Inspection on 16/06/08 for Victoria Park Care Home

People living at the home and their relatives were complimentary about the care and support provided to them by the staff team. People spoken with confirmed the meals were enjoyed as they were of a good quality and variety. Records relating to people`s care and support needs were detailed and provided staff with clear instruction about the support each person required in order for their needs to be met. Signatures were in place within care plans, from either the person that owned the care plan or their representative. This demonstrated that they had access to their care plans and had been consulted about the support they needed.

What has improved since the last inspection?

An air conditioning unit has been installed in the medication room. This has ensured that the temperature within this room is appropriate for the storage of medicines, to ensure they do not lose their potency and remain safe to use. Medication administration records seen were clear and accurate and codes used were easily identified. Staff recruitment files contained all of the necessary documents that are required by law. This demonstrates that the service has ensured that the staff appointed are safe to work with the people living at the home.

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

CARE HOMES FOR OLDER PEOPLE Victoria Park Care Home Manners Road Ilkeston Derbyshire DE7 5HB Lead Inspector Angela Kennedy Unannounced Inspection 16th June 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Victoria Park Care Home DS0000058110.V366838.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Victoria Park Care Home DS0000058110.V366838.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Park Care Home Address Manners Road Ilkeston Derbyshire DE7 5HB 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) 01159 440774 01159 443148 victoriapark_ilkeston@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Limited Manager post vacant Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Victoria Park Care Home DS0000058110.V366838.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Variation to admit one (named) service user under the age of 65 years in the category PD as named in the notice of proposal letter. One place for named service user under 65 years of age (CB) One named individual (EMT) with dementia - see Notice of Registration. 18th June 2007 Date of last inspection Brief Description of the Service: Victoria Park Care Home overlooks open parkland and is situated close to the town centre of Ilkeston, eight miles from Nottingham and ten miles from Derby. The home is a converted building providing facilities for thirty-nine elderly service users and is registered to admit residents with nursing and personal needs. There is a main day room and lounge area situated on the ground floor. The first floor of the home is served by a passenger lift and there is also staircase access to this floor. There are seventeen single bedrooms (five with en-suite facility) and eleven double bedrooms (none with en-suite facility). Some of these double rooms are being used as single rooms. Information provided by the home confirmed that the scale of fees for 2008 was in the range £463.77 - £525 plus the free nursing contribution per week, and was calculated on whether nursing or residential care was provided. The most recent inspection report is on display in the entrance of the home. Victoria Park Care Home DS0000058110.V366838.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 star. This means the people who use this service experience good quality outcomes. This key inspection was unannounced and took place over approximately eight hours. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with the people using the service. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. An Annual Quality Assurance Assessment (AQAA) had been completed by the service. This is a self-assessment for providers, which is a legal requirement. This assessment gives the provider an opportunity to let us know about their service and how well they think they are performing. The information provided in the AQAA is reflected within this report. At this inspection visit three people were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at care plans and other documents relating to that persons care, talking to staff regarding the care they provide and if possible talking to the individual. Not all of the people case tracked were able to express their views of the service and the support it provided. However those that were able were spoken with and other people living at the home that were not case tracked were also spoken with. Their views of the service and the care and support provided are included within this report. Two members of staff were spoken with at some length and their views and opinions of the care provided, the support and training given to them is included within this report. The homes administration manager and deputy manager were on duty on the day of this inspection and provided the relevant information requested. What the service does well: Victoria Park Care Home DS0000058110.V366838.R01.S.doc Version 5.2 Page 6 People living at the home and their relatives were complimentary about the care and support provided to them by the staff team. People spoken with confirmed the meals were enjoyed as they were of a good quality and variety. Records relating to people’s care and support needs were detailed and provided staff with clear instruction about the support each person required in order for their needs to be met. Signatures were in place within care plans, from either the person that owned the care plan or their representative. This demonstrated that they had access to their care plans and had been consulted about the support they needed. What has improved since the last inspection? What they could do better: The quality assurance practices such as relatives meetings should be maintained on a regular basis despite the lack of a manager. This will ensure continuity is maintained and demonstrate that the lack of a designated manager has not impacted on the service provision. Questionnaires should be sent out to all residents and or their representatives to demonstrate that their views on the running of the service are heard and responded to. Staffing levels should be reviewed to ensure that each person has the support required to enable their individual social and recreational needs to be met as well as their care needs. Victoria Park Care Home DS0000058110.V366838.R01.S.doc Version 5.2 Page 7 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 Park Care Home DS0000058110.V366838.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 Park Care Home DS0000058110.V366838.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An accurate assessment of needs prior to admission means people moving into the home can be confident that their needs will be met. EVIDENCE: A recommendation from a previous inspection was regarding people’s views of the home being incorporated into the service user guide. This is a document that informs readers about the home and the services it provides. A copy of this document was provided. It was noted that the views of the people living at the home have not as yet been included. Once this is in place it will further enhance the information provided for people considering residence at the home. To ensure the service was able to meet the needs of individual’s, an accurate assessment of their needs was undertaken prior to admission. Victoria Park Care Home DS0000058110.V366838.R01.S.doc Version 5.2 Page 10 As stated in the AQAA, the assessments seen were detailed and endured staff had sufficient information about each person to enable them to be supported appropriately. Assessments undertaken by the home included all required information such as each individual’s personal details, their health, social and personal care needs. Evidence was also seen of assessments that had been undertaken by individuals who were Care Managed. (Funded by the local authority or local health care team.) Some of the people spoken with were able to confirm that they were able to visit the home before they made a decision about moving in. One person had stayed at the home for a respite stay before making a decision to live there permanently. This enabled people to decide whether the home could meet their support and accommodation needs. Victoria Park Care Home DS0000058110.V366838.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples health, personal and social care needs are met in a way that respects dignity and privacy. The staff support people to take their medication in a safe way. EVIDENCE: Care plans were seen that had been generated from the initial needs assessment. Either the individual or their representative had signed the care plans seen. This demonstrates that individual’s or people close to them have been involved in their care plans and shows that their care plans are accessible to them. It was noted that photographs to identify individuals were not available on the care files seen. This information is particularly useful for new staff and for identifying individual’s in the event of them being missing from the home. People’s health, social and personal care needs were met. The care plans seen addressed all areas of need. This included personal care support, health care needs, dietary requirements and preferences and social interests and religious/ Victoria Park Care Home DS0000058110.V366838.R01.S.doc Version 5.2 Page 12 faith needs. All care plans seen had been signed and dated to demonstrate their validity and reviewed on a monthly basis. This demonstrated that any changing needs were identified and the appropriate actions taken to ensure those needs were met. Where risks had been identified, this was recorded within the relevant care plans and linked with the risk assessment that related to the identified risk. Risk assessments within the files seen identified any risks and the actions that were to be taken to minimise the risks. This ensured the support provided to individuals maintained their well-being and safety. The risk assessments seen included, pressure ulcer assessments, moving and handling assessments, falls assessments, continence assessments, nutritional assessments and dependency assessments. Records seen clearly demonstrated that people had access to health care services and professional as required. As stated in the AQAA this demonstrated that the service had good working relationships with G.P’s and healthcare professionals. Such as opticians, dentists, and specialist health care services. Health care needs were also identified and addressed through care plans, risk assessments, weight and BMI recording charts. Some of the people living at the home were spoken with and were very complimentary regarding the support and care provided to them by the staff team. Comments included, “ the staff are very good, they look after us well.” And “ the staff are lovely, they are very caring”. The rapport noted between the people living at Victoria Park and the staff team was very positive and demonstrated a friendly and caring approach. The home supports people to manage their medicines in a safe way. Medications were stored correctly and records were in place to demonstrate that medication was received, administered, and disposed of appropriately. However it was noted that none of the three people case tracked had photographs in place on their medication administration recording (MAR) sheets to identify them. As stated in standards 1-6 photographs are a useful tool in identifying individuals, and in the case of administering medication are a useful tool in ensuring medicines are administered safely. At the last inspection concerns were raised regarding the temperature of the medication storage area. This has now been addressed and a new air conditioning system maintained the room temperature at an appropriate level, which ensured medication was stored at safe temperatures that would not affect its potency. Appropriate records were in place that demonstrated that room temperatures and clinical fridge temperatures were maintained. This ensured medication was stored at the required temperatures and remained safe and effective to use. Victoria Park Care Home DS0000058110.V366838.R01.S.doc Version 5.2 Page 13 The controlled drugs stored at the home where checked against the records held in the controlled drugs register and corresponded appropriately. The register had been completed correctly. This demonstrates that the staff team ensure that the practices regarding controlled drugs are managed in a safe and appropriate way. People spoken with confirmed that the staff team were respectful of their privacy and provided personal care support in a respectful way that ensured their dignity wasn’t compromised. Victoria Park Care Home DS0000058110.V366838.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities were available for those who wished to participate and people were able to keep in touch with their family and friends. Meals were enjoyed and alternatives available as required. EVIDENCE: Within the AQAA information provided it was stated that a designated activity area was available which has low work surfaces for people using wheelchairs to access. This area, adjacent to the main lounge was seen, although no activities were observed to be undertaken during the inspection. The activity coordinator was not on duty on the day of the inspection and the record of activities was unavailable to look at, therefore it was difficult to ascertain if people were supported to follow personal interests and activities. However evidence was seen of recent activities that had been undertaken, such as the spring fayre and photographs of a game of garden bowls. Information within the homes May 08 Newsletter, which went out to the people living at the home and their representatives, provided information on day trips organised, arts and crafts activities, walks planned and external entertainers booked. Victoria Park Care Home DS0000058110.V366838.R01.S.doc Version 5.2 Page 15 From discussions held with the people living at the home it was confirmed that activities were planned and available for them to join in with, if they chose to. People were able to keep in touch with their friends and family. Visitors spoken with confirmed that they were able to visit at any time and were made to feel welcome. People spoken with confirmed that they were able to get up and go to bed at a time that suited them. One person discussed her routine in the evening and confirmed that the staff supported her to maintain this. The general menus were not looked at during this inspection visit, but from discussions with people living at the home it was confirmed that the meals provided were of a good quality and alternative choices were available. Records within one person’s care plan demonstrated that a specialist diet was provided to ensure their health care needs were met. The information provided regarding the food types suitable for this person was detailed and ensured that their meals were varied and nutritious. The dining area was not well used as the majority of people chose to have meals from their armchair on a portable table. This meant that there was less opportunity for social interaction and meals were not always seen as a social occasion. However the people spoken with confirmed that this was their preference. Victoria Park Care Home DS0000058110.V366838.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1618 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples concerns are taken seriously and actions are taken to put things right. The practices in place safeguard people from abuse and neglect. EVIDENCE: As stated in the AQAA, the complaints procedure was displayed on the notice board. It was clear and stated that complaints would be dealt with in twentyeight days. One complaint had been received by the service in the last twelve months. Records were seen relating to this complaint that demonstrated that the appropriate action had been taken to address the issues raised. This demonstrates that concerns are looked into and actions are taken to put thing right. People that were spoken with said they were aware of the complaints procedure and their right to raise any concerns they had. All of the people spoken with said they were confident that any concerns they raised would be addressed promptly. Staff were spoken with regarding the training provided to ensure the people living at the home were kept safe. They confirmed that they had received training in Safeguarding Adults and demonstrated a clear understanding of the procedure to follow if any concerns or suspicions of abuse were brought to their attention. The training matrix demonstrated that the majority of the staff team were up to date in Safeguarding training. Victoria Park Care Home DS0000058110.V366838.R01.S.doc Version 5.2 Page 17 A copy of the company’s policy on Safeguarding Adults was seen and this was in line with the Local Authority procedure, who are the lead investigators in any safeguarding referrals or investigations. The policy clearly defined the safeguarding adults process in investigating any concerns. This demonstrates that the home safeguards people from abuse and neglect and takes the correct action to follow up any allegations. Victoria Park Care Home DS0000058110.V366838.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a safe environment with pleasing views of the surrounding area. EVIDENCE: A partial tour of the building was undertaken that focused on the communal areas of the home and the laundry area. It was stated that the bath in room 28 was not used as the accessibility of the hoist with this bath proved difficult. The lounge area was bright and as stated in the AQAA had good views that overlooked the park. The laundry facilities were seen and housed suitable equipment to meet disinfection standards. Staff were aware of how to maintain good hygiene and were able to confirm the measures in place to control the spread of infection. Victoria Park Care Home DS0000058110.V366838.R01.S.doc Version 5.2 Page 19 Information in the AQAA confirmed that 27 members of staff had received infection control training and that there was an infection control policy in place at the home. This indicates that the staff ensure the home is clean and hygienic for the people living there. The kitchen was looked at and appeared clean and well organised. Some areas of the home required redecoration and it was confirmed that plans were in place for this to be undertaken. Discussions regarding the plans for refurbishment and redecoration were discussed. The issue of excessive temperatures found at the last inspection have not been fully resolved. It was stated that air conditioning was to be installed on the first floor corridor and the lounge area. New carpets and furniture such as new armchairs were also being purchased. People spoken with said that the standards of cleanliness at the home were generally good. It was however noted on the day of this visit that there was a malodour within some areas of the home. However one visitor spoken with did state that this was unusual as the home generally smelt clean and fresh. Victoria Park Care Home DS0000058110.V366838.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Safe and appropriate support was provided but staffing levels did not clearly demonstrate that individual’s holistic needs could always be met. EVIDENCE: From the records seen, discussions held with staff, people living at the home and visitors, it was confirmed that there had been occasions recently when staffing levels had been reduced. This could impact on the levels of support provided to the people living at the home. Twenty-eight people were using the service at the time of the inspection visit. The rota demonstrated that on the day of this inspection there was one nurse on duty in the morning and one in the afternoon. The nurse on duty in the afternoon was an agency nurse. Four care staff were on duty in the morning and 3 care staff were on duty in the afternoon/evening. Rostered on shift for that night was one nurse with two care staff. The rotas showed that there were some occasions when an additional member of staff was on duty on the early and late shift. Some of the staff spoken with stated that recently they had been short staffed due to staff sickness. One member of staff confirmed that they had worked additional hours to support the staffing levels. Victoria Park Care Home DS0000058110.V366838.R01.S.doc Version 5.2 Page 21 Some of the people living at the home were asked if they felt there was sufficient staff on duty to meet their needs. The comments made indicated that individual’s needs were met but at times there were staff shortages. Some of the people spoken with did say that the staff worked very hard and were always busy. Visitors spoken with said that they felt that generally there was enough staff to meet individuals needs. They did however comment that there were times when they appeared short staffed. It was noted that there was staff available within the communal areas to support and assist people as required. However as stated earlier in this report, it was also noted that no activities were observed to be taking place on the day of this inspection. During the inspection a telephone discussion with the homes operational manager confirmed that a further three people had been appointed in post as care staff. These people were awaiting satisfactory recruitment clearance prior to commencing in post. Out of a total of eighteen care staff the training matrix showed that three staff had achieved a National Vocational Qualification (NVQ) in care at level 2, one person had achieved an NVQ 3 in care and the deputy manager had achieved an NVQ 4 in care. Information within the AQAA stated that nine staff were working towards NVQ level 2 or above. Once this has been achieved the target of having a minimum of 50 of care staff with this qualification will have been met. This will then further demonstrate that staff that have received the relevant training to enable them to meet individual’s needs. The recruitment records for two members of staff were looked at and contained all of the information required by law. This ensures that the people living at the home are safeguarded because checks are made to ensure the staff are suitable to care for them. People are supported in safe way because the staff receive training and updates in safe working practices. The training matrix seen demonstrated that staff training was kept up to date within all mandatory training areas and other relevant training courses, such as fire safety, food hygiene, moving and handling, health and safety, infection control, nutrition and bed rail safety. Staff spoken with confirmed that the training provided to them was good and supported them in maintaining safe working practices and meeting the needs of the people using the service. Victoria Park Care Home DS0000058110.V366838.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management support at the home ensured that people were cared for in a safe way. The health and safety practices in place ensured the safety of everyone at the home was maintained. EVIDENCE: There was no manager in post at the time of this inspection visit. The previous manager had transferred to another service within the company on the 1st April 2008. Discussions with the operational manager confirmed that the operational manager and the previous manager of the service were supporting the deputy manager and staff team. It was stated that the manager’s post had been advertised. Victoria Park Care Home DS0000058110.V366838.R01.S.doc Version 5.2 Page 23 Staff spoken with indicated that they were supported by the deputy manager but felt that the absence of a full time manager had impacted on staff morale. Discussions with people living at the home and their visitors regarding the management of the service were positive. They said that the deputy manager was very caring and approachable. Quality assurance processes were in place. As stated in the AQAA, the company undertook monthly visits to audit the quality of care provided and a sample of these reports were seen. Relatives meetings were held monthly and the minutes of these meetings were seen. The feedback seen was generally positive and demonstrated that the opinions of relatives was sought. It was noted that these meetings had not taken place since the previous manager had transferred to another service. There was no evidence seen of surveys being sent out to residents, relatives or other interested parties. Staff were given an opportunity to be updated and involved in the development of the service. Evidence was seen to demonstrate that staff meetings were held on a regular basis, usually between every 4-6 weeks. Records of the monies held by the home for the people case tracked were seen, and demonstrated that the accounting procedures for individual’s personal finances was managed in a safe way. The safety of the people living at the home, their visitors and the staff team was maintained A sample of service certificates and health and safety records and practices were seen. Such as hoist services, fire fighting equipment service and gas safety checks. Information was also provided within the AQAA to confirm equipment was serviced as required. Victoria Park Care Home DS0000058110.V366838.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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 X X X 2 3 STAFFING Standard No Score 27 3 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 X X 3 Victoria Park Care Home DS0000058110.V366838.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 OP19 Regulation 23 (2) (d) Requirement The refurbishment and redecoration of the home must be maintained to a good standard. Ventilation, heating and lighting suitable for residents must be provided in all parts of the home that are used by residents and excessively high temperatures must be addressed to ensure residents’ comfort and safety. Timescale of 01/08/07 not met. The registered provider must appoint a person to manage the home. Timescale for action 31/10/08 2. OP25 23 (2) (p) 01/09/08 3. OP31 8 23/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations Residents’ views of the home should be incorporated into DS0000058110.V366838.R01.S.doc Version 5.2 Page 26 Victoria Park Care Home 2. OP2 3. 4. 5. OP7 OP9 OP12 6. 7. 8. 9. OP21 OP26 OP27 OP33 the residents’ guide. The terms and conditions of residence should state which room is to be occupied. This is a previous recommendation and was not assessed on this occasion. Recent photographs of individuals should be in place on their care files to assist in identifying individuals. Recent photographs of individuals should be in place on medication administration records to assist in identifying individuals prior to administering medication. A wider range of activities should be arranged that takes into account individual interests. (Previous recommendation unable to assess at this inspection.) Consideration should be given to the purpose of the bath in room 28 as this has been identified as unsuitable to use for the people living at the home. Pro-active measures should be in place to eliminate any offensive odours within the home. Staffing levels should be reviewed to ensure the holistic needs of each person living at the home can be met. The views of visiting professionals, relatives and residents should be sought for quality assurance purposes and should include written surveys where possible. This is a previous recommendation and has not yet been implemented. Victoria Park Care Home DS0000058110.V366838.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Park Care Home DS0000058110.V366838.R01.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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