Inspection on 18/04/07 for Victoria Lodge Nursing Home

This inspection was carried out on 18th April 2007.

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 01/11/05

Victoria Lodge Nursing Home 14/06/05

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 Eileen Hulse Unannounced Inspection 18th April and 14th May 2007 08:45 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.V336454.R02.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 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.V336454.R02.S.doc Version 5.2 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 www.fshc.co.uk Tamaris Healthcare (England) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) ** Post Vacant *** 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.V336454.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 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 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 public transport, shops and other amenities close by. The weekly fees are £359:00 to £412:00 per week depending upon care needs. Additional charges are made for Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took 14hrs 30mins to complete visiting the home over two days and was carried out as part of the annual inspection programme. The Acting Manager was present throughout the two visits and some time was spent with her looking at the progress of the service. How care staff help and support service users was observed throughout the visit and a lunchtime meal was taken with the service users. Information about the quality of life and care received by service users was collected using a system called ‘case tracking’. This involves following the care and experience of a group of service users by looking at care plans, talking with people, sampling records such as assessment records, complaint records, medication taken by service users and their records. Discussions took place with other staff members who were on duty at various times throughout the visit. The judgements made are based on the evidence made available during the visit to the home and from information obtained from the home before the visit was made. This gave up to date information about the home to include within the report. During the visit, discussions with service users and their families also gave some insight on what it is like to live in the home and their views on the service that is provided. Some comments included: ‘The home always keep me informed of my relatives condition’ ‘This is a lovely home and everybody is so friendly’ ‘I wouldn’t want to live anywhere else’ Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The care plans do not give clear information to staff that can tell them how to meet a persons needs. Staff know the people well but they must follow the care plans to make sure the needs are met. The mealtime arrangements need to be looked at and staff must ensure that service users have what they need during the mealtime. The menus are repetitive and some areas do not offer a distinct choice at mealtimes, they do not always take account of the wishes of the service users. Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 7 The Manager must be registered to manage the service and money held in safekeeping for service users should be stored individually 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 Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 8 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.V336454.R02.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 (Older People) and 2 (Younger Adults) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good assessments are included within the care plans that help to form the basis of the care to be provided. This should ensure that before admission, the home is able to know if they can meet the care needs of service users. The home does not provide intermediate care EVIDENCE: The home accepts referrals from Care Managers, palliative care nurses, hospices and from family members and whenever a referral is made to the Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 10 home, the Acting Manager will visit the prospective service user to assess that the home can meet their needs prior to an admission arrangement. The home has its own assessment documentation, this is a Dependency Assessment Rating Tool (Dart Tool) and this is completed during the initial visit to the prospective service user and for all other assessments made following admission into the home, the information is used to ensure the home can meet the care needs and to develop the person centred care plan that will be followed after admission. The information is then discussed with the staff that will be involved in providing the care. Visits are offered to the service user to spend the day at the home where this is possible. Following this area of assessment, the Care Manager and family are contacted and a letter is then sent to the service user to offer a place in the home or to explain to them the reasons why the home cannot meet the needs. A date is then arranged for admission that is suitable to all. On rare occasions an emergency admission may be necessary and at these times, details of the service user’s care needed and a care managers care plan are faxed to the service and followed up with a phone call from the Care Manager to the home to discuss any other issues prior to the arranged admission. The personal files of younger adults viewed all had up to date contracts in place, and the statement of purpose had been given to service users or their representatives prior to them deciding to move into the home. Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 (Older People) and 6, 9, 16, 18, 19 and 20 (Younger Adults) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users have an individual plan of care that are organised and generally maintained, however, they do not contain sufficient information or detail within them to give guidance to staff to ensure that all of the identified care needs of service users are met. The administration and management of medication is good and service users have regular access to all healthcare professionals and this can help to contribute to service users general health and well being. Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 12 Personal care and support by staff is offered to service users in a way that respects and protects their privacy and dignity. EVIDENCE: Each service user has a care plan that is based on information held within the assessment documentation. The information is organised and the file index enables various records to be accessed easily, an identification sheet includes the personal details of the service user with a photograph attached and the original assessment records. The risk assessments detail the hazard, how frequent the risk is, comments on how to reduce the risk and include areas such as moving and handling and nutrition. All of the risk assessments looked at were fully completed. However, some of the information and guidance is not made clear for staff to follow. One care plan stated that (name) is dependant on staff for many needs due to his (condition). The care plan stated the need, the aim or outcome and numbered points to guide staff on how to meet each particular need but the information is vague such as (name) has difficulty with verbal communication. The care plan states ‘allow time for (name) to communicate using non verbals’, ‘observe non verbal gestures’, ‘develop a rapport to form a trusting relationship’, but do not give staff the information they need to follow up this practice and do not tell staff how this can be achieved. The service user or their representative have not signed some of the care plans in place. In discussions with some of the staff and relatives it was very clear that staff are knowledgeable about the care needs of the people who live in the home and observations of the care practice showed staff have a good understanding of how to support service users needs and this helps to give a good quality of care. A monitored dosage system is used by the home that is supplied by a well known pharmacy and Registered General Nurses are the only people in the home to administer medication. Gel boxes are used for any unwanted or unused drugs and a waste company that have been contracted by the supplying pharmacy collects these boxes monthly. The examination of the medication system indicated that clear systems were in place for safe practice with medicines. The policies, procedures and practices for the ordering, receipt, and disposal of medicines were satisfactory. The standard of medicine administration records (MAR) show staff signatures when a medicine had been administered. An audit trail of some medicines and controlled drugs carried out was correct and all other records associated with medicines were satisfactory. Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 (Older People) and 12, 13, 15 and 17 (Younger Adults) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are offered a good selection of social activities to participate in and this enables them to lead lifestyles based on their choices and abilities. EVIDENCE: An activity co-ordinator is employed by the home to provide social activities every day and organise events for the service users. A programme of activities are on display so that service users are kept informed of events that are Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 14 happening every morning and afternoon for the coming week. Once a week, the activity co-ordinator meets with the service users to discuss what they would like to do for the next week. The home have good community links, one person visits her local church every Sunday, four people access Nookside day centre twice week and two people attend the Scope day centre twice a week. Talking with service users and relatives they were complimentary about the activities that take place and stated: ‘The home tries hard to occupy the people who are living here’ ‘The girls are lovely, there is always something going on whenever I visit’ ‘ My relative goes out now’ ‘We have a bus now so that is better’ The home also has the use of a mini bus for outings that is shared between four sister homes in the Sunderland area. The Stroke Association visit a gentleman once a week and the speech and language therapist comes in for another person to improve their speech with use of communication aids and to work with the activity co-ordinator in this area. All activities are recorded on individual records for each person living in the home. The records state the date of the activity, what the activity is, any comments and signature of the staff member. However, the records do not always contain all the activities that service users have taken part in, the date of the activity and do not include which service users have been asked to do an activity and refused and therefore do not demonstrate some of the good practice that takes place. During the visit, a meal was taken with the service users. Due to the laying of new flooring on the ground floor and the hot lock trolley unable to be used, a cold lunch was served consisting of assorted sandwiches or cold mackerel salad. Due to the small size of one of the two dining rooms, there are two lunchtime sittings to allow service users more space. During the meal, staff were very helpful and attentive to service users, if help or support was needed this was given in a discreet and sensitive manner and staff sat with the service users. Tables were set with necessary equipment such as place mats and condiments, serviettes were available on top of a cupboard however, they were only given out if they were needed or asked for. A hot drink was served with the meal. Jugs of juice and bowls of fruit were in all lounges so that service users could help themselves throughout the day. The menus showed they are very repetitive and little variation, many of the choices were the same type of meal but cooked a different way, for example, one day’s menu showed scrambled egg for breakfast, beans and scrambled Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 15 egg or scrambled egg on toast for lunch. Many of the choices showed the choices to be virtually the same such as, roast chicken or chicken curry, shepherds pie or mince and dumpling, soft boiled egg or scrambled egg and fried fish or poached fish. The only cooked breakfast available is scrambled eggs, this gives no real alternative or choice for people. Service users gave mixed comments about the meals that included: ‘I would love a bacon sandwich for my breakfast’ ‘Food is my main concern in the home, not a lot of choice now’ ‘They have took off the cooked breakfasts and I miss having the choice’ ‘Sometimes the meals are ok’ ‘I suppose the meals are alright, I miss not having what I ate at home’ Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 (older people) and 22 and 23 (Younger Adults) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A complaints procedure is available to service users and their relatives. This provides the opportunity for service users and their relatives to make a complaint should they have any concerns about the service. Staff are aware of the Protection of Vulnerable Adults procedures and with staff training ensures service users are protected from abuse. EVIDENCE: The complaints procedure details how to make a complaint about the service and the information is accessible within the entrance to the home and made available to service users, families and any visitors to the home Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 17 All complaints are recorded. On receiving a complaint, a letter is sent out within 48 hrs to the complainant, the info is recorded and held on a month by month file for reference. Only one complaint has been received by the home in the last 12 months, records showed it was well documented and the complainant was happy with outcome. Service users spoken with all knew how to make a complaint and who to speak to if they have an issue they are unhappy about. One service user said: ‘Nobody should have anything to complain about in here’ another said ‘I would see my key worker or tell the manager if I wasnt happy’, ‘Everybody is always asking us if we are all right’. No complaints have been received received by CSCI in the last twelve months. Over 30 staff have received protection of vulnerable adults training and six staff new to the service have dates identified for pova training to be completed before the end of June. One pova situation arose last year and this has now been dealt with in a satisfactorily way and the employee no longer works for the company. Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 (Older People) and 24 and 30 (Younger Adults) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of furnishings, fittings and decoration throughout the home present a comfortable and homely place for service users to live in and this offers service users a homely and safe place to live. The home have good procedures in place regarding infection control that helps to keep service users healthy and safe. Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 19 EVIDENCE: The home has recently undergone a major refurbishment. Furniture, carpets and furnishings have been renewed throughout the home and twenty beds in the younger adults area of the home have been adapted changing the number of bedrooms to sixteen. Twelve bedrooms have been completely refurbished installing en-suite facilities, new furnishings and decoration and the remaining four bedrooms also now have also have en-suite facilities but a shower has been installed. One room has been adapted to become a private room that can be used for service users to receive guests, meetings or reviews and another room has been changed into a treatment room. The original treatment room has been identified to become a sluice and macerator area. The small second dining room has been refurbished and is now used for the people who live on the ground floor. Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30 (Older People) and 34 and 35 (Younger Adults) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good staffing levels that help to meet the needs of the service users and they are protected and safe by a good recruitment policy and procedure. The staff receive good levels of training that provide staff with the knowledge and skills to ensure that people are cared for efficiently and effectively. EVIDENCE: The home has a policy and procedure on staff recruitment that is used when recruiting prospective staff. The Acting Manager was able to explain in detail the process that is used from sending out an application form to the letter that tells prospective staff if they have been successful in gaining employment. Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 21 Fifteen staff members have acquired NVQ Level 2 and applications have been sent off for staff to apply to complete NVQ Level 3. The home has achieved 75 of the staff team with a qualification. Discussions held with the Acting Manager and members of staff during the visit, show that staff have a good understanding of their roles and responsibilities. Staff stated that they are provided with training specific to the needs of the service users and this has allowed the home to have a mix of skills and experience among the staff group. Good staffing levels on both floors on both days the home was visited. The staff training matrix is up on the office wall so that staff can access the information easily. The information includes the staff name and the title of the course but it does not include the date on which the training took place. Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 (Older People) and 37, 39 and 42 (Younger Adults) Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home is well managed by a person who is appropriately qualified to competently manage the home. Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 23 Service users personal financial accounts are well managed to ensure their best interests are protected. However, money held for service users is not stored individually. Risks to the health and safety of service users, visitors and staff are minimised to a good level. This helps to protect service users and promote health and safety practice. EVIDENCE: The Manager of the home has now left the service and the Acting Manager has only been in post since February 2007. She is a Registered General Nurse and has worked in the home as first level nurse in 2001 and the Deputy Manager since 2003. Since taking up the Acting Managers post she has completed further specialist training in ‘Infection Control’, organised by the Health Protection Agency, ‘Palliative Care’, ‘Risk Assessment’, ‘Safer handling of drugs four day course’ and some mandatory training. Application has been made to CSCI to be registered as Manager of the home. The home employs a financial administrator who works full time and deals with the petty cash, service user’s accounts and personal allowances for some of the service users. Records are held individually on the computer that can be printed off should service users request this. The individual sheets show the date, the withdrawal or deposit, the amount, the reason for the expenditure and the outstanding balance. All entries are numbered and showing the type of deposit i.e. cheque or cash and they are referenced with the week number and the year. The support administrator for the company carried out a full audit in April 07 and a certificate was given to show that the audit was correct. The accounts were unable to be audited on this occasion as all funds belonging to service users are held jointly in a no interest bank account and the money held in the home was pooled together in one tin. The home have a system in place to gather the views of service users and their families. Questionnaires are sent out annually and if an area is highlighted as needing addressed this information is fed back to the Manager of the home. The next questionnaires will be sent out in June 07. Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 24 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 X 33 3 34 X 35 2 36 X 37 X 38 3 Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement Care plans must include sufficient information that will guide staff in their practice to meet service users needs The mealtime arrangements must be reviewed to ensure service users have everything they need Service users must be offered a well balanced diet that is varied and wholesome and offers choice The Acting Manager must be registered to manage the home Timescale for action 01/08/07 2 OP15 12 01/08/07 3 OP15 12 01/08/07 4 5 OP31 OP35 7 20 01/08/07 Service users money held by the home must be stored individually 01/08/07 and not pooled RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 26 No. Refer to Standard Good Practice Recommendations Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Victoria Lodge Nursing Home DS0000018212.V336454.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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