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Inspection on 18/05/05 for The Victoria Residential Home

Also see our care home review for The Victoria Residential Home for more information

This inspection was carried out on 18th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The residents maintained good contact with family and friends, who were able to visit at any time. Staff ensured residents had a choice at mealtimes and a choice of when they got up or went to bed. Staff and residents enjoyed positive relationships on both the Dementia Care Unit and the Residential Unit. To minimise the risk of scalding, all water outlets were fitted with preset valves and radiators and exposed pipe work were fitted with guards.

What has improved since the last inspection?

The programme of replacing windows had been completed, to good effect. The fire alarm system had been upgraded in line with the requirements made by the Fire Authority. The furnishings in the "red" lounge had been replaced and many areas of the home had been redecorated.

CARE HOMES FOR OLDER PEOPLE The Victoria Residential Home Thursby Road Burnley Lancashire BB10 3AU Lead Inspector Julie Playfer Unannounced 18 May 2005 10:00 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 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 F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Victoria Residential Home Address Thursby Road Burnley Lancashire BB10 3AU 01282 416475 01282 441447 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Ranjay Trehan Victoria Care Homes Limited Mrs Lynn June Plane Care Home (CRH) 36 Category(ies) of Old age, not falling within any other category registration, with number (OP) - 25 of places Dementia - over 65 years of age DE(E) - 11 The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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. Maintain at all times staffing levels agreed with the previous registration authority. Employ at all times, a suitably qualified and experienced manager who is registered with the CSCI. Date of last inspection 8th October 2004 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 reflect guidance previously issued by the Local Authority. The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day and a total of 9 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 of the home and the staff on duty. A tour of the building took place both internally and externally. At the time of inspection a total of 27 people were living in the home. Since the last inspection three additional unannounced visits have been made to The Victoria Residential Home. The purpose of the first visit was to investigate a complaint, which highlighted concerns about the management of medication. These concerns prompted a full pharmacy inspection, which was carried out over the subsequent two visits. The home has since been issued with a Statutory Requirement Notice in respect of medication practices in the home. What the service does well: What has improved since the last inspection? What they could do better: There are a number of legal requirements and good practice issues, which need to be addressed by the registered persons. These include amending the The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 6 written information for residents and improving the admission procedure to ensure residents and their families have sufficient information to make a choice about whether to live at the home. The registered manager must also make sure that residents have a full assessment of their needs before admission and she must tell the resident how the home will meet their needs. In addition the manager must improve the care planning system to ensure the residents’ needs (including those for healthcare) are fully met. Medication practices were poor and placed resident’s at significant risk. A statutory requirement notice has been issued in respect to the management of medication, which has not been compiled with. Following discussion with residents, the manager and staff should ensure that the home provides a programme of daily activities that are suited to the needs, choices and wishes of the residents. Improvements must be made to record keeping, particularly records about residents’ care and staff recruitment records. The standard of cleanliness was unacceptable in many areas of the home and must be improved. Arrangements should also be put into place to enhance the residents’ right to dignity. Minimum staffing levels must be maintained at all times to ensure residents are not placed at risk and receive the appropriate standard of care. Staff must have access to specialist dementia care training to provide underpinning knowledge and an insight into the difficulties associated with dementia. Formal consultation should be improved and regular Resident’s Meetings should be held so that residents may express their views and opinions of life in the home and have some input on any future planning. 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 F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 8 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 standard(s) 1, 2, 3, 4 and 6 The written information provided for residents was useful, however the details must be accurate so as not to present a misleading picture of life in the home. The admission procedure must be improved. Without access to a proper assessment prior to admission; it is not possible to determine whether the home is suitable for meeting a particular resident’s needs. EVIDENCE: Written information in the form of a service users guide, which contained details about the services provided in the home, was supplied to residents. However, the guide must be amended in order to provide residents with accurate information. For instance the guide stated there were “quite often outings and trips”, this was not the perception of residents and there were no records to demonstrate such activities were arranged on a regular basis. A written contract was included in the service users guide; however, the contract should clarify the issues around personal insurance. The “case tracking” process showed that the majority of residents had their needs assessed prior to admission to the home by a social worker and/or the The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 9 registered manager. However, there was a problem for one resident recently admitted to the Residential Unit. Although the admission had previously been agreed with the home, there were no records and no-one told the person in charge of the home until the day the new person arrived. The assessment of needs was faxed through to the home minutes before the person was admitted. Consequently, the new resident had not been told how the home was to meet her needs and the staff had little time to prepare a plan of care or welcome the person into the home. There were several residents on the Residential Unit who had a diagnosis of dementia. The registered persons must ensure the needs of these residents can be fully met within this unit and be mindful of the outcomes for other residents. For instance it was evident one resident was frequently aggressive towards another resident and this situation was difficult for other residents to cope with. The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 10 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 standard(s) 7, 8 and 9 Care planning should be improved to ensure the plans fully address the needs of the residents and provide clear guidance to staff on how these needs are to be met. Some healthcare needs were not met and as a result residents were placed at risk of harm or neglect. Medication management within The Victoria Residential Home was poor and placed residents at significant risk of harm. A Statutory Requirement notice has been issued in respect of these concerns, but the requirements of the notice had not been complied with. EVIDENCE: All established residents on both the Residential Unit and the Dementia Care Unit had a plan of care and these were reviewed monthly. However, care plans were not always followed for example the record for one resident on the Dementia Care Unit stated she wore glasses “all the time”, but this resident did not have glasses on during the inspection. The care plans were not always changed following review, for instance following a visit,by the Consultant Geriatrician to a resident on the Residential Unit, information regarding the person’s psychological condition was not transferred to the plan. Such information must be included in the main care plan with clear guidance on how staff should support this person. The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 11 There was documentary evidence to demonstrate residents had accessed specialist healthcare services. However, staff had not always acted on the advice of the healthcare professional. For instance, a chiropodist had requested a referral to a Doctor for one particular resident on the Residential Unit for a routine test. There was no evidence to indicate the Doctor had been contacted or the test had been carried out. Furthermore care plans on the Dementia Care Unit stated that weight should be monitored, but staff were unable to do this accurately as there were no suitable scales. People who have a dementia are at risk of nutritional problems and suitable “sit on” scales should be provided. Residents who wear dentures should have the opportunity for regular checks with a dentist. The goals and aims in some care plans could be improved by being more personalised and detailed. For example the type of dementia diagnosis and how this affects outcomes for the individual should be recorded. Preferences of daily routine and detailed plans for daily beneficial therapies should be included (such as opportunities for physical exercise). It was noted that wheelchairs without footrests were being used to transport residents on the Dementia Care Unit. One person’s feet were touching the floor and there was a risk of injury, especially as not all residents wore shoes (several wore socks). All such equipment should be regularly cleaned and properly maintained and used according to the manufacturer’s instructions, or if this is not possible, according to a risk assessment in the individual’s care plan. Detailed plans and risk assessments for people unable to wear proper footwear should be carried out. Accurate administration and documentation of medication is essential to the health and well being of residents. However, a number of Medication Administration Record charts were unclear, with incorrect dosage instructions, incorrect timing of doses and many gaps. Medication reorder procedures were poor and put residents at risk of harm. Records and supplies showed that medicines were unavailable for four residents. One resident had not had eye drops administered for 15 days, whilst another frequently had diabetic tablets omitted. Due to lack of stock, some medicines were being ‘shared’ between residents. This practice is illegal and must stop. The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 12 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 standard(s) 12 -15 The residents were able to maintain good contact with their family and friends. Residents had very few opportunities to engage in meaningful activities, which resulted in a lack of stimulation. There was no system in place to formally consult residents and there was no evidence that the residents’ needs in respect to activities had been acted upon. Due to a lack of training, staff had limited knowledge on the promotion activities throughout the home. The lack of record keeping in relation to meals served meant it was not possible to ascertain whether the resident’s nutritional needs were met. EVIDENCE: The residents had visitors at any time during the day and one visitor said that she was offered refreshment. A visitor said she was satisfied with the care her relative received. Staff explained that residents could see visitors in privacy of their bedrooms if they wished. Staff made efforts to ensure that residents had choices of meals, having a liein in the morning and freedom of movement. The choice of and opportunities for stimulating activities were extremely poor on the Dementia Unit there was a reliance on videos, music tapes and some residents attending a monthly entertainment downstairs on the Residential Unit. There were no appropriate activities on the day of inspection or planned The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 13 for the future and staff thought it was difficult to motivate residents. The day was punctuated by meals and the residents slept at other times. Staff were keen to help residents with activities but reported that they did not have activity equipment that was suitable for the cognitive needs of the current residents. The residents rarely went outside on the Dementia Care Unit. Some people had not been out for several months. Staff reported that some residents got to the door, and then did not want to go out. Staff had a poor understanding of the underlying problems associated with dementia and the effects of different types of dementia. Staff should therefore receive proper training on how to meet the needs of people with a dementia. There were very few activities arranged on the Residential Unit. The activity record had not been completed since January 2005. One resident had some craft materials provided by the home, however, she said she had to motivate herself to make use of the resources, as staff had no time to spend making things with her. One resident commented there was “nothing much going on” and she got “fed up” and another person said there were no activities and “the days seemed long”. The resident’s could not recall the last Resident’s Meeting and there were no minutes available for inspection. The staff on duty confirmed they were very busy and had little time to engage in deep conversation or pursue activities. The main meal looked appetising and residents had a choice. Portion size was satisfactory for those who did not require assistance. However, staff should ensure that proper records are kept of the nutritional content and size of meals for residents who miss the main meal, eat a different meal or who need assistance, related to weight monitoring. The record of meals served for the week of inspection had not been completed and vague terms in care records such as “some fluids taken”, “good diet” were not sufficient to evidence that proper attention is given to individual’s nutritional needs. The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 14 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 standard(s) 18 Procedures were in place to respond to suspicion or evidence of abuse. Staff had a good understanding of the procedures. EVIDENCE: 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 F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 15 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 standard(s) 19 - 26 Whilst there were noticeable improvements to the overall decoration of the home, the environment was not clean and hygienic, presented risks to the resident’s health and safety and compromised their right to dignity. EVIDENCE: Since the last inspection the programme to replace all the windows in the home had been completed to good effect. The fire system had been upgraded in line with the requirements of the Fire Authority and the furniture in the “red” lounge had been replaced. In addition, many areas of the home had been redecorated. A tour of the premises took place of both the Residential and Dementia Care Unit. Overall, the Dementia Care Unit had a bad odour of urine and poor state of cleanliness. The corridor was very dark. A hoist and other equipment was stored in the corridor, which was a potential hazard for residents. The furniture in the lounge was unsuited to the resident’s needs. Some of the chairs and settees were very low on both the Dementia Care Unit and Residential Unit and residents had difficulty in getting up unaided. They were not suitable for residents who had continence problems. Consequently, plastic covers and The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 16 white sheets were used on the Dementia Care Unit. These were unsightly and did not respect resident’s dignity. Similarly the dining room chairs on the Dementia Care Unit were not easy to clean and were dirty. The chair covers were stapled on and some staples and tacks were loose, which were hazardous for residents and staff. The covers were highly coloured which can cause perception problems for some people who have a dementia. Likewise the carpets were highly patterned, which again could cause problems of perception in some kinds of dementia. The windows between the dining room and lounge were dirty and overall gave a poor impression. Bedrooms were inspected with the permission of the residents. Many residents had personalised their rooms with their own belongings and generally decoration was satisfactory throughout. However, several of the rooms on the Dementia Care Unit were odorous and dirty with faecal smears on the carpet in two rooms and on a door. A room was in a similar condition on the Residential Unit. It was a concern to note there was no equipment available in the home on the day of inspection to clean the carpets. It was reported one machine had gone for repair and the other machine was not operating properly. Consequently these rooms were not cleaned thoroughly and so presented a significant risk of infection to residents and staff. There were stickers on the drawers on the Dementia Care Unit, which wrongly described the contents. These are a hindrance to memory enhancement as well as looking unsightly and not respecting resident’s dignity. The storeroom on the Dementia Care Unit, containing cleaning products was unlocked and thus presented a risk to residents’ safety. The sluice on the Residential Unit would benefit from redecoration. Clean continence pads and towels were stored in toilets and bathrooms on both floors. For infection control and for reasons of dignity for residents, such items must be stored in a clean utility area. Notices about continence products should be removed from toilet walls on the Dementia Care Unit. The refurbishment of the bathrooms had been completed (residual work was ongoing in shower rooms). However, it was noted several tiles were badly chipped at floor level in the bathroom on the Residential Unit; these must be repaired to prevent risk of injury to residents. The bathroom on the Dementia Care Unit and the bath hoist were dirty. The residents on the ground floor had access to the grounds. However, the weeds should be removed from the sitting area at the front of the building to ensure residents are able to sit in pleasant surroundings. The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 - 30 The residents and staff had positive relationships and the staff treated the residents with respect. The residents on the Residential Unit were placed at significant risk on at least three occasions by not having sufficient staff on duty. In order to enhance the residents’ quality of life on the Dementia Care Unit all staff must have access to proper training and gain a good understanding of the special needs of people with dementia. The recruitment and selection procedure was not robust in all cases and in order to safeguard the welfare of the residents must be improved. EVIDENCE: The residents on both units said that they liked the staff and got on well with the staff. There was kindness and consideration in the interactions between the staff and residents on the Dementia Care Unit. Conversations with staff showed that they had the best interests of residents at heart and it was noted the staff were respectful. It was a significant concern to note that on at least three occasions the Residential Unit was operating below minimum staffing levels during the evening shift. This situation is unacceptable and is a breach of Conditions of Registration. It must therefore not reoccur. At the time of the inspection there was only one domestic staff on duty, who was cleaning the Residential Unit. There was no one assigned to clean the Dementia Care Unit. The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 18 The staff on duty on the Dementia Care Unit were working towards NVQ level 2 and the senior staff was due to complete NVQ level 3 in care in August 2005. The staff had also completed moving and handling and medicines awareness course. However, none of the staff had undertaken any training about the specific needs of older people who have a dementia. They said they would welcome such training and would like to have a better understanding. Some information about dementia care was available, but rarely read. Without underpinning knowledge the information would be difficult to understand and to put into practice in the unit. The files of staff recently employed in the home were inspected. With the exception of one person, records and information associated with recruitment had been collated and documented appropriately. There was also evidence of appropriate induction and foundation training as well as NVQ training. However, one member of staff’s file seen was incomplete, a full employment history had not been provided, references had not been obtained from the referees nominated on the application form and there was no evidence of a POVA (Protection of Vulnerable Adults List) or CRB (Criminal Records Bureau) check. The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33 and 37 The lack of formal consultation and quality monitoring systems resulted in the residents not being able to voice their opinions in a formal way. As such, the residents had very little formal input into the overall running of the home and their ability to effect change was therefore limited. EVIDENCE: Consultation in the home was informal there was no record of Residents’ Meetings or Staff Meetings, neither residents or staff could recall attending the last meeting. Whilst the home achieved a post recognition Investors in People Award in September 2004, there had been limited progress made on developing a quality assurance system to monitor outcomes for residents. Hence satisfaction questionnaires had not been distributed to residents, their representatives or professional staff involved with the home for some time and none were seen at the time of the inspection. The registered person reported the annual development plan had not been updated. The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 20 Some records required under the Care Homes Regulations 2001 had not been kept up to date, for instance the record of meals served and staff records. The registered provider had also not provided the Commission with reports of visits carried out under Regulation 26 since September 2004. The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 2 2 2 3 2 3 1 STAFFING Standard No Score 27 1 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 x 2 1 x x x 2 x The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 22 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 1 3 Regulation 5 14 Requirement The service users guide must contain accurate and up to date information. Residents must not be admitted into the home without full consideration and consultation regarding the assessment of needs. Residents must be informed in writing that having regard to their assessment the home is suitable for meeting their needs. The care plans must address the residents current needs and include clear guidance for staff on how these needs are to be met. Following review the care plans must be updated. The residents healthcare needs must be fully addressed in the care plan. Advice given by healthcare professionals must be acted upon without delay. Residents on the Dementia Care Unit who wear dentures must have the opportunity for regular checks with a dentist. Safe systems for moving F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Timescale for action 30 June 2005 Immediate and ongoing from the date of inspection. Immediate and ongoing from the date of inspection. 15 June 2005 3. 4 14 4. 7 15 5. 8 15 15 June 2005 6. 8 13 30 June 2005 Immediate Page 23 7. 8 13 The Victoria Residential Home Version 1.30 residents who use wheelchairs must be implemented to eliminate unnecessary risks to residents. 8. 8 13 Detailed plans and risk assessments must be carried out and put in place for all residents who are unable to wear proper footwear. Policies and procedures must be in place for all aspects of medicines management. Staff must be fully aware of these follow them at all times. (Previous timescale not met) A full and detailed record must be maintained of all medicines received, all doses administered and all items disposed of for each resident. This must include creams, external products and nutritional supplements. (Previous timescale of 9 May 2005 - not met) Medication dosage instructions must be clear and in accordance with the prescribers directions. Where verbal dose changes have been made by the prescriber, these must be clearly documented. (Previous timescale of 9 May 2005 - not met). There must be sufficient supplies of medication available for residents at all times. (Previous timescale of 9 May 2005 - not met). Residents must receive medication only from their own named supplies. (Previous timescale of 9 May 2005 - not met). Medication must only be administered according to the prescribers and ongoing from the date of inspection. 30 June 2005 9. 9 13(2) 30 June 2005 10. 9 13(2) 17(1)(a) Sch 3(i) Immediate and ongoing from the date of inspection. 11. 9 13(2) 17(1)(a) Sch 3(i) Immediate and ongoing from the date of inspection. Immediate and ongoing from the date of inspection. Immediate and ongoing from the date of inspection. Immediate and ongoing Page 24 12. 9 13(2) 13. 9 13(2) 14. 9 13(2) The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 instructions.(Previous timescale of 9 May 2005 - not met). 15. 9 17(1)(a) Sch 3(i) 16. 12 16 17. 15 17, Schedule 4 18. 19. 19 20 23 16 20. 21. 22. 20 21 21 16 23 23 from the date of inspection. All medication must be verified Immediate on admission and details must and be accurately transferred to ongoing Medication Administration Record from the date of charts where appropriate. (Previous timescale of 9 May inspection. 2005 - not met) Residents must be consulted 30 June about their preferences in regard 2005 to activities, following which a programme of activities must be arranged which meets their needs in relation to fitness and recreation. Arrangements must also be made for residents on the Dementia Care Unit to take part in appropriate leisure and social interests and community activities. The record of meals served must Immediate be kept in sufficient detail to and enable any person inspecting the ongoing record to determine whether the from the diet is satisfactory in relation to date of nutrition and otherwise and of inspection. any special diets prepared for individual residents. (Previous timescale of immediate - not met). The seating area in front of 30 June building should be appropriately 2005 maintained. Furniture provided in the 15 July communal areas must meet the 2005 needs of the residents and respect the residents right to dignity. The covers on the dining room 15 July chairs on the Dementia Care Unit 2005 must be replaced. The residual work in the shower 30 June rooms must be completed. 2005 The chipped tiles at floor level in 30 June the bathroom on the Residential 2005 Unit must be repaired. Version 1.30 Page 25 The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc 23. 24. 22 22 23 23 Floorcoverings must also be repaired as appropriate. Equipment must be stored appropriately and not present a hazard to residents. The bath hoist and wheel chairs must be kept clean and properly maintained. 15 June 2005 25. 26 23 26. 26 13 27. 26 13 28. 27 18 29. 27 18 30. 29 18, 19 Schedule 2 and 4 Immediate and ongoing from the date of inspection. The home must be kept clean at Immediate all times and free from offensive and odours. A thorough clean should ongoing be undertaken of the Dementia from the date of Care Unit. Carpets must not be left with faecal smears. inspection. Cleaning materials on the Immediate Dementia Care Unit must be and stored in a locked ongoing cupboard/room at all times. from the (Previous timescale of immediate date of - not met). inspection. Clean towels must be stored in a Immediate clean utility area away from and bathrooms and toilets. ongoing from the date of inspection. Staffing levels must be Immediate maintained at all times in line and ongoing with the conditions of registration. from the date of inspection. Domestic staff must be provided Immediate in sufficient numbers to ensure and the standards relating to hygiene ongoing and cleanliness are fully met. from the date of inspection. All documentation and records Immediate relating to the employment of and new staff must be collated and ongoing maintained at all times. from the Appropriate checks must also be date of carried out prior to employment. inspection. Version 1.30 Page 26 The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc 31. 30 18 32. 33 24 33. 33 24 34. 37 4, 17, 18, 19 Staff working on the Dementia Care Unit must have training appropriate to the specific needs and understanding of people with dementia. An annual development plan must be devised based on a systematic cycle of planning, action and review, reflecting the aims reflecting the aims and outcomes for service users. There must also be continuous monitoring, using an objective, consistently obtained and reviewed and verifiable method (preferably a professionally recognised quality assurance system and involves the service users and an internal audit takes place at least annually. (Previous timescale 1st February 2005 - not met). Feedback must be sought from service users about the services provided in the home, through for example the use of anonymous user satisfaction questionnaires and individual and group discussion. All records listed in the regulations must be kept complete and up to date all times. The responsible individual must supply the Commission with a monthly report carried out under Regulation 26. 31 July 2005 31 July 2005 31 July 2005 35. 37 26 Immediate and ongoing from the date of inspection. Immediate and ongoing from the date of inspection. The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 27 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 1 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. The contract should provide clear details of the need for personal insurance. Sit on scales should be provided on the Dementia Unit to monitor the residents weight. Weight gain or loss should be monitored and recorded, within the plan of care. Residents should be given the choice of self medicating where possible. Criteria for the administration of when required and variable dose medication should be clearly defined. A second member of staff should witness all handwritten entries and alterations on Medication Administration Record charts. The temperature of medication storage areas should be monitored and recorded regularly. Medication requiring refrigeration should be stored in a dedicated medication fridge, or in a locked container within the domestic fridge. The temperature of fridges should be recorded daily. The fridge in the clinical room downstairs needs servicing as it did not appear to be working correctly. There should be a formal system for identifying residents prior to administration of medication. This could include keeping photographs of the residents with the Medication Administration Record charts. The opening dates should be recorded on all eye drops and other short dated products. Controlled drugs should be stored in a Controlled Drugs cabinet which complies with the Misuse of Drugs (Safe Custody) Regulations 1973. Staff should be assessed as competent to administer medication prior to being responsible for the process. There should be a signature list of staff who administer medication. There should be a formal system for prompting medication reviews in line with the National Service Framework for F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 28 2. 3. 4. 5. 2 8 9 9 6. 9 7. 8. 9 9 9. 9 The Victoria Residential Home 10. 11. 18 19 12. 13. 14. 15. 24 28 32 32 Older People. The information relating to the protection of vulnerable adults contained in the service users guide should be revised. Appropriate expert advice is obtained on suitable environmental standards for colour, texture and design of furniture, furnishings and fittings in the Dementia Care Unit. Stickers on drawers should be removed to respect the residents right to dignity. A minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) is achieved by 2005. The frequency of residents meetings should be increased. The frequency of staff meetings should be increased. The Victoria Residential Home F57 F07 S46704 Victoria V225119 18.05.05 Stage4.doc Version 1.30 Page 29 Commission for Social Care Inspection Unit 4, Petre Road Clayton Business Park Accrington Lancashire 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. 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