Inspection on 06/06/07 for The Victoria Residential Home

This inspection was carried out on 6th June 2007.

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 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 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 09:30 6th June 2007 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.V336429.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.V336429.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.V336429.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. 17th May 2006 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 £332 to £374. 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.V336429.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at The Victoria Residential Home on 6th June 2007. The inspection was carried out by two inspectors. At the time of the inspection there were 30 people accommodated in the home. The inspection comprised of spending time with the residents, looking round the home, looking at the residents’ care records and other documents and discussion with the staff and the registered manager. As part of the inspection process the inspectors used “case tracking” as a means of gathering information. This process allows to the inspectors to focus on a small group of people living at the home. An in depth observation exercise was also undertaken on the Dementia Care Unit, to gain an insight into the life and experiences of people living on this unit. Prior to the inspection the registered manager completed a questionnaire, which provided useful information and evidence for the inspection. Satisfaction questionnaires were sent to the home for the residents and their relatives. None of the questionnaires were returned to the Commission. A random unannounced inspection of the home was carried out on 7th December 2006. A report of this inspection can be obtained on request. What the service does well: The admission procedures involved an assessment of peoples’ needs. This enabled the registered manager and prospective residents to determine whether or not the home could meet their needs. Prospective residents were also encouraged to visit the home prior to admission, so they could meet the other people living in the home and staff. Each resident had a plan of care, which was easy to understand and follow. This document provided details about the residents’ needs, which meant the staff had guidance on how best to meet the residents’ needs. Residents spoken to felt they received a good standard of care and the staff respected their rights to privacy and dignity. The residents described the staff as “nice” and one person said, “they’re really good – I’m happy with everything”. Varied meals were served and choice was offered at all meal times. All the residents spoken to said they liked the meals and confirmed there was always plenty to eat. Visitors were welcome in the home at any time and residents were supported to maintain good contact with their family and friends. The Victoria Residential Home DS0000046704.V336429.R01.S.doc Version 5.2 Page 6 The residents felt they were listened to and were confident by the manager and staff would respond wherever possible to their ideas and views. A high percentage of staff had achieved NVQ level 2 or above, this meant the staff had received the necessary training to enable them to carry out their caring role effectively. What has improved since the last inspection? What they could do better: The registered manager must ensure a thorough risk assessment is undertaken, in circumstances where a resident requires the use of bed rails, in order to recognise and reduce any risks to the resident. Staff must also receive specific training to enable them to safely assist/supervise residents carrying out any specialist healthcare tasks. Medication must be administered in line with the prescribers’ instructions to ensure residents receive the correct dose of medication to treat their medical condition. The residents living on the Dementia Care Unit must be consulted and provided with meaningful recreational activities to ensure they have a good quality of life. The records of meals provided on the Dementia Care Unit must be kept complete and up to date at all times, so it is clear what residents have eaten and any problems can easily be identified. The carpets in the corridors must be thoroughly cleaned to remove all staining or replaced to ensure the comfort and dignity of the residents. The level of cleanliness throughout the building must be improved to safeguard the health and safety of the residents. The Victoria Residential Home DS0000046704.V336429.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Victoria Residential Home DS0000046704.V336429.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.V336429.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, 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. The residents’ needs were properly assessed prior to admission and they were assured their needs could be met. EVIDENCE: Since the last inspection the service user’s guide had been updated to reflect an increase in the number of people accommodated in the home, following the refurbishment of the second floor. The guide was available in resident’s bedrooms, so that residents and their visitors could look at the document at any time. However, it was noted the guide contained extracts from the summary of the latest inspection report rather than the actual summary itself. The guide provided an overview of the services and facilities available in the home. 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 The Victoria Residential Home DS0000046704.V336429.R01.S.doc Version 5.2 Page 10 registered manager. Copies of the preadmission assessments were seen on the residents’ files and it was noted that the format covered all aspects of need, as listed in the National Minimum Standards. The registered manager had also informed the residents in writing that, having regard to the assessment, their needs could be met within the home. Prospective residents were encouraged to spend some time in the home prior to making the decision to move in. One person spoken to on the ground floor residential unit recalled her first visit to the home with her family. She said that everyone was very “friendly” and she liked the other residents. The Victoria Residential Home DS0000046704.V336429.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. Information on care plans was not always in sufficient detail to ensure all health and personal care needs could be fully met. EVIDENCE: From the case files seen on the ground floor residential unit, it was evident each resident had a plan of care, based on an assessment of needs. Personal profiles had been incorporated into the care plans and provided details about past life experience. The plans were easy to read and included general guidance for staff on how best to meet the residents’ needs. However, there was no specific guidance for staff on how to respond and manage one resident’s aggressive behaviour. The plans had been reviewed each month and had been updated in respect of changing needs. Charts had been maintained for personal care and hygiene; however, these had not been consistently completed and therefore gave the impression that some residents had not received regular baths or showers. The Victoria Residential Home DS0000046704.V336429.R01.S.doc Version 5.2 Page 12 The residents’ healthcare needs were detailed in the care plans, however, staff had not received training on how to assist/supervise one resident who carried out a specialist healthcare task and details of what was involved was not included in the plan. Risk assessments formed part of the care plan documentation, however, there was no clear evidence to indicate action had been taken in response to the management of some risks. The residents’ care plans on the Dementia Care Unit (DCU) on the first floor were based on a needs assessment. Relatives had signed a statement to indicate they had contributed and read the plan, but there was no evidence to indicate they were aware of current needs and the care to be given. The care plans provided general guidance for staff, however, there was limited information about how best to respond to some more complex areas of needs. For instance, there was little direction on how the residents’ dementia impacted on their lives or how the staff were to respond to the residents’ frustration and cognitive impairments. It was also noted there were no details for staff on how to observe and respond to signs and symptoms of one resident’s specific medical condition. The care plans made reference to the residents’ preferred religion, however, there was no indication of how the residents wished to practice their religion or what it meant to them in their daily lives. It was noted that one resident required the use of rails on her bed, however, there was no risk assessment in respect of the use of bed rails and a maintenance check had not been carried out on the rails. Residents spoken to on the ground floor unit, felt their right to privacy was respected by the staff and personal care was carried out with respect to their dignity. All residents were referred to by their preferred mode address, which was documented on the care plan. Observations made on the DCU also indicated that staff spoke to the residents in respectful terms and listened to their comments with interest. Since the last inspection a weekly audit of the medication had been introduced as a means of monitoring the management of medication. There was a set of policies and procedures and a monitored dosage system was in operation for the administration of medicines. Appropriate records were in place to record the receipt; administration and disposal of medicines and suitable arrangements were in place for the storage and administration of controlled drugs. A pen picture and photograph was included with each resident’s medication records. There was evidence seen that handwritten entries were signed and witnessed by two staff and protocols had been established for the administration of medication prescribed “as necessary”. However, it was noted that prescribed creams for one resident had not been applied in line with the The Victoria Residential Home DS0000046704.V336429.R01.S.doc Version 5.2 Page 13 prescribers’ instructions and a prescribed food supplement had not been entered on one resident’s medication administration record. The Victoria Residential Home DS0000046704.V336429.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 relatives. However, there were insufficient meaningful activities on the Dementia Care Unit. EVIDENCE: The residents on the ground floor unit said the daily routine was flexible and they were able to get up and go to bed at time of their choosing. The care plan provided information on the residents’ preferred routine. The residents’ interests were discussed during the assessment process and were documented in the care plans. Activities arranged on the ground floor 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 the Residents’ meetings, which were held approximately once a month. The residents had recently participated in a Summer Fayre held at the home and there was a planned trip to Towneley Park. The Victoria Residential Home DS0000046704.V336429.R01.S.doc Version 5.2 Page 15 The residents were able to receive visitors at any time and several residents informed the inspector that their family visited on a regular basis. The residents’ interests living on the DCU were recorded within a personal profile. However, the care plans did not always reflect this information, for instance the personal profile of one resident indicated he enjoyed a particular type of music, but there was no mention in the care plan of how music could be used to enhance his quality of life. Whilst staff reported activities were instigated on a regular basis, there were few records to support this. There was no information seen about suitable activities for people with dementia and there were limited resources available to use for activities. For example, there were no reminiscence tools available. There were no activities observed during the inspection. Further to this, a relative spoken to on the day of the visit commented, “there are no activities going on – it’s very rare they do stuff on a daily basis”. The routines on the DCU were flexible, the daily notes made reference to residents having a lie-in, going to have a lie down in the afternoon and going to bed at different times. The residents on the ground floor unit said the food was “nice” and “not too bad overall”. A choice was provided at all meal times and the cook regularly discussed the food with the residents. The record of meals provided on the ground floor residential unit was complete and up to date and included variations to the main menu. However, the record of meals provided on the DCU had not been completed for three days. There were menu sheets in the office on the DCU, but nothing was on display for the residents to read. The meal served on the day of the visit looked well presented, plentiful and appetising. The Victoria Residential Home DS0000046704.V336429.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. Systems were in place to ensure any concerns of residents would be listened to and acted upon. Policies and procedures were in place to respond effectively to any allegations or suspicions of abuse. EVIDENCE: The residents were provided with a copy of the complaints procedure, which was readily accessible in each bedroom. The procedure had been updated since the last inspection, in line with the Commission’s change of address and included clear directions on who a resident should address a complaint and the time scales. Two complaints had been received during the last 12 months. Both complaints had been investigated by the registered manager, who had maintained detailed records of the investigations. One complaint was found to be substantiated and the second complaint was found to be partially substantiated. Reports were sent to the complainant detailing the outcome of the complaints. The residents spoken to on the residential unit were confident their views were listened to and taken into account. They said they would talk to a member of staff or the manager if they had a concern. 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 The Victoria Residential Home DS0000046704.V336429.R01.S.doc Version 5.2 Page 17 interviewed had an understanding of the procedure and as such were aware of the agencies, which must be informed in the event of ant allegations being made. The Victoria Residential Home DS0000046704.V336429.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, 23 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents were provided with comfortable bedrooms. Cleanliness throughout the building was not to a satisfactory standard. EVIDENCE: The Victoria Residential Home is a converted hospital with a spacious layout. Accommodation is provided on three floors in 30 single rooms and 5 double rooms. There is a passenger lift on linking the floors. It was evident from a tour of the premises that residents had personalised their rooms with their own belongings. The residents spoken to said they liked their bedrooms, which they described as “smashing” and “very nice”. A visitor spoken to on the DCU also said her relative had a “nice room”. The doors to residents’ bedrooms had been fitted with locks and keys had been distributed to residents, as appropriate. The Victoria Residential Home DS0000046704.V336429.R01.S.doc Version 5.2 Page 19 The carpets in the corridors on the ground floor and first floor were noticeably stained, unsightly and in some places sticky. However, it was noted that plans were in place to replace these floor coverings in the near future. A new plain carpet had been fitted in the lounge on the DCU. The plain colour helped the residents to negotiate the room as it provided a contrast to the patterned fabric on the chairs. There was no privacy lock on one of the toilets on the DCU and the pull cords to the staff call system were either been tied up or were not long enough to allow a resident to reach them should they fall onto the floor. Pads were stored in the bathrooms and toilets, which gave the impression these were used as a communal resource. The overall level of cleanliness on the DCU was unsatisfactory. The staff were carrying out the cleaning tasks on this unit in addition to caring for the residents. A relative spoken to on this unit said, “the cleanliness of the place could be improved”. There were mattresses stained with urine in two unoccupied rooms and several of the bedrooms had torn or scuffed wallpaper. Similarly, the level of cleanliness on the residential unit was not of a good standard. Most carpets required vacuuming and there was food on the carpet in the dining room. The Victoria Residential Home DS0000046704.V336429.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: The registered manager maintained a duty rota, which was completed in advance. From inspection of the rota, it was noted there were additional staff on duty at busy times. All staff providing personal care were aged over 18 and all staff left in charge of the building were aged over 21. The files of two members of staff, who had commenced work in the home since the previous key inspection, were examined. Both 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 new staff received appropriate induction training. Further to this, a member of staff spoken to said, she had found her induction training useful and informative. Staff received mandatory health and safety training such as moving and handling and first aid and other training in line with the needs of the residents, for example Dementia Awareness training. Information contained in the pre inspection questionnaire indicated that 15 The Victoria Residential Home DS0000046704.V336429.R01.S.doc Version 5.2 Page 21 members of staff had achieved NVQ 2 or above, this equated to 65 of the staff team. In addition, three members of staff were working towards an NVQ qualification. The Victoria Residential Home DS0000046704.V336429.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, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Effective systems had been established to consult both the residents and staff and monitor the quality of service in the home. Some aspects of record keeping and the arrangements for health and safety did not safeguard the residents’ best interests. EVIDENCE: The registered manager had overall responsibility for the management of the home and had commenced working towards the Registered Manager’s Award. The registered manager anticipated completing the Award by the end of 2007. Relationships within the home were good and the staff spoke about the residents with respect. All residents spoken to on the residential unit liked the staff, one person said, “I am looked after very well, I like all the staff”. The The Victoria Residential Home DS0000046704.V336429.R01.S.doc Version 5.2 Page 23 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. Senior 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. The registered manager had developed systems to monitor the quality of service and had produced an annual development plan. The plan was based on a systematic cycle of planning, action and review and reflected the aims and outcomes for the residents. A satisfaction survey had been carried out of the residents, their relatives and professional staff in January 2007. The results of the survey had been collated, published and fed back 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 the residents. A random check of monies was found to be correct. Records were also maintained in respect to the amount of fees charged and received. Records seen during the inspection were generally update to date, although some shortfalls were noted for instance the record of meals served. It was also noted that regular monthly reports of unannounced visits by the Responsible Individual or a representative were not seen. Staff received health and safety training, which included moving and handling, food hygiene, first aid, fire safety and infection control. There was a set of health and safety policies and procedures. Systems were in place to record accidents and the Commission had been notified of incidents in the home in accordance with the relevant legislation. Since the last key inspection, the bedroom doors had been upgraded to meet with Fire Regulations and door guards had been fitted linked to the main fire alarm system. The fire log indicated that fire drills were arranged at regular intervals and according to the log the last fire drill was 12th March 2007. All water outlets were fitted with preset valves to control the water temperature and maintenance checks and servicing had been carried out on the electrical and gas installations. Risk assessments had been carried out in relation to safe working practices; however, these had not been reviewed for sometime. It was also noted that the bath hoists had not been examined. The Victoria Residential Home DS0000046704.V336429.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 2 X 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 1 2 2 3 X X 1 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 2 3 3 X 3 3 2 2 The Victoria Residential Home DS0000046704.V336429.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP8 Regulation 13 (4) (c) Requirement Where a resident requires the use of bed rails a risk assessment must be undertaken to ensure the safety and well being of the residents. The staff must be provided with specific training to enable them to assist/supervise specialist healthcare tasks. All medication must be administered in line with the prescribers’ instructions, to ensure the residents receive the correct dose of medication. Residents living on the Dementia Care Unit must be consulted and provided with meaningful recreational activities to ensure a good quality of life. The record of meals provided on the Dementia Care Unit must be kept up to date at all times, so it is clear what the residents have eaten. The carpets in the corridors must be either thoroughly cleaned to remove all staining or replaced. (Previous timescale of 01/03/06 15/07/06 and 01/03 07 - not DS0000046704.V336429.R01.S.doc Timescale for action 01/07/07 2 OP8 18 (1) (c) (i) 13 (2) 15/07/07 3 OP9 06/06/07 4 OP12 16 (2) (n) 15/07/07 5 OP15 17 (2) Schedule 4 (13) 23 (2) (d 06/06/07 6 OP20 01/08/07 The Victoria Residential Home Version 5.2 Page 26 7 OP26 16 (2) (k) met). All areas of the home must be kept free of offensive odours at all times. (Previous timescale 07/12/06 – not met). 06/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The actual inspection report published by CSCI should be appended to the service user’s guide, to ensure the residents’ are provided with an accurate account of the inspection findings. The care plans should include clear guidance for staff on how to monitor and respond to the residents’ needs, particularly in respect to the management of behaviour, which challenges others. Specific information should also be provided about a person’s dementia, how this manifests itself and how it affects the person’s daily life. This is to ensure staff are aware of how best to meet the residents’ individual needs. The care plans should include specific directions for staff on how to monitor and respond to the residents’ medical conditions. Charts devised to monitor personal care should be maintained on a consistent basis, so the records accurately reflect the care provided to residents. Risk assessments should include risk management strategies to control the identified risks and regular maintenance checks should be carried out on all bed rails, to ensure the health and safety of residents. The menu should be displayed in the dining rooms. A privacy lock should be fitted to the toilet door on the Dementia Care Unit to protect the privacy of the residents. The pull cords used to activate the call system must be accessible to residents at all times. The registered manager should complete the NVQ level 4 in management/Registered Manager’s Award. The responsible individual or a representative should ensure an unannounced visit is made to the home on a monthly basis and a report of the findings of the visit is DS0000046704.V336429.R01.S.doc Version 5.2 Page 27 2 OP7 3 OP8 4 5 6 7 8 OP15 OP21 OP22 OP31 OP37 The Victoria Residential Home 9 OP38 available in the home. The health and safety risk assessments carried out in relation to safe working practice topics should be reviewed and updated where necessary. The Victoria Residential Home DS0000046704.V336429.R01.S.doc Version 5.2 Page 28 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.V336429.R01.S.doc Version 5.2 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. 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