Inspection on 17/05/06 for The Victoria Residential Home

This inspection was carried out on 17th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Victoria Residential Home 29/03/10

The Victoria Residential Home 11/01/10

The Victoria Residential Home 01/12/09

The Victoria Residential Home 06/10/09

The Victoria Residential Home 14/04/09

The Victoria Residential Home 22/04/08

The Victoria Residential Home 06/06/07

The Victoria Residential Home 14/12/05

The Victoria Residential Home 18/05/05

The Victoria Residential Home 08/10/04

The Victoria Residential Home 11/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Victoria Residential Home Thursby Road Burnley Lancashire BB10 3AU Lead Inspector Mrs Julie Playfer Unannounced Inspection 17th May 2006 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 The Victoria Residential Home DS0000046704.V287783.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.V287783.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.V287783.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The replacement of all bathrooms fixtures and fittings. The refurbishment, 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 and experienced 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.V287783.R01.S.doc Version 5.1 Page 5 Date of last inspection 14th December 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 18 Older People and 18 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 25 single bedrooms and 5 double bedrooms on two floors. There is a passenger lift linking the floors. Twelve of the single bedrooms and one double 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. At the time of the inspection the scale of charges was £320 to £360.50. Additional charges were made for toiletries, hairdressing, chiropody, holidays and outings. The registered manager made information available to prospective residents by means of a statement of purpose and service users guide. The service users guide was usually given to relatives and/or prospective residents on viewing the home or at the point of assessment. The Victoria Residential Home DS0000046704.V287783.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over nine hours on 17th May 2006. 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 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 30 people were living in the home. 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. Prior to the inspection the registered manager completed a questionnaire, which provided useful information for the inspection. Comment cards had been sent to the home for residents and their relatives; however, none were returned to the Commission. What the service does well: What has improved since the last inspection? Since the last inspection, the registered manager had collated the records relating to new staff in line with legal requirements and had ensured that references and police checks had been received prior to employment. The number of trained staff with NVQ level 2 had increased. The residents were The Victoria Residential Home DS0000046704.V287783.R01.S.doc Version 5.1 Page 7 therefore protected from unsuitable people and were cared for by staff who had completed the necessary training to fulfil their role as a care worker. The care planning system had been developed to incorporate personal profiles of residents. The profiles included information about the residents’ cultural needs and past life experiences. This provided staff with a greater insight into the needs of the residents. Staff based on the DCU had completed a short level 1 training, to help them better understand the special needs of people who have a dementia. The range of activities had improved, so residents had something to keep their interest every day. The purchase of ‘sit on’ scales meant that staff could better monitor everyone’s weight and nutritional plans. Residents liked the new dining room, which was a pleasant place to eat. The systems in place to monitor the quality of the service had been developed and the registered manager had produced an annual development plan, based on feedback from the residents, their representatives and the staff. Thus the residents were able to express their views in a formal manner and have input into future planning. What they could do better: Written information provided for residents including the service users guide and the contract must be updated to ensure residents receive clear information about the services and facilities and the amount and payment of fees. Significant improvements must be made to the environment to ensure the residents are comfortable and safe. It was a concern to note the relevant authorities had not checked the new ensuites, before residents returned to their rooms and the electrical safety certificate had expired several months ago. The registered person must address these issues as a matter of urgency. In addition, all residents must be provided with appropriate furnishings and equipment, which meet their needs in order to promote and protect their rights to independence and dignity. So the quality of life of people confined to bed is improved, the registered manager should ensure every aspect of care is identified (including social and psychological needs) and those care plans detail the actions to be taken to meet these needs. The daily records made by staff should say how needs have been met. Foods should be liquidised separately on the DCU, to improve choice for residents and meal presentation. To make sure the dementia care unit is safe and comfortable for residents, and promotes their independence, light bulbs must be replaced as soon as they go The Victoria Residential Home DS0000046704.V287783.R01.S.doc Version 5.1 Page 8 out, commodes should be thoroughly cleaned, grab rails should be provided in toilets and the bathroom made more inviting to use. So that residents can be confident that staff on the dementia care unit are competent and expert in meeting their special needs, staff should continue with more advanced training. 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.V287783.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.V287783.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents’ needs were properly assessed prior to admission. However, the written information supplied to residents was incomplete. EVIDENCE: Since the last inspection, the statement of purpose and service users guide had been revised and updated to include useful addresses and the residents’ views. The service users guide had been supplied in residents’ bedrooms, so that residents and their relatives could take a look at them at any time. However, it was noted the guide did not cover the elements listed in the National Minimum Standards and extracts from the summary of last inspection report had been retyped, without the permission of the Commission. The latter did not include the section “could do better”. A copy of the contract was included in the service users guide. However, the contracts issued to residents, seen during the inspection, were not signed and the section on the amount and payment of fees had not been completed. The Victoria Residential Home DS0000046704.V287783.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 preadmission assessment covered the residents’ personal, social and health care needs. The registered manager also informed residents in writing that having regard to the assessment the home was suitable for meeting their needs. The Victoria Residential Home DS0000046704.V287783.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The care planning system covered the personal and social care needs of the residents. However, the specific needs of residents confined to bed were not properly addressed. Some aspects of the management of medication must be improved. 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. Charts were maintained for personal hygiene, however, these were not consistently completed. The Victoria Residential Home DS0000046704.V287783.R01.S.doc Version 5.1 Page 13 Risk assessments formed part of the care plan documentation, however, where risks had been identified, management strategies to reduce or eliminate the risks were not seen. It was noted that the care planning system took account of the residents’ cultural and spiritual needs and records were made of special dietary requirements. Since the last inspection, a personal profile had been developed with each resident, which provided useful information in respect of the residents’ origins and past life experiences. Residents care plans on the Dementia Care Unit (DCU) were based on needs assessment and were up to date. However, daily records related poorly to care plans and did not adequately describe or analyse the care and attention provided to residents. Typical entries for every resident on the DCU were “good diet, plenty of fluids, no problems” and at night, “slept well, no problems”. A particular concern was lack of plans for social, psychological and mobility care for people confined to bed for long periods, with the consequence that residents had little stimulation and were becoming stiff from lying in bed. The home had no suitable chairs for some people to sit out of bed and staff had not noticed that an air mattress was over-inflated which presented risk and discomfort to the resident. Since the last inspection the registered person had purchased some “sit on” scales to monitor the weight of the most vulnerable residents’ weight. However, plans for weight gain, loss or maintenance were not in place for vulnerable residents. 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 pharmacy inspector identified several shortfalls in the management of medication, along with some areas of good practice. The Victoria Residential Home DS0000046704.V287783.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents were supported to maintain good contact with their friends and relatives and were provided the opportunity to pursue meaningful activities. However, some practices around meal times must be improved to ensure the safety and dignity of residents on the dementia care unit. EVIDENCE: 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 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. At the time of the inspection, the residents were making various gifts for the Spring Fayre and one resident told the inspector that she “really enjoyed doing various crafts, especially painting decorative The Victoria Residential Home DS0000046704.V287783.R01.S.doc Version 5.1 Page 15 things”. However, two of the residents informed the inspector, “that there was not much going on” and “the staff leave you to sort yourself out”. The residents were able to receive visitors at any time and several residents informed the inspector that their family visited on a regular basis. Residents on the DCU said they were enjoying an improved range of activities. These included colouring books, sitting out with staff, going for walks, cake decoration and face painting. Several people had enjoyed making Easter Bonnets and the home kept a picture board of activities and entertainments. Since the last inspection, visits by professional entertainers had taken place on the DCU, which meant the people on this unit could enjoy the entertainment in familiar surroundings. The residents on the ground floor residential unit made complimentary comments about the food, which they described as “very tasty”. A choice was provided at all meals and the cook regularly discussed the food with the residents. The record of meals served was seen to be complete and up to date and included variations to the main menu. Similarly, residents on DCU said they enjoyed the meals – “the dinner was good and I ate it all” and there was a choice for every meal. Residents said the new dining room was a nice “quiet” place to have meals and staff reported residents’ improved appetite and independent eating. However, it was noted that whilst the meal was individually liquidised for a specific resident on the residential unit, the meal was liquidised as a whole on the DCU and one resident was offered assistance to eat whilst laid on her back. The Victoria Residential Home DS0000046704.V287783.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents had access to a clear up to date complaints procedure and staff had access and an awareness of the adult protection procedure. 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. The residents spoken to on the residential unit said that they could talk to any member of staff or the manager, if they had any concerns and they were confident their views were listened to and taken into account. However, all the residents spoken to stressed they had “no complaints”. 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 Victoria Residential Home DS0000046704.V287783.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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The residents were provided with an unsafe and unsatisfactory environment, which placed them at risk of harm. EVIDENCE: Victoria Residential Home is a converted hospital with a spacious layout. Accommodation is provided in 25 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. It was evident from a tour of the home that residents had personalised their rooms with their own belongings. The residents told the inspectors that their rooms were to their liking, however, it was apparent that one resident on the residential unit had been provided with an unsuitable chair, which compromised her comfort and dignity. There was a call facility in every room, however, the pull cord was out of reach of residents in the ground floor The Victoria Residential Home DS0000046704.V287783.R01.S.doc Version 5.1 Page 18 bathroom and residents using this room were heard calling for assistance. The doors to residents’ bedrooms had been fitted with suitable locks and keys had been distributed to residents, as appropriate. Since the last inspection four ensuite facilities had been added to pre existing rooms. Whilst it was reported that residents had vacated their rooms during the major building work, they had returned to their rooms before the ensuites had been completed. The new electrical installations had not been tested and none of the works had been checked by the building department. In addition, it was noted one ensuite did not have a suitable floor covering or blind and hot pipes were exposed in another ensuite. The wallpaper had been repaired in some bedrooms following the building work with a different pattern. No progress had been made to improve the carpets in the corridors, which were noticeably stained and in some places sticky. The residents on the ground floor residential unit had access to the grounds, however, the garden areas looked untidy and unkempt. The floor coverings in the toilets and bathrooms had been repaired, however, several of the repairs were an unsatisfactory standard. The bathrooms on the ground floor were uninviting and bare. The bath hoist was unclean in the ground floor bathroom and there were no grab rails to assist the independence of residents using the shower room on the residential unit. Further to this, the shower chair was unsuitable for one resident’s needs. The standard of cleanliness was satisfactory in all areas seen, although one resident on the residential unit said that her room “was not as clean as it should be”. All the residents spoken to said the their bedrooms and lounges were always at a comfortable temperature. The use of the new dining room on the DCU enhanced people’s enjoyment of meals and residents liked using the new lounge, which was calming, comfortable and homely. However, some areas in the DCU did not respect the dignity, comfort, safety and needs of residents: for example, ceiling lights in 3 bedrooms were not working; most rooms did not have towels; one toilet was used as a store; one bathroom was out of order; several toilets did not have grab rails; the main bathroom looked stark and clinical; the ‘smoking lounge’ furniture was in very poor condition; the corridor carpet was sticky underfoot; several commode frames needed cleaning and varnishing and one bedroom had a very strong odour. The registered manager should also consider whether the highly patterned furnishings in the large lounge suit the needs of people with dementia. The Victoria Residential Home DS0000046704.V287783.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staff were provided with appropriate training and were deployed in sufficient numbers to meet the needs of the residents. The residents were protected by the home’s recruitment policy and practices. EVIDENCE: The registered person maintained a staff roster, which was completed in advance. From inspection of the roster, it was noted that there were additional staff placed on duty at busy times and a member of staff was employed two afternoons a week to facilitate activities. The files of three members of staff, who had commenced work in the home since the last inspection, were examined. The registered manager had implemented a recruitment and selection checklist and it was noted that all staff had completed an application form, provided a full working history and attended a face-to-face interview. Two written references and police checks had been sought and received prior to the staff commencing work in the home. Arrangements were in place to ensure staff received appropriate induction training and other training such as moving and handling in line with the needs of the residents. Information contained in the pre inspection questionnaire indicated that 17 members of staff had completed NVQ level 2 or above, this equated to 63 of the care staff were qualified. The Victoria Residential Home DS0000046704.V287783.R01.S.doc Version 5.1 Page 20 Since the last inspection, the staff team on the DCU had completed a level 1 dementia care course, which had given them grounding in understanding the needs of people with dementia. In order to be competent and expert in recognising and meeting the changing needs of very vulnerable people who have dementia and their environment, staff should continue their education with more in depth training. The Victoria Residential Home DS0000046704.V287783.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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. A means had been established to formally consult both residents and staff and systems were in place to monitor the quality of the service. The arrangements in place to test the safety of the electrical installations were inadequate and placed the residents at risk of harm. EVIDENCE: The registered manager had the overall responsibility for the management of the home and had commenced working towards the Registered Manager’s Award. The registered manager had also undertaken various short courses, including the care of older people with dementia and first aid, in order to update her knowledge and skills. Relationships within the home were good and staff spoke about the residents with respect. All the residents spoken to valued the help and support they The Victoria Residential Home DS0000046704.V287783.R01.S.doc Version 5.1 Page 22 received from the staff, one person said “they are a grand set of girls” and another person said, “I like all the staff, everything is perfect”. The staff received supervision at least six times a year. Topics discussed during supervision were recorded on a suitable format and records were seen during the inspection. Staff were also offered the opportunity to attend regular staff meetings with the registered manager. The home achieved an Investors in People Award in 2001 and this was reaccredited in 2004. Since the last inspection, the registered manager had further developed the systems to monitor the quality of care in the home and had produced an annual development plan based on a systematic cycle of planning, action and review, which reflected the aims and outcomes for residents. A satisfaction survey had been carried out of residents and their relatives/representatives, during December 2005 and January 2006. Results of the surveys had been collated, published and feedback to all interested parties. The registered manager had also carried out a review of the policies and procedures. 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. Records were also maintained in respect to the amount of fees charged and received. 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. However, bedding and towels were seen stacked on the floor in the storage areas of the DCU and there were no disposable towels in the sluice. Systems were in place in record accidents and the Commission had been notified of incidents in the home in accordance with the relevant legislation. Risk assessments had been carried out in relation to safe working practices and the fire risk assessment had been updated in line with advice from the Fire and Rescue Authority. 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, which had expired at the last inspection had not been renewed. The Victoria Residential Home DS0000046704.V287783.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 2 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 1 1 1 3 2 1 2 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 3 X 1 The Victoria Residential Home DS0000046704.V287783.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 cover the elements listed under Regulation 5 and Standard 1. Extracts must not be transcribed from CSCI inspection reports. The manager must prepare care plans that take into account the health and welfare needs of residents who are confined to bed, (especially for long periods) and detail the action that staff must take to meet health, personal, social and mobility needs. Plans for weight gain, loss or maintenance should be identified in care plans and followed in practice. (See Recommendations from previous inspections on 18/5/05, 20/9/05 and 14/12/06). Where risks are identified management strategies must be devised in order to minimise or eliminate the risks. A suitably qualified person must check the safety of all new electrical installations. All new building work must be DS0000046704.V287783.R01.S.doc Timescale for action 30/06/06 2. OP7 12 (1) 30/06/06 3. OP8 12 (1) 30/06/06 4. OP8 13 (4) (c) 15/06/06 5. 6. OP19 OP19 13 (4) (c) 13 (4) (c) 27/05/06 27/05/06 Page 25 The Victoria Residential Home Version 5.1 23 (1) (4) 7. 8. OP19 OP20 23 (2) (o) 23 (2) (d) 9. 10. OP21 OP21 23(2)(j) 16 (2) (c) 11. OP21 16 (2) (c) 12. OP21 23 (2) (d) 13. 14. OP22 OP22 23 (2) (c) 23(2)(n) 15. OP24 23 (2) (c) 16. 17. OP25 OP38 23(2) (p) 13 (4) (c) checked and comply with the requirements of the Building Department and the Fire and Rescue Authority. The grounds must be kept tidy, safe and attractive. The carpets in the corridors must be either thoroughly cleaned to remove all staining or replaced. (Previous timescale of 01/03/06 – not met) The toilet and the bathroom in the dementia care unit must be made available for use. Repairs to floor coverings in all bathrooms and toilets must be repaired to a satisfactory standard to ensure the surface can be readily cleaned and is comfortable for the residents. (Previous timescale of 15/02/06 – not met). The new ensuite facilities must be completed and fitted with an appropriate floor covering and blind, as necessary. The bath hoist must be kept clean at all times on the residential unit. (Previous timescale of 14/12/05 – not met). The pull cords to activate the call system must be accessible to residents at all times. To ensure the safety and independence of residents, grab rails must be provided in ensuites, toilets and the ground floor shower room. All residents must be provided with comfortable seating in their bedroom, which is suitable for their needs. To ensure the safety of everyone at the home, light bulbs must be replaced immediately. The registered person must DS0000046704.V287783.R01.S.doc 30/06/06 15/07/06 15/06/06 15/07/06 27/05/06 17/05/06 17/05/06 30/06/06 15/06/06 17/05/06 27/05/06 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.(Previous timescale of 15/01/06 – not met). 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. 2. Refer to Standard OP2 OP7 Good Practice Recommendations The contracts issued to residents should be signed and completed. This recommendation carried forward from the last inspection: Daily records should describe how care is delivered (in accordance with the resident’s plan) for each resident. Assessments for people confined to bed for long periods should ensure maintenance of all health needs; including psychological health (8.7), opportunities for physical activity (8.8) access to specialist services (8.11) (such as physiotherapy and occupational therapy etc.) Charts devised to monitor personal care should be maintained on a consistent basis. So residents have choice, and to improve presentation of meals, foodstuffs should be liquidised separately. The manager should consider whether the highly patterned furnishings in the large lounge in the dementia care unit are suitable for the needs of people with a dementia. Comfort for residents should be in mind when improving the main bathrooms (for example, by making the rooms more inviting and ‘homely’) Aids (such as appropriate chairs) should be provided in communal rooms and resident’s bedrooms to enable residents to sit comfortably out of bed. The cause of the offensive odour in one bedroom on the Dementia Care Unit should be addressed. Commodes should be thoroughly cleaned and varnished as necessary. DS0000046704.V287783.R01.S.doc Version 5.1 Page 27 3. OP8 4. 5. 7. OP8 OP15 OP20 8. 9. 10. 11. OP21 OP22 OP26 OP26 The Victoria Residential Home 12. OP30 13. 14. OP31 OP38 The manager should implement a programme of continued training for staff in dementia care, in order that staff are competent and expert in providing a service, which meets the needs of residents on the specialist dementia care unit. The registered manager should complete the NVQ level 4 in management. To promote infection control measures, bedding and towels should not be stored on the floor, and disposable towels should be provided in the sluice. The Victoria Residential Home DS0000046704.V287783.R01.S.doc Version 5.1 Page 28 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 © 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 The Victoria Residential Home DS0000046704.V287783.R01.S.doc Version 5.1 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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