Inspection on 22/04/08 for The Victoria Residential Home

This inspection was carried out on 22nd April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 06/06/07

The Victoria Residential Home 17/05/06

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE The Victoria Residential Home Thursby Road Burnley Lancashire BB10 3AU Lead Inspector Mrs Julie Playfer Unannounced Inspection 09:00 22 and 23rd April 2008 nd 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.V359063.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 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 41 Category(ies) of Dementia (18), Old age, not falling within any registration, with number other category (23) of places The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to accommodate up to 18 service users in the category of dementia - DE and 23 service users in the category of older people (aged over 65 years) - OP. 6th June 2007 Date of last inspection 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 23 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 30 single bedrooms and 5 double bedrooms on three floors. There is a passenger lift linking the floors. Seventeen of the single bedrooms and one double room have ensuite facilities comprising of a toilet and wash hand basin. The home is split into three units and is staffed accordingly. The ground floor unit and the second floor unit provide personal care for older people. The first floor provides personal care for older people who have a dementia and this part of the home is known as the Dementia Care Unit. At the time of the inspection the scale of charges was £346.00 to £407.50. Additional charges were made for toiletries, hairdressing, chiropody, holidays and outings. There were no additional fees payable for privately funded residents. 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.V359063.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. A key unannounced inspection, which included a visit to the home, was conducted at The Victoria Residential Home on 22nd and 23rd April 2008. At the time of the inspection there were 26 people accommodated in the home. The inspection comprised of spending time with the residents, looking round the home, reading some of the residents’ care records and other documents and discussion with the staff and the registered manager. As part of the inspection process we (the commission) used “case tracking” as a means of gathering information. This process allows us to focus on a small group of people living at the home, to assess the quality of the service provided. Prior to the inspection the registered manager completed a detailed factual questionnaire about all aspects of the care home, which provided useful information and evidence for the inspection. Satisfaction questionnaires were sent to the home for distribution to the staff, the residents and their relatives. Thirteen questionnaires were returned from relatives/visitors to the home and eight questionnaires were received from the people who live in the home. In addition thirteen questionnaires were received from staff. The responses from the questionnaires were collated and used for evidence purposes throughout the inspection process. What the service does well: Current and prospective residents were provided with appropriate written information. This ensured the residents were aware of the services and facilities available in the home. The admission procedure involved an assessment of people’s needs. This enabled the registered manager and prospective residents to determine whether or not their needs could be met within the home. Each resident had a plan of care, which was easy to understand and follow. This meant the staff had clear guidance on how to meet the residents’ needs in a consistent manner. The residents were able to exercise choice and control over their lives. The daily routines were flexible and designed to meet the wishes and preferences of the residents. As such the residents could decide when they wished to get up and go to bed. The residents spoken to felt that the staff respected their rights to privacy and personal care was delivered appropriately. The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 6 Visitors were welcome in the home at any time and residents were supported to maintain good contact with their family and friends. The relatives who completed a questionnaire were satisfied with the quality of care provided, one person wrote, “The staff are excellent in the support and care of the residents”. The residents were aware of the complaints procedure and knew who to talk to in the event of a concern. Residents’ meetings were held on a regular basis, which gave the residents the opportunity to discuss all aspects of life in the home. The residents were provided with clean and comfortable bedrooms, which they could personalise with their own belongings. A good percentage of staff had achieved NVQ level 2 or above. This qualification provided the staff with the necessary knowledge to carry out their role effectively. What has improved since the last inspection? Since the last inspection, the care plans and had been updated to incorporate more information for staff on how they should respond to the residents’ frustrations and cognitive impairments. The strategies recommended to staff were based on positive intervention such as distraction techniques to ensure such behaviours were managed appropriately and the residents were treated with understanding and courtesy. The nutritional risk assessments had been further developed to incorporate more detailed information for staff on the residents’ dietary needs. The assessments had been reviewed each month to ensure any changing needs were promptly identified. The registered manager had provided the staff with information about suitable activities for people with dementia. This was designed to inform the staff about the instigation of appropriate activities for people living on the dementia care unit. The record of meals served was complete and up to date for both Units. This meant each resident’s diet could be easily monitored. Floor coverings in the main corridors had been replaced with non-slip floor coverings. Part of the walls and handrails had also been painted in the corridors. Such improvements had significantly enhanced the appearance of these areas. In addition the kitchen, hairdressers room and dining room on the ground floor had been decorated and new carpet had been fitted in one of the bedrooms. There had been a significant increase in the number of staff who had achieved NVQ level 2. This meant there were more staff who had completed the appropriate training for their role. The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 7 The registered manager had completed the Registered Manager’s Award. This award added to the manager’s previous qualifications and ensured that she had the necessary knowledge and skills to carry out her role effectively. The quality assurance systems had been further developed. This ensured that the planned developments in the home were based on improving the service for the residents. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home had their needs properly assessed and they were provided with appropriate written information to enable them to make an informed choice about where to live. EVIDENCE: Written information was available for the residents in the form of a statement of purpose and service users guide. The guide was available for reference in the main reception and in each of the bedrooms. The registered manager had ensured the guide had been updated in line with any changes in the home. A copy of the inspection report summary was included in each service users guide. Both the statement of purpose and service users guide provided useful information about the services and facilities offered in the home. The majority of the residents, who completed a questionnaire, indicated that they had received enough information prior to moving into the home. The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 10 All residents were issued with a statement of terms and conditions of residence or contract. The contracts had been signed by the residents and/or their representative and included information about the current level and payment of fees. The ‘case tracking’ process demonstrated that the residents had their needs assessed prior to admission to the home by a social worker and/or the registered manager. Copies of the preadmission assessments were seen on the residents’ files. The registered manager ensured that admissions were not made to the home in the absence of a full needs assessment. This meant the registered manager was confident that the staff had the necessary skills and knowledge to meet the assessed needs of the prospective resident. Prospective residents were encouraged to spend time in the home prior to making the decision to move in. This enabled the resident to meet other residents and staff and experience life in the home. Following admission, a trial period was offered to every resident, so that both parties could make sure the placement was successful and the resident’s individual needs could be met. The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans did not always provide clear information about how best to meet the residents’ healthcare needs. Arrangements for the administration of medicines helped ensure they were given to residents correctly. EVIDENCE: From the case files seen, it was evident each resident had a plan of care, based on their assessment of needs. Personal profiles were incorporated into the care plans and provided details about past life experience. The plans were easy to read and understand and included general guidance for staff on how best to meet the residents’ needs. Since the last inspection, the care plans and had been updated to incorporate more information for staff about how they should respond to any behaviours which challenge others and the service. The strategies recommended to staff were based on positive intervention such as distraction techniques to ensure such behaviours were managed appropriately and the residents were treated with understanding and courtesy. The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 12 The plans were supported by records of personal care, which provided information on changing needs and any recurring difficulties. Charts had been maintained for personal care and hygiene; however, these had not been consistently completed. This meant it was difficult to determine the frequency of some personal care provided to the residents. Whilst the residents spoken to could not recall participating in the development of their care plan, there was documentation signed by the residents or their relatives within their personal file indicating their involvement. The relatives who completed the questionnaires felt they were kept up to date about important issues affecting their family member, one person spoken to during the inspection said the staff kept him informed about his wife’s condition and were always “happy to chat”. The care plans had been reviewed on a monthly basis. The review forms included prompts for staff, to ensure any changing needs were identified. Risk assessments in respect to moving and handling, pressure sores, falls and nutrition had been incorporated into the care plan documentation. Since the last inspection, the nutritional risk assessments had been further developed to incorporate more detailed information for staff about the residents’ dietary needs. However, whilst moving and handling assessments had been carried out there was no guidance for staff on how to assist the mobility of one person. Further to this, there was no evidence seen that this person who was confined bed, had been helped to sit in chair in line with instructions set out in the care plan. It was noted that one resident spent a few hours on the first day of the inspection sat strapped in a wheelchair with no footrests. This position had the potential to be very uncomfortable and did not allow the resident free movement around the lounge. This person’s care was discussed with the senior care worker who was keen to make improvements to this resident’s quality of life. Healthcare needs were considered during the assessment process and medical conditions were listed on the admissions forms. However, a similar statement was included in each person’s plan under healthcare and it was not always clear how staff should specifically monitor the residents’ medical conditions. The residents’ weight was recorded in the care plan to ensure any significant fluctuations were noted and acted upon. Care plan documentation demonstrated that the residents accessed NHS services and received specialist support as necessary. The residents spoken to felt the staff respected their rights to privacy and dignity and all made complimentary remarks about the staff, for instance one person said, “The staff are very good, I get on with them all”. The residents, The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 13 who completed the questionnaires prior to the inspection, indicated that staff listened to them and acted upon what they said. The staff were observed to interact with the residents in a positive manner and they referred to the residents in their preferred term of address. Policies and procedures were in place to cover all aspects of the management of medication and the weekly audit of medication had continued as a means of monitoring the medicines. The home operated a monitored dosage system for the administration of medication, which was dispensed into blister packs by a local pharmacist. Appropriate records were maintained in respect to the receipt, administration and disposal of medication and all staff designated to administer medication had received accredited training. However, it was noted that not all medication had been entered on the medication administration records and some medication to be returned to the Pharmacist had been stored in a plastic bag with current medication stocks. Systems were in place for the management and administration of controlled drugs and a check of stocks corresponded accurately with the controlled drugs register. However, it was noted the controlled drugs were stored in a locked metal tin and not within a cupboard, which is compliant with the relevant Regulations. The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefited from flexible routines and were supported to maintain good contact with their friends and families. However, there were insufficient meaningful activities on the Dementia Care Unit. EVIDENCE: The residents on the ground floor residential unit said the daily routines were flexible and they were able to get up and go to bed at a time of their choosing. One person said, “I like to go to bed at 7 o’clock and get up at 7 o’clock and I really like a cup of tea in bed”. The care plan provided information on the residents’ preferred routine. The residents’ preferences in respect of social activities were recorded as part of the assessment process and included in the care plan documentation. Activities arranged on the ground floor had been recorded and included music and movement, dominoes, bingo, nail painting and occasional professional entertainment. The residents had discussed their choice of recreational activities at the Residents’ meetings, which were held approximately once a The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 15 month. A list of forthcoming activities was displayed around the home. The list indicated that at least two main activities were arranged each month, some of which included trips out of the home to places of local interest. In addition, the registered manager had purchased various resources, which could be used on a daily basis for individual or group activities. The residents’ interests on the Dementia Care Unit were recorded in the care plan. However, the activities record had not been fully completed and the type and frequency of activities arranged for the residents was unclear. Relatives spoken to during the inspection said there were few activities to provide the residents stimulation and interest. This view was reflected in the questionnaires received from relatives, one person wrote, “I think it could improve by having more entertainment for the residents” and another person commented, “The home could improve on stimulation for dementia residents”. Since the last inspection, information had been made available for staff about appropriate activities for people with dementia, but there was little evidence to demonstrate regular activities had been arranged. A member of staff spoken to confirmed this was an area for future development. During the inspection the residents enjoyed a visit from a professional entertainer, which had been planned in advance. The routines on the Dementia Care Unit were flexible, the daily care notes made references to residents having a lie in, going to have a lie down during the day and going to bed at different times. There were no restrictions placed on visiting times and residents were able to receive their guests in the privacy of their own rooms, should they wish to do so. A relative spoken to on the day of inspection said he was satisfied with the care and support provided. The relatives who completed the questionnaires indicated they were satisfied with the overall quality of care provided, one person wrote, “I am happy with the care they give my mother” and another person commented, “My father is well fed and always clean and tidy with lots of encouragement from the staff”. The residents on the ground floor said the food was “very good” and “lovely”. A choice was provided at all mealtimes and the cook regularly discussed food with the residents. The record of meals served was complete and up to date for both Units. The meals served during the inspection looked plentiful and appetising. Residents were given appropriate support and assistance to eat their meals, however, not all residents on the Dementia Care Unit were given assistance in a timely manner. Drinks and snacks were served at specific times throughout the day and at other times on request. Menu sheets were available, however there was nothing on display designed to inform the residents of the forthcoming meal. The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were able to express their views and had access to a clear complaints procedure. Policies and procedures were in place to respond effectively to any allegations or suspicions of abuse. EVIDENCE: The complaints procedure was included in the statement of purpose and service users guide. In addition, the residents were provided with a copy of the procedure, which was readily available in each bedroom. The procedure contained the necessary information should a resident wish to raise a concern. The residents spoken to said they could speak to the manager or staff if they had a problem. All the residents who completed a questionnaire indicated that they were aware of how to make a complaint. The relatives who completed the questionnaires were also aware of the complaints procedure. The registered manager had not received any complaints since the last inspection. General concerns raised by residents and relatives had been recorded appropriately. The policies and procedures for safeguarding vulnerable adults were available and provided guidance to staff should they suspect or witness any harmful practice. These issues were incorporated into the induction training and staff The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 17 received specific tuition as part of their NVQ training. Staff spoken to were aware of whom to refer any incident to and the various agencies involved. The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents were provided with comfortable bedrooms. The arrangements to manage laundry on the Dementia Care Unit were unsatisfactory. EVIDENCE: The Victoria Residential Home is a converted hospital with a spacious layout. Accommodation is provided on three floors in 30 single bedrooms and 5 double rooms. Seventeen of the single rooms and one double room have ensuite facilities comprising of a toilet and hand washbasin. A large passenger lift provides access to all floors. Communal space is provided in lounges and dining rooms on each floor. All rooms provided sufficient space for the pursuit of recreational activities and the entertainment of visitors. The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 19 It was evident from a tour of premises that residents had personalised their rooms with their own belongings, which included photographs, ornaments, furniture and televisions. The residents spoken to said they liked their bedrooms, which they described as comfortable and warm. One person said she enjoyed keeping her room clean and tidy. Since the last inspection floor coverings in the main corridors had been replaced with non-slip floorings. Part of the walls and handrails had also been painted in the corridors. Such improvements had significantly enhanced the appearance of these areas. In addition the kitchen, hairdressers room and dining room on the ground floor had been decorated and new carpet had been fitted in one of the bedrooms. However, it was noted that there was no privacy lock on one of the toilet doors on the Dementia Care Unit and the shower room was out of use on this floor. The latter meant that some of the residents on the Dementia Care Unit had to go downstairs to use the shower on the ground floor. This was arrangement inconvenient and had the potential to compromise their dignity. The overall level of cleanliness was satisfactory throughout the home. However, soiled laundry was piled into a trolley on the Dementia Care Unit and left in the bathroom corridor before it was taken to the laundry area to wash in the afternoon. This caused an unpleasant odour and had implications for infection control. This situation was mentioned by a resident and relative during the inspection and was referred to by the relatives who completed a questionnaire. One person wrote, “Dirty washing is left on the toilet floor and in the corridor for too long which causes bad smells on the corridor”. Further to this it was noted that a member of care staff had to carry out the laundry duties, which took time away from caring for the residents. One person commented in the questionnaire, “They need someone to do the laundry, it’s not right as it’s taking a member of staff away from the unit. A dementia unit needs staff as the residents need a lot of watching”. The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this 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 recruitment policy and practices. EVIDENCE: A staff rota was maintained, which indicated which staff were on duty at any time on a particular day. The registered manager confirmed all staff providing personal care were aged over 18 and all staff left in charge were aged over 21. The number of care staff on duty was sufficient for the number of residents living in the home. A recruitment and selection procedure was available and a checklist was used to track documentation required for the recruitment of new staff. The files of two new members of staff were inspected. It was evident both people had completed an application form and had attended the home for an interview. Two written references and a CRB (Criminal Records Bureau) check had been received prior to the staff commencing work in the home. Whilst the applicants had not recorded a full working history at the time of recruitment, the manager obtained a detailed list of past employment details from both people for file purposes. The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 21 Arrangements were in place for all new employees to undertake an in house induction programme and complete a “Skills for Care” induction. The latter provided underpinning knowledge for NVQ level 2. According to information supplied by the registered manager, 16 out 19 members of staff had achieved NVQ level 2, this equated to 84 of the overall staff team. In addition, four members of staff were working towards this qualification. All members of staff who completed a questionnaire confirmed they had received training relevant to their role and all staff interviewed during the inspection said they had access to good training opportunities. One member of staff wrote on a questionnaire, “Training is always ongoing and extremely helpful. The manager always acts on requests for training the best she can”. Staff attended both internal and external training courses and had at least three paid days training a year. All members of staff had a training and development profile, which was incorporated into the supervision records and the staff training plan had been updated. This meant the manager was able to plan future training effectively in line with the needs of the residents and the staff team. The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management approach promoted positive relationships between the staff and the residents. Effective systems were in place to monitor the quality of service provided. EVIDENCE: The registered manager had overall responsibility for the management of the home and had a job description, which reflected the aims and objectives set out in the statement of purpose. Since the last inspection the manager had completed the Registered Manager’s Award. The manager has many years of experience caring for older people in a management capacity. The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 23 The management approach was consultative and there were established ways of working to consult the staff and residents on an ongoing basis. Relationships within the home were positive and staff spoke to and about the residents with respect. The registered manager had established a programme of staff supervision to ensure each member of staff received supervision six times a year. This gave staff the opportunity to discuss the work within the home and identify any future training needs. Senior staff also met with the manager on a regular basis, to discuss the needs of the residents. The service was awarded an Investor’s in People Award in 2001 and had achieved a post recognition award in October 2007. Further to this, the registered manager had developed the internal quality assurance systems by using systematic planning techniques. All systems in the home had been audited and evaluated and detailed annual development plan had been produced. The plan was based on the outcomes of the monitoring processes and identified the planned developments for the service. This document linked to the annual quality assurance questionnaire (AQAA) submitted to the Commission. The AQAA contained detailed information about the service and the plans for improvement over the next twelve months. Satisfaction questionnaires had been distributed to the residents, their relatives and the staff and the results had been collated and published to provide people with feedback from the survey. Residents were consulted on a daily basis as part of daily care practice and more formally at Residents’ meetings. 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. There was a set of health and safety policies and procedures available, which included the safe storage of hazardous substances. Staff had received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. Documentation seen during the inspection demonstrated that the fire and electrical safety systems were serviced at regular intervals. The fire log demonstrated that staff had received instructions about the fire system and fire alarms were tested weekly. Systems were in place to carry out regular health and safety checks around the building and risk assessments had been undertaken on safe working practice topics. The registered manager ensured that accidents were recorded and the Commission was notified of incidents in the home in accordance with the relevant legislation. The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 2 X 3 X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 X 3 3 X 3 The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 25 No 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. Standard OP8 Regulation 15 (1) Requirement The care plans must contain clear and specific information about the residents’ healthcare needs. This is to ensure the staff are aware of how to monitor and respond to the residents’ medical conditions. All current medication must be entered onto the medication administration records, to ensure the residents receive their medication as prescribed. Controlled drugs must be stored in a controlled drugs cupboard, which is fully compliant with the Misuse of Drugs (Safe Custody) Regulations 1973 as amended in 2007. This is to ensure such drugs are stored safely and separately from other medication. The programme of activities for people living on the Dementia Care Unit must be further developed to ensure the residents have good access to a choice of meaningful leisure pursuits. The management of laundry on DS0000046704.V359063.R01.S.doc Timescale for action 01/06/08 2. OP9 13 (2) 23/04/08 3. OP9 13 (2) 23/07/08 4. OP12 16 (2) (n) 01/06/08 5. OP26 16 (2) (k) 23/04/08 Page 26 The Victoria Residential Home Version 5.2 the Dementia Care Unit must be reviewed, to ensure soiled laundry is managed in a way to prevent unpleasant smells and in a manner which respects the dignity of the residents. 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 OP7 Good Practice Recommendations The personal hygiene charts should be completed on a regular basis, to ensure residents receive the level of personal care set out in the care plan. A moving and handling risk assessment should be completed for all residents to ensure they are moved safely in line with guidance set out in the care plans. The menu should be displayed in the dining rooms. All residents should receive assistance to eat their meals in a timely fashion. A privacy lock should be fitted to the toilet door on the Dementia Care Unit to protect the privacy of the residents. The shower facility on the Dementia Care Unit should be made fully operational to allow residents to have a shower within their own Unit. 2. OP8 3. 4. 5. OP15 OP21 OP22 The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Victoria Residential Home DS0000046704.V359063.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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