CARE HOMES FOR OLDER PEOPLE
The Victoria Residential Home Thursby Road Burnley Lancashire BB10 3AU Lead Inspector
Mrs Julie Playfer Unannounced Inspection 14th December 2005 10:00 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 The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 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. The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service The Victoria Residential Home Address Thursby Road Burnley Lancashire BB10 3AU 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) 01282 416475 01282 441447 Victoria Care Homes Limited Mrs Lynn June Plane Care Home 36 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18) of places The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The replacement of all bathrooms fixtures and fittings. The refubishment, redecoration and provision of aids and adaptations in the bathrooms in line with the needs of service users within 15 months of the date of registration. Employ at all times, a suitably qualified manager who is registered with the CSCI The following minimum staffing levels must be provided at all times: Residential Unit - Ground Floor Waking day 8:00am - 9:00 pm 1 Senior Care Staff on duty at all times 2 Care Staff on duty at all times Night Time 9:00pm - 8:00am 1 Senior Care Staff on waking watch duty 1 Care Staff on waking watch duty Dementia Care Unit - First Floor Waking Day 8:00am-9:00pm 1 Senior Care Staff on duty at all times 3 Care staff on duty at all times. Night Time 9:00pm - 8:00am 1 Senior Care Staff on waking watch duty 1 Care Staff on waking watch duty Ancillary Staff Cook - 56 hours a week Domestic and laundry - 56 hours a week The above staffing levels take no account of duties such as maintenance and gardening for which additional provision should be made. 2. 3. The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 5 Date of last inspection 18th May 2005 Brief Description of the Service: The Victoria Residential Home is registered with the Commission for Social Care Inspection to provide accommodation and personal care for 25 Older People and 11 Older People with a Dementia. The home is a converted hospital with a spacious layout. It is located approximately 2 miles from Burnley town centre and there is a main bus route nearby. There are car-parking facilities at the front of the home and there is a public park directly opposite. Accommodation is provided in 24 single bedrooms and 5 double bedrooms on two floors. There is a passenger lift linking the floors. Five of the single bedrooms have ensuite facilities comprising of a toilet and wash hand basin. The home is split into two units and is staffed accordingly. The ground floor unit provides personal care for older people and is known as the Residential Unit. The second floor provides personal care for older people who have a dementia and this part of the home is known as the Dementia Care Unit. The staffing levels in the home are listed under the home’s conditions of registration. The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over one day and a total of eight and a quarter hours were spent on the premises. Two inspectors and a Pharmacy inspector carried out the inspection. During the visit the inspectors looked at written information including records and spoke with the people who live at the home and some of their relatives. The inspectors also talked to the owner, the registered manager and the staff on duty. A tour of the building took place both internally and externally. At the time of inspection a total of 33 people were living in the home. Since the last inspection three additional visits have been made to The Victoria Residential Home. The purpose of the visits was to follow up the issues identified at the unannounced inspection on 18th May 2005. The pharmacy inspector carried out an inspection of the management of medication in the home. The findings of this inspection have been sent to the home in a separate report. What the service does well: What has improved since the last inspection? The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 7 Since the last inspection significant improvements had been made to all aspects of service provided by the home. The registered manager had ensured that an assessment of needs had been carried out with all residents prior to admission and had included a member of staff in the pre admission assessment of all residents admitted to the dementia care unit. This gave staff the opportunity to better understand the needs of the residents. Following the assessment all residents had received a written assurance that their needs could be met by the home. The details of the contract had been made much clearer and easier to understand. The care plans covered the needs of the residents and gave the staff guidance on how to meet these needs in a consistent way. Residents on the residential unit had discussed their choice of activities in regular Residents’ Meetings and were satisfied with the frequency and type of activities provided. All residents spoken to said they enjoyed the meals and made complimentary comments about the cook. The record made of meals served to residents was complete and up to date and clearly demonstrated the food provided was wholesome, varied and nutritious. Residents’ dignity was respected by the improvements made to the environment, which included the completion of the shower rooms. This meant residents on the residential unit could easily access a shower within their own unit. In addition, the overall level of cleanliness had improved, dining chairs had been recovered and the benches at the front of the building had been repaired. The staffing rotas demonstrated that the staffing levels had been maintained and staff had been given to opportunity to attend more frequent staff meetings. Staff based on the dementia care unit had attended a training day to help them better care for the special needs of people living at the home who have a dementia. The views of residents and their representatives had been sought by means of a “customer survey” questionnaire and the results had been collated by the owner and the manager. What they could do better:
Some written information provided for residents should present a clear and accurate picture of the home. The manager and staff must improve the activities programme on the dementia care unit, so everyone has opportunities for an interesting and fulfilling life. The manager and staff must be able to monitor the weight of the most vulnerable residents and ensure the daily care records describe how care is delivered in line with the plan of care.
The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 8 Some improvements must be made to the premises to ensure the comfort and welfare of the residents. The carpets in the corridors must be thoroughly cleaned or replaced, the bath hoists must be kept clean and all furniture must meet the needs of the residents. In addition the water temperature at the bath outlet on the ground floor must be monitored, along with the overall temperature of the rooms. The electrical systems must be tested on time. Attention must be given to the recruitment of new staff, to ensure the protection of the residents. As such, all relevant checks, including police checks must be carried out prior to employment. The owner and manager should devise a written plan to describe how improvements will be made to the services and facilities in response to the things identified within the residents “customer survey” questionnaires. 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 Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 9 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 The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4 The written information provided for residents was useful, however the service users guide must accurately reflect the services and facilities provided in the home. The admission procedure was well managed. The residents’ needs were properly assessed and they received written assurances their needs could be met by the home. EVIDENCE: Written information in the form of a service users guide was supplied to residents, which contained details about the services provided in the home. However, whilst the registered manager reported the guide had been amended since the last inspection an updated copy could not be found at the time of the visit and none of the residents spoken to on the ground floor had received a revised version. A copy of the contract was included in the service users guide. It was noted this document had been updated to include details about the home’s insurance of personal belongings.
The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 11 The ‘case tracking’ process demonstrated that residents had their needs assessed prior to admission by the registered manager and social worker, where applicable. The registered manager also informed residents in writing that having regard to the assessment the home was suitable for meeting their needs. The registered manager had improved the admission process of those residents admitted to the dementia care unit by ensuring that a staff member based on the unit assisted with the preadmission assessment. This helped new residents as staff better understood their background and needs. The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The care planning system addressed the health, personal and social care needs of the residents. However, this process could be further improved by ensuring the daily care records maintained on the dementia care unit are more detailed. Overall care practice took account of the residents’ rights to privacy and dignity. EVIDENCE: From the case files seen on the residential unit, it was evident each resident had a plan of care, based on an assessment of needs. The plans set out the action needed to be taken by staff to ensure all needs were met. It was apparent the plans had been reviewed once a month and agreed with the resident and/or their representative. The plans had been updated in respect to any changing needs. The plans were detailed and were written in a suitable format for both staff and residents. The residents’ health was monitored and promoted and care records demonstrated that they had access to the necessary health care facilities. Specialist advice had been sought as appropriate in line with the needs of the residents for instance the continence nurse. The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 13 Care planning had improved on the dementia care unit with the addition of nutritional screening, risk assessments and risk management strategies. However, daily diary records were poor. Typical daytime entries were ‘eaten and drunk well’, ‘no problems’ and night reports ‘slept well, nothing to report’. Reports related poorly to care plans and did not adequately describe or analyse the care and attention provided to residents. Whilst the residents’ healthcare needs were addressed within the care plan on the dementia care unit, there were no ‘sit on’ scales, so the most vulnerable residents’ weight was not monitored. Residents spoken to on the residential unit felt their right to privacy was respected by the care staff and personal care was carried out with respect to their dignity. All residents were referred to by their preferred mode of address, which was documented on the care plan. The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The residents were able to maintain good contact with their family and friends. Whilst residents on the residential unit were given the opportunity to discuss and pursue activities of their choice, there had been little progress made to establish a programme of activities on the dementia care unit. Residents were provided with wholesome and appealing food, which they enjoyed. EVIDENCE: The residents had visitors at any time during the day and one visitor said that he was offered refreshment, which he sometimes made himself in the kitchen. A visitor said he was satisfied with the care his relative received. Staff explained that residents could see visitors in privacy of their bedrooms if they wished. The residents on the residential unit said the daily routine was flexible and they were able to get up and go to bed at a time of their choosing. The plan of care provided information on the resident’s preferred daily routine for instance one resident wanted a bath every morning at a particular time of her choice. The residents’ interests were discussed during the assessment process and were documented on the care plans. Activities arranged on the ground floor residential unit included listening to music, a social afternoon with drinks and
The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 15 snacks every Friday, occasional professional entertainment and film nights. The residents had discussed their choice of activities at Resident’s meetings, which were held on a regular basis. The activities provided on the dementia care unit were limited. Suggestions were made during the inspection on how a programme of appropriate activities could be developed. All the residents who spoke to the inspectors made complimentary comments about the meals provided in the home. The record of actual meals served was complete and up to date. The residents said there was always plenty to eat and a good variety of food. Staff were observed to provide assistance with meals promptly and sensitively. The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Systems were in place to ensure any concerns of residents would be listened to and acted upon. The vulnerable adult procedures in place at the home ensured residents were protected from harm. EVIDENCE: The residents were provided with a copy of the complaints procedure, which was readily accessible in each bedroom. The procedure gave clear directions on whom to make a complaint to and the timescales for the process. The home had a recording system in place should any complaints be made. There had been no complaints received since the last inspection. There was a copy of “No Secrets in Lancashire” and an adult protection procedure available in the home. These documents set out the response should there be any allegations or evidence of abusive practice in the home. Staff interviewed had a good understanding of the procedure and as such were aware of the agencies, which must be informed in the event of any allegations being made. The service users guide also contained information on the protection of vulnerable adults, however, this was difficult to understand and it was recommended the information is revised and updated. The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Improvements had been made to the overall environment, however, some aspects of the home required attention to ensure the comfort and safety of the residents. EVIDENCE: Victoria Residential Home is a converted hospital with a spacious layout. Accommodation is provided in 24 single rooms and 5 double rooms on two floors. There is a passenger lift linking the floors. The ground floor residential unit provided care for older people and the first floor unit provided care for older people with a dementia. There were improvements to the dementia care unit, which provided a safe, comfortable and clean environment for the residents. New furniture (dining and easy chairs had been provided and there was generally a satisfactory standard of cleanliness. Staff had experimented with using the large dining room as a main lounge, which provided better choice for residents and enhanced their dining experience.
The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 18 Since the last inspection the seating at the front of the building had been refurbished, the residual work in the shower rooms had been completed, the cleaning materials on the dementia unit had been securely stored and the chipped tiles at floor level in the bathroom on the residential unit had been repaired. It was evident from a tour of the home that residents had personalised their rooms with their own belongings. The residents told the inspector that their rooms were comfortable and pleasant. There was a call facility in every room. The doors to residents’ bedrooms had been fitted with suitable locks and keys had been distributed to residents, as appropriate. It was noted that the carpets in the corridors were noticeably stained and the bath hoist on the ground floor was unclean. In addition, some of the seating in the lounge on the residential unit was unsuitable for the needs of older people. To minimise the risk of scalding all water outlets were fitted with preset valves. However, the temperature of the water at the bath outlet was found to be 48°C. It was also noted that the ambient temperature of many of the rooms was cool. The floor coverings in the toilets and bathrooms had been repaired, however, several of the repairs were an unsatisfactory standard. The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The procedures for the recruitment of staff were not robust and must be improved to ensure protection for the people living in the home. Good arrangements were in place to ensure staff received appropriate training in line with the needs of the residents. EVIDENCE: A recorded staff rota was completed in advance, which indicated which staff were on duty and how many hours they had worked. All staff providing personal care were aged over 18 and all staff left in charge of the building were aged over 21. Several people on the dementia care unit said they liked the staff. One person commented “they never grumble or pull a face if you ask them anything”. Recent dementia care training had given staff a better understanding of the special needs of residents and of a “person centred” care approach. Staff were motivated and were looking forward to the follow up training day. The registered manager had a recruitment and selection procedure, however, this did not reflect the requirements of the current legislation. Three files were inspected of staff recently employed in the home. All three people had completed an application form and had attended for an interview. However, there shortfalls in the recruitment procedure, these included gaps in employment and some written references received after the person commenced working in the home. It was also noted that two CRB checks had been carried out by a previous employer and not by the home.
The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 20 All new employees undertook an in house induction programme. This provided underpinning knowledge for NVQ level 2. At the time of inspection the equivalent of 32 of the care staff were trained to NVQ level 2 or above and 12 members of staff were working towards this qualification. All staff had opportunities to attend various training courses in line with the needs of the residents. The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38 Staff and residents enjoyed positive relationships, which promoted an open and friendly atmosphere. Some aspects of health and safety required attention to ensure the welfare of the residents. Progress had been made to improve the quality assurance system, however, the registered persons must specify how they will make improvements to the home in response to the feedback received from residents and their representatives. EVIDENCE: The registered manager had the overall responsibility for the management of the home and had enrolled on Registered Manager’s Award course, which included NVQ level 4 in Management. Relationships within the home were good and staff spoke about the residents with respect. The residents valued the help and support they received from the staff, who they described as “kind and caring”. The staff received supervision
The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 22 at least six times a year, topics discussed during supervision were recorded on a suitable format. The home’s quality assurance system had improved: residents and staff meetings were held regularly; annual “customer satisfaction” surveys for residents and visitors had been carried out; comments were gathered from stakeholders; and the provider had a business plan for 2005. However, the registered persons had not put all the information they had gained from everyone’s views into an annual report. Consequently there were few details about how the home will continue with things that it does well and how the registered persons intend to improve in areas identified as “fair” or “poor”. Appropriate arrangements were in place for handling money, which had been deposited with the home by or on behalf of a resident. A random check of monies was found to be correct. Some records had not been maintained in line with legal requirements, for instance the staff records. The registered provider supplied the inspector with 14 reports of visits made to the home under Regulation 26. These reports should be supplied to the Commission each month following the visits. Staff received health and safety training, which included moving and handling, food hygiene, first aid, fire safety and infection control. The home had a set of health and safety polices and procedures. Documentation was seen during the inspection which, confirmed gas and electrical appliances were serviced/tested at regular intervals. However, it was noted that the electrical safety certificate had recently expired. The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 23 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 2 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 2 2 3 3 3 2 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 3 2 2 The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 24 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 OP1 Regulation 5 (1) Requirement The service users guide must contain accurate and up to date information. It must also be written in plain English to ensure the guide is easy to understand. (Previous timescale of 30/06/05 – not met). The registered manager must be able the properly monitor the weight of residents at nutritional risk on the dementia care unit. Weight gain or loss should be monitored and recorded, within the plan of care. (See recommendations from previous inspections on 18/05/05 and 20/09/05) Arrangements must be made for residents on the Dementia Care Unit to take part in appropriate leisure and social interests and community activities. (Previous timescales of 18/05/05 and 20/09/05 not met). The carpets in the corridors must be either thoroughly cleaned to remove all staining or replaced. Furniture provided in the communal areas must meet the
DS0000046704.V261155.R01.S.doc Timescale for action 01/02/06 2 OP8 12 (1) 15/02/06 3 OP12 16 (m) 01/02/06 4 5 OP20 OP20 23 (2) (d) 16(1) (c) 01/03/06 15/02/06 The Victoria Residential Home Version 5.1 Page 25 6 OP21 16 (2) (c) 7 8 OP21 OP25 23 (2) (d) 13 (4) (b) and (c) 9 OP25 23 (2) (p) 10. OP29 18,19 S2&4 11 OP33 24 12 OP37 4,17,18, 19 13 (4) (c) 13 OP38 needs of the residents. (Previous timescale of 15/07/05 – not met). Repairs to floor coverings in the all bathrooms and toilets must be to a satisfactory standard to ensure the surface can be readily cleaned and is comfortable for the residents. The bath hoist must be kept clean at all times on the residential unit. The water temperature on the bath outlet on the ground floor must be monitored and arrangements must be made as necessary to maintain the water temperature at 43°C plus or minus 2°C. The ambient temperature of the home must be monitored and maintained at an appropriate level to ensure the comfort of the residents. All documentation and records relating to the employment of new staff must be collated and maintained at all times. Appropriate checks including CRB checks must also be carried out prior to employment. (Previous timescale of 18/05/05 – not met). The registered persons must supply a copy of the quality of care (quality assurance – QA) report to the Commission and make the report available to the residents. The QA system must show how residents and their representatives were consulted. (Previous timescales of 01/02/05 and 31/07/05). All records listed in the regulations must be kept complete and up to date all times. The registered person must
DS0000046704.V261155.R01.S.doc 15/02/06 14/12/05 14/12/05 14/12/05 14/12/05 31/07/05 18/05/05 15/01/05
Page 26 The Victoria Residential Home Version 5.1 electrical systems are tested and a copy of the safety certificate is forwarded to the Commission. 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 The addresses of the Health Authority and Advocacy Schemes provided in the service users guide should be updated. The residents’ views should also be included in the guide. Daily care records on the dementia care unit should describe how care is delivered in accordance with the service user’s plan for each individual. The information relating to the protection of vulnerable adults contained in the service users guide should be revised. The recruitment and selection procedure should be updated to ensure the procedure covers the amendments to the Care Homes Regulations 2001 and the POVA scheme. A minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) is achieved by 2005. The registered manager should complete the NVQ level 4 in management. The registered person should supply the Commission with a report each month following the visits made to the home under Regulation 26. 2 3 4 OP7 OP18 OP29 5 6 7 OP28 OP31 OP37 The Victoria Residential Home DS0000046704.V261155.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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