Care Home: Victoria House Care Home

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What the care home does well There is a detailed and informative Statement of Purpose and Service Users Guide that gives prospective residents the information required to enable them to make an informed choice about where they live. There are robust admission processes to the home. A full needs assessment by a competent person is undertaken and they are now assured in writing that their needs will be met before they move in. Some residents were able to Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 confirm that they were visited by the appointed manager prior to admission to the home. Quality assurance systems are in place which enables the service to monitor and improve their service and ensure that the home is run in the best interests of residents. Satisfactory arrangements are in place to safeguard residents’ finances. The atmosphere of the home is pleasant with good interaction seen between residents and staff. The comments received from residents and families regarding the care received included, `Look after us very well, couldn`t be better`, ‘Lovely staff’` ‘A nice place to live’. What has improved since the last inspection? The requirements set at the last key inspection have mainly been met or are very nearly met and the home are following their improvement plan implemented at the last key inspection. The staff have worked hard on the care plans and risk assessments to ensure that a person centred approach is used along with involvement with the residents where possible. There was evidence of regular review and monitoring of resident’s health needs. The medication practices now seen in the home promote and safeguard the health needs of the residents. The AQAA stated that activities are an area that are constantly being reviewed and improved to meet the residents’ social needs in the home. There is a building and redecoration plan in place, which has started that are improving the facilities and environment of the home for the residents and staff. This is on going. The AQAA states that recruitment of staff is a priority, as there are vacancies for care staff at this time. What the care home could do better: There have been no requirements made at this time as the areas that still need to be improved have been acknowledged and will be acted on by the appointed manager. These include the following: That the appointed manager submits her application for registration with the CQC.Victoria HouseDS0000021277.V376638.R01.S.docVersion 5.2That the management team of the home are confident that the staffing ratio at night is sufficient to meet their statement of purpose and ensure the residents safety. That the menus (in particular the breakfast and supper) are created with the involvement of the residents so as to ensure the meals provided meet their expectations and wishes. That the lifestyle experienced by the residents satisfies their social and recreational interests and provides mental and physical stimulation. Key inspection report CARE HOMES FOR OLDER PEOPLE Victoria House 71-73 Victoria Road Polegate East Sussex BN26 6BX Lead Inspector Debbie Calveley Key Unannounced Inspection 31 July 2009 12.30 DS0000021277.V376638.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria House Address 71-73 Victoria Road Polegate East Sussex BN26 6BX 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) 01323 487178 01323 487178 ered4867@aol.com Supreme Care UK Ltd Manager post vacant Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 20. Date of last inspection 14th August 2008 Brief Description of the Service: Victoria House is registered to provide care and accommodation for up to twenty older people. The home is a three-storey detached property situated in a residential area of Polegate. It is located in close proximity to local amenities including bus and rail links. Service users accommodation consists of twenty single rooms, eleven of which have en-suite facilities. All bedrooms have at least a wash hand basin. The home has a range of communal areas including a large lounge and dining area. There are two communal bathrooms, both of which are assisted, and four communal toilets. There are toilet riser seats and handrails fitted as required. The external grounds offer an attractive garden and patio area. Car parking is available at the front of the property. The home has a passenger lift and a series of ramps that enable service users to access all parts of the home; however there are some internal steps so service users on the upper floors need to be mobile. The service provides prospective service users and their families with a copy of the Statement of Purpose and Service Users Guide when the pre-admission assessment takes place. Copies of inspections reports are made available on request. Fees are available on request from the home. Additional charges are made for hairdressing, chiropody and newspapers. Intermediate care is not provided. Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term service user to describe those living in care home settings. For the purpose of this report those living at Victoria House will be referred to as residents. This was a key inspection that included an unannounced visit to the home and follow up contact with residents representatives and visiting health and social care professionals. This unannounced inspection was carried out over 5 hours on the 31 July 2009. There were 14 residents living in the home on the day of the site visit of which five were case tracked and spoken with and a further three residents both male and female were also spoken with. The purpose of the inspection was to focus on the quality of life experienced and the outcomes for the people who use the service. This included checking that the check that the requirements of previous inspections had been met and inspect all other key standards. During the site visit, a range of documentation was viewed. These included the Service Users Guide, Statement of Purpose, care plans, medication records and recruitment files. Three members of the care team were spoken with in addition to discussion with the appointed manager. Telephone contact was made with visiting health professionals following the visit. An Annual Quality Assurance Assessment was received from the appointed manager completed in full prior to this key inspection. The improvement plan received following the last key inspection was also reviewed against the AQAA and evidence from the site visit. What the service does well: There is a detailed and informative Statement of Purpose and Service Users Guide that gives prospective residents the information required to enable them to make an informed choice about where they live. There are robust admission processes to the home. A full needs assessment by a competent person is undertaken and they are now assured in writing that their needs will be met before they move in. Some residents were able to Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 6 confirm that they were visited by the appointed manager prior to admission to the home. Quality assurance systems are in place which enables the service to monitor and improve their service and ensure that the home is run in the best interests of residents. Satisfactory arrangements are in place to safeguard residents’ finances. The atmosphere of the home is pleasant with good interaction seen between residents and staff. The comments received from residents and families regarding the care received included, Look after us very well, couldnt be better, ‘Lovely staff’ ‘A nice place to live’. What has improved since the last inspection? What they could do better: There have been no requirements made at this time as the areas that still need to be improved have been acknowledged and will be acted on by the appointed manager. These include the following: That the appointed manager submits her application for registration with the CQC. Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 7 That the management team of the home are confident that the staffing ratio at night is sufficient to meet their statement of purpose and ensure the residents safety. That the menus (in particular the breakfast and supper) are created with the involvement of the residents so as to ensure the meals provided meet their expectations and wishes. That the lifestyle experienced by the residents satisfies their social and recreational interests and provides mental and physical stimulation. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides prospective residents and relatives with a good level of information about the home, its facilities, services and the costs involved. The admission procedures allow for the needs of prospective residents to be assessed by a competent person before admission. EVIDENCE: There is a comprehensive Statement of Purpose and Service Users Guide which contains clear information about the home the facilities and the services it provides. These documents give prospective residents and their families the information they need to make an informed choice about where to live. These documents have been recently updated by the appointed manager. The Service Users Guide has been transformed in to a well illustrated and person friendly document and was seen in draft at this visit. When finalised a copy will Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 10 be given to all the people who use the service and also sent to the Care Quality Commission (CQC). It was confirmed whilst talking to residents that the contract arrangements were clear and understood. There is a copy of the terms and conditions of residency included in the homes documentation. The latest admissions to the home were identified and the pre assessment documentation reviewed. It demonstrated that the appointed manager completes a thorough assessment with the prospective person and family and/or health professionals prior to admission to the home. These assessments ensure new admissions to the home are appropriate and that the home have the staff, equipment and environment to meet their care needs. The improvement plan received stated that the home now confirm in writing that the home and staff have the knowledge and facilities to meet the assessed needs. This was confirmed at this site visit. Trial visits to the home can be arranged. It was confirmed that all residents are invited to a trial period to ensure suitability of the home; this is clearly stated in the Statement of Purpose and in the statement of terms and conditions. Victoria House does not provide intermediate care. Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans provide a good framework for the delivery of care which give clear guidance to care staff on all the care needs of all the residents. The home was found to be meeting resident’s health and general needs with accessed additional specialist support when needed. Medication practices in the home promote and protect the health needs of residents and the privacy and dignity of residents are promoted. EVIDENCE: The care documentation pertaining to four residents were reviewed as part of the inspection process, these residents were also visited and spoken with. Areas for improvement that had been identified at the last key inspection have been actioned and the care plans viewed evidenced the improvements. Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 12 It is acknowledged that a lot of work has been undertaken in the past year to improve the care documentation. The care plans viewed were person centred and clearly identified the individual resident’s health, social and welfare needs with the expected outcome and steps for care staff to follow to ensure these needs are met in a consistent manner. As discussed at the site visit, there are areas that need still need to be developed to ensure that changes in the health needs of residents are appropriately monitored and acted on. The home has introduced a range of risk assessments that ensure the residents safety is promoted and protected. Residents are registered with a GP from local surgeries. Residents are supported and enabled to access appropriate health professionals to promote their health. There are policies and procedures in place for staff to refer to regarding the safe administration, storage, disposal and recording of medication. There are no residents at this time on controlled medication, but there are appropriate systems in place when required. A new controlled medication cabinet has been provided by their medication supplier. Administration Charts were found to be competently completed. The appointed manager undertakes regular medication audits which pick up poor practice early and these are then discussed with staff. Some recommendations of good practice were discussed with the appointed manager. Staff were seen to be respectful and considerate to all residents and visitors, whilst attending to their needs. The resident’s comments in respect of their dignity included, The staff are very kind and ensure that I look my best’ ‘Very good to us’ ‘Will help us with anything, and always respectful and polite’. All the residents spoken with were clean and well dressed and their footwear was appropriate for the weather and their mobility needs. The gentleman living in the home were well shaven and their care plan identified their wishes in this. The care plans all had reference to the residents preferred form of address and their identified needs regarding their sexuality and religious needs Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lifestyle and meals experienced by residents at this time does not fully meet their expectations, choices and preferences. EVIDENCE: The pre admission document explores residents past history and this could be used more effectively in their social care plan and the activity programme. The appointed manager has introduced a morning activity programme and there is a planned activity every day, Monday to Friday. These are organised by the care staff on duty. On the day of the site visit, the morning visit from the PAT dog had been cancelled, and in the afternoon the residents chose to play bingo which the staff facilitated. The weekly activity programmes are displayed on the lounge and dining room doors but none of the residents spoken with knew what was happening. It Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 14 would benefit residents if they were given a programme each and they could then plan their day. The appointed manager is consulting residents about the activities and has started to arrange trips out in a mini bus. Some residents did say that they do get bored and would like more variety. Activities are still a work in progress and still needs to be further developed to ensure that the people who use the service have a stimulating life style that meets their expectations and desires. Residents are facilitated to maintain their independence for as long as they are able. There are no restrictions on visiting times as long as consideration is shown to all the residents. Many of the residents have individualised their bedroom with items from home and residents and relatives spoken with confirmed that they are encouraged to make it homely. It was observed during the inspection that the routines at the home are flexible, residents spoken with confirmed that they were consulted about all aspects of their lives. The home has an advocacy policy in place and the information regarding this is available to all residents. The dining area is well furnished and comfortable with natural lighting and residents can choose where they wish to sit. The residents have a choice daily of the main meal; a vegetarian option or a salad of their choice, there is also a choice of pudding. The catering manager visits every resident daily to ask them their choice. There is evidence that residents’ dietary requirements regarding their diet were taken into consideration and catered for. The menus were viewed and demonstrated that the midday meal was varied and nutritious; the supper menu was seen to be inconsistent in dietary value and needs to be reviewed and discussed with the residents. Residents spoken with commented ‘Don’t really get much of a choice’ ‘Breakfast is always cereal, would be nice to be offered a cooked breakfast occasionally’ ‘It’s good, but not exciting’ ‘The supper menu is not to my liking, sometimes it’s a choice of sandwiches or a crumpet’. It was stated that the resident’s likes and dislikes are recorded and taken into consideration when planning the meals, but the residents feedback did not confirm this. Therefore it is recommended that residents are consulted and invited to contribute to the planning of all meals. A record of residents’ choice of meal is kept, but not the Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 15 amount, this would be beneficial so as to be able to fortify food when seen as required. Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are safeguarded from abuse through relevant staff training and robust policies and procedures. EVIDENCE: The complaint policy and procedure is clear and uncomplicated and a copy of this is readily available in the home and in the Service Users Guide. The system of recording complaints evidenced that complaints are taken seriously, that an investigation is undertaken within the timescales set and the outcome and action taken are clearly recorded. The home operate an open door policy and have regular meetings with residents, relatives and staff that encourage people to voice their concerns. These meetings are documented and the concerns then answered. Some residents spoken with confirmed that they were confident that any complaints or concerns that they had would be listened to and responded to effectively. However a few residents said that nothing was done after they had raised the concern. To reassure residents that their views matter would be beneficial and this could be accomplished by sharing the outcomes of audits and meetings with the residents. Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 17 The home has relevant guidelines on the safeguarding of vulnerable adults and staff have received appropriate training. The management team has a clear understanding of adult protection guidelines and are aware of how to initiate an investigation if required. There have been no safeguarding referrals since the last key inspection. Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a comfortable, clean and safe environment for those living in the home and visiting. Residents are enabled and encouraged to personalise their room and rooms are homely and reflect the residents personalities and interests. EVIDENCE: The location and layout of the home is suitable for its stated purpose and meets the homes aims and objectives. The home is at the present time following a refurbishment and building upgrade plan. To protect the residents whilst this work is on-going, environmental risk assessments have been updated to reflect the presence of Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 19 builders, areas that are unsuitable for staff and residents and the fire hazards from paint pots and stored equipment. The entrance area to the home has been enlarged and refurbished with a new floor which has improved the initial feel of the home. The plans for the lounge, dining area and kitchen were discussed and will improve the outcomes for the people who use the service. There will be a second small lounge area/quiet room which will give people a choice of where to sit. The garden area is secure, but use of the garden area is restricted at present due to the building work. Some of the residents are missing the use of the garden, especially as the weather is nice. In relation to fire safety, all records are current and in place to protect the safety of those living and visiting the home. All of the staff team attend regular fire safety training. The home is clean and hygienic, a couple of rooms were found to have a slight unpleasant odour and this was discussed with staff and will be investigated. It was confirmed that all staff receive training in infection control and that the policies and procedures are updated regularly. They are easily accessible to staff thus protecting those living and visiting the home from risk of cross infection. Good practice in respect of infection control by staff was observed during the inspection visit and there were gloves and aprons freely available in the home. There was a lack of liquid soap and paper hand towels in the communal toilets and this was rectified during the inspection. The laundry area was seen to kept clean with appropriate systems in place for soiled linen and waste. However the floor is not totally impermeable and this does need to be attended to prevent cross infection. Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Robust recruitment procedures and appropriate staff training ensure the safety and protection of service users. EVIDENCE: The staffing rota was viewed and evidenced that there are two care staff on duty during the day to give support to all the residents, serve meals, teas and coffees, administer medication, provide activities/interact with the residents, make beds and attend to the laundry. The manager is supernummery to the numbers, but says she does do the activities with the residents. The rota also identified that there is only one waking carer on at night. Resident bedrooms are situated on three floors and in some areas of the home the bedrooms are behind a fire door and also near very steep stairs and therefore the management team need to be confident that the staffing ratio is sufficient to meet their statement of purpose and ensure the residents safety. It is therefore necessary for the home to review the staffing levels on a regular basis taking in to account the changing needs of the residents and to ensure that the staffing provision is sufficient to ensure the safety and health of its residents. The manager is also to audit the accidents and incidents occurring in Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 21 the early mornings or evenings to ensure that staffing levels are sufficient to monitor and support residents at these times. This was fully discussed at the site visit and will be further discussed with the registered providers. A selection of staff recruitment files were viewed and demonstrate that a robust recruitment process has been maintained to protect residents and contained all the relevant information required. These robust recruitment systems ensure the protection of service users. The appointed manager has introduced a training matrix which enables the management team to track the training needs and ensures that all staff receive the training required to perform their job competently and therefore promoting the health and well being of the residents living in the home. As discussed this needs to include the management team. The staff all said they were well supported by the senior staff and the management team, ‘really enjoy working here’ ‘Very good support from the manager’. Staff are all encouraged to undertake National Vocational Qualification (NVQ) training, at present 3 of the 9 permanent care staff have a NVQ or are working toward a qualification. The home has induction and foundation training programmes that meet the Care Skills Sector specifications. The induction records for one new staff member was available for viewing at this time. Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The overall management of this home is good with effective systems in place to protect residents and promote their best interests. EVIDENCE: The appointed manager has been in post for approximately fifteen months and has the experience and knowledge to run the home in the best interests of the people who use the service. She has the Registered Managers Award and has previously managed homes for older people. She is committed to improving the outcomes for the residents living in the home, and again from information received from the residents, the staff and visiting professionals she is approachable and knowledgeable. Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 23 The manager’s hours are not included in the caring rota as she is supernummery to the numbers. The appointed manager and the staff team have worked hard over the past year to meet the requirements made at the last key inspection. The requirements have been met and there are no outstanding issues that impact on positive outcomes for the people living in the home. The appointed manager was able to discuss areas that are areas that are a ‘work’ in progress and these are reflected clearly in the improvement plan received and in the AQAA. The quality assurance systems in the home include questionnaires sent out to residents and relatives following admission to the home. The introduction of this formal quality assurance and quality monitoring systems has enabled the management to objectively evaluate the service and ensure it is run in the residents’ best interests. Regulation 26 visits are undertaken monthly and are used towards the quality monitoring systems in the home. Residents’ financial interests are safe guarded by satisfactory policies. Staff spoken with confirmed that they receive supervision and a plan of the year’s supervision sessions was seen. Copies of supervision sessions and yearly appraisals are kept secure in the recruitment files. Accident records were seen and are audited weekly; these results should be highlighting that a large majority of falls and incidents occur during the night shift and systems should be put in place to manage this effectively and thus promoting the safety of the residents. The appointed manager confirmed and the staff training records show that all staff are kept updated on the Health and Safety policies. The manual is available to all and clearly defined with regularly updated policies and procedures and best practice guidelines. This ensures that the health, safety and welfare of the people using the service are both protected and promoted. Victoria House DS0000021277.V376638.R01.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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 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 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 3 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 3 2 Victoria House DS0000021277.V376638.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 House DS0000021277.V376638.R01.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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