSCI informed of significant and potential complaints made about the Home and of the actions taken to deal with them. Some service users and relatives who were spoken to indicated that they are aware of who to make complaints to should they wish to do so and felt confident to raise any concerns to staff and the Manager. Victoria Lodge Nursing Home DS0000018212.V254951.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 & 22 (Older people) and 24 & 29 (Adults 18-65). The environment of the Home is clean, safe, well maintained and decorated offering residents a homely and attractive place to live. Appropriate furnishings and specialist equipment are provided for residents’ safety and comfort and to enable them to maximise their independence. Victoria Lodge Nursing Home DS0000018212.V254951.R01.S.doc Version 5.0 Page 15 EVIDENCE: A partial tour of the Home was carried out and all areas seen were clean to a good standard, well maintained, and the Home was odour free. A selection of bedrooms were looked at and were homely in appearance, provided appropriate furnishings and contained many items of residents’ own belongings, which personalised the rooms. The ground floor, main dining room has recently been decorated and refurbished with co-ordinating furnishings and accessories. New slide/glide chairs have been provided, which are safer and easier for residents to move. The room now offers a more homely, bright and pleasant environment for residents during mealtimes. The re-decoration of individual bedrooms continues as a rolling programme and plans are in hand for some refurbishments on the first floor. All rooms with potentially hazardous items inside, for example cleaning solutions and equipment, were locked. All areas used by residents, including wheelchair users, are accessible with the wide corridors and room widths, and by the passenger lift between floors. Grab rails are provided throughout the building and specialist baths and equipment is available for those who need assistance. The Manager spoke of plans to develop, better facilitate and improve the service for the younger physically disabled residents within the Home. A project involving managers who run other physically disabled units within the Company, has been set up and an action plan developed as to how to take this forward. It is planned to involve service users in this development and one resident in the Home who wished to be involved spoke positively of the opportunity this gave to influence the project in providing specialist equipment and facilities, and looked forward to this. Victoria Lodge Nursing Home DS0000018212.V254951.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): 27 & 29 (Older people) and 33 & 34 (Adults 18-65). Staffing numbers and skill mix are appropriate to the assessed needs of residents and ensures that at all times residents are supported by an experienced group of staff. The procedures for the recruitment of staff are satisfactory and provide the safeguards to offer protection to people living in the Home. EVIDENCE: Discussions with the Manager and examination of staffing rotas indicated that appropriate numbers of staff are provided and maintained over the twenty-four hour period to meet the needs of the current residents. The Manager works supernumerary to the rota, and a good level of ancillary/support staff are in post. Victoria Lodge Nursing Home DS0000018212.V254951.R01.S.doc Version 5.0 Page 17 In conversation with some residents they said they trusted the staff, felt safe living in the Home and were well cared for. They commented that the staff were generally kind and helpful. One resident said “I’m happy here, there’s nothing I would change, staff see to all my needs”. Another resident said “ I’m happy with the home and the staff, but some’s better than others”. Inspection of two staff files confirmed that appropriate checks are carried out prior to staff taking up post that includes Criminal Records Bureau (CRB) and POVA register checks, and two written references being obtained. Evidence was also seen of induction training for new staff. Victoria Lodge Nursing Home DS0000018212.V254951.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): 36 & 38 (Older people) and 36 & 42 (Adults 18-65). Staff receive appropriate supervision, which assists in promoting and safeguarding the best interests of service users. The health and safety of service users and staff is promoted and protected by a well managed Home. Victoria Lodge Nursing Home DS0000018212.V254951.R01.S.doc Version 5.0 Page 19 EVIDENCE: Discussions with a number of staff confirmed that they receive regular and appropriate supervision, notes of which are kept, and evidence of this was seen in staff files. Staff commented that they felt valued and that the Manager and senior staff were approachable and helpful. All staff receive training in health and safety, which includes moving and handling, first aid, Control of Substances Hazardous to Health (COSHH), fire safety, infection control and first aid. 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.V254951.R01.S.doc Version 5.0 Page 20 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 3 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 3 23 X 24 X 25 X 26 X STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No Score 31 X 32 X 33 X 34 X 35 X 36 3 37 X 38 3 Victoria Lodge Nursing Home DS0000018212.V254951.R01.S.doc Version 5.0 Page 21 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 YA6OP7 Regulation 15 Requirement Service users care plans must fully and accurately reflect their needs and how they are met. Timescale for action 30/09/05 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.V254951.R01.S.doc Version 5.0 Page 22 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.V254951.R01.S.doc Version 5.0 Page 23 - 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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