CARE HOMES FOR OLDER PEOPLE
Victoria Care Home Victoria Street Rainford St Helens Merseyside WA11 8DA Lead Inspector
Miss Diane Sharrock Debbie Corcoran Unannounced Inspection 10:00 10 & 11th May 2006
th 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 Victoria Care Home DS0000005474.V295188.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. Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Victoria Care Home Address Victoria Street Rainford St Helens Merseyside WA11 8DA 01744 88 6225 01744 886193 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) None Four Seasons Healthcare (England) Limited (Wholly owned subsidiary of Four Seasons Health Care Ltd) Care Home 53 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (30), Old age, not falling within any other of places category (23) Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include up to 23 OP and up to 30 DE(E) Service users to include up to 3 DE (out of 30 DE(E) category) Date of last inspection Brief Description of the Service: Victoria Care Home is owned and managed by Four Seasons Health Care and is a two storey detached premises set in a residential area close to the centre of Rainford Village. A bypass is near by with links to motorways and the east Lancashire road. The home is registered to accommodate older people with nursing needs (Alexandra Unit) and Older people who experience mental health problems and also require nursing care (Emily Unit). Theses two categories of care are provided on separate floors. The Responsible Person for the Company is Diana Rigg. The home’s Manager is currently Mrs Carol Ann Baker who commenced employment at the home approximately 8 weeks ago. Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over 2 days and was unannounced. A detailed tour of the premises took place and Resident care plans and various other records were inspected. A selection of comment cards were left for 9 named Residents and further comment cards have been sent to local bodies currently visiting the home. Interviews took place with both Staff and Service Users. All areas of the inspection and findings were discussed with the Manager at the end of this inspection. Currently the home are not permitted by the Local Authority to accept any admissions which has been the situation for the past 7 months aproximately and they have not been permitted to admit anyone with insulin diabetes over the past 12 months. Further information should be given by Company Representatives or sought from St Helens Social Services for any persons requiring further information regarding this situation. The Manager confirmed they are still not able to admit residents due to the embargo and did not know when this would be lifted. The district nurses are still visiting the home and providing support and review of Residents needs. The Manager confirms that all requests for the GP visits are still reviewed by the on call Rota to screen for the appropriateness of the requests. What the service does well: What has improved since the last inspection?
The home now has a Manager in place who has been at the home for the last 8 weeks. The previous manager had resigned. The Activities organiser is also now working at the home and organising activities on both floors. During day 2 of the inspection the organiser was organising gardening sessions for some residents with the use of raised flower beds.
Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 6 Menus appeared to have improved and Residents are now offered cooked breakfasts every day. The home was generally much cleaner and had 2 domestics on duty. Most Residents seen were noted to have been supported with their personal needs and looked well dressed. The company had arranged internal audits for some areas covering medications, care plans and falls. A company care audit had taken place 18/4/06. Staff moral seemed much improved with general compliments made about the current manager who was thought of as being very approachable. What they could do better:
Full feedback was given to the Manager during and on conclusion of this inspection. Some areas of improvement were noted in the environment and in the moral of staff. Staff stated that “moral had much improved” and they also reported that they were really positive about the new manager. They stated that they like her approach. Areas of concern were noted to need action taken and further evidence to be in place to meet most standards. Some concerns noted were repeated from previous inspections. 1) The home need an accurate and updated statement of purpose accessible to everyone. The home also need a Service User Guide to be accessible to all Residents at the home. 2) The management of the health and safety of the home needs urgent review. The home must have an up to date maintenance certificates including ie an electrical installation and portable appliance test. It was of great concern that the local fire brigade had visited the home twice in the past month due to risks noted that needed attention and a lack of action taken by the company. The fire brigade have confirmed the work has been carried out by the company. However as already acknowledged the company had submitted an action plan in December 05 to CSCI stating the fire system was to be repaired yet 4 months later due to the fire brigade spot check, their safety arrangements still needed further work to ensure the safety of all present in the building. Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 7 3) The kitchen area needed cleaning and regular review and management of this area is needed to ensure adequate standards are maintained at all times. 4) An Urgent review of the management of staff recruitment and selection must take place and personnel files must be up to date and have necessary legal checks before staff are employed at the home. 5) A review and management of the training needs of all staff must be carried out to ensure all staff at the home will be suitably qualified, competent and experienced to meet the needs of the Service Users. 6) Staff must have necessary supervisions and appraisals. 7) Care plans must be specific to Resident’s needs and kept updated using the necessary records. Continued review and auditing of care plans must be carried out. Internal care plan audits were seen but none seen for the last 2 months but staff stated they have been carried out.. 8) Complaints records must be reviewed and updated to ensure the company policies are in practice. Everyone must have access to the homes complaints policy. 9) There was no type of Provider audit or any other type of evidence in place to demonstrate the company has measured themselves against the NMS and regulations. This should be considered to assist the manager and staff in achieving compliance of eventually meeting all parts of the national minimum standards. 10) Regulation 37 reports must be submitted to CSCI as detailed in the care home regulations 2001. 11) An action plan should be in place to address what actions the company are taken regarding care issues already noted by the company at previous staff meetings ie regarding supervision of the lounges, toileting regimes being too long,4hourly. 12) A maintenance decorating and refurbishment programme should be developed to show a planned approach in maintaining the home and could be used to involve Residents in the development of their home. Replacement of bedding and linen should be carried out to improve on present standard used. 13) The gardens needed attention, the grass needed cutting and weeding was needed over all areas in the grounds. 14) A Pharmacist for CSCI has carried out 2 recent unannounced inspections. Both visits identified breaches in the regulations, separate report have been completed for these visits, and an enforcement notice has now been served on the company for these breaches. It was acknowledged that individually the company had specific audits for various processes such as medicines and care plans. However the manager had not been given any type of action plan to address overall issues at the home or to demonstrate how the staff have been supported to evidence they are competent in their practice. The main focus from the company seemed to be on responding to the Local Authority’s action plan to improve care plans for individual residents. There was no evidence of any type of overall strategy of what the company were doing in terms of measurement and specific outcomes.
Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 8 This inspection identified various breaches in the regulations and enforcement notices are being served following this visit. The above issues in some ways indicate that the overall management and lack of continuity over the past few months have put many people at risk. This has not been helpful for the new Manager to assist with continuity and to demonstrate suitable management of the home. There are noted improvements and evidence of good practice in some areas but clear breaches of regulations in other areas. 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. Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1/3/4 The required documents- Statement of Purpose and Service User Guide still needing to be updated and supplied to all Parties. The present embargo on the home not being permitted to admit prospective Residents continues. The home need to demonstrate they have competently trained staff to administer the care assessed as needed for Residents. Quality in this outcome area is poor. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: The Statement of Purpose, has a number of topics that are not included in the file and it also needs updating regarding details of the manager/ Responsible Person and the training qualifications of staff. This document was located in the office and not really on show for access to all parties as the Manager explained that she intended to update this document. Staff could not find a Service User guide. This would mean that all parties do not have easy access regarding information needed about the home. The Manager has had recent meeting with both Staff and Residents and Relatives.
Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 11 The Manager confirmed they are still not able to admit residents due to the Local Authority embargo and did not know when this would be lifted. She confirmed they are still unable to accept anyone with insulin dependent diabetes. The District Nurses are still visiting the home and providing support and review of residents needs, including the review of wounds, fluid balance charts and diabetes. The Manager confirmed that all requests for GP visits are still reviewed by the on call rota to screen for the appropriateness of the requests, this was organised by the Primary Care Trust. In reviewing staff training records and training matrix some staff had still not received certain training but quite alot of other staff had. Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10 Although progress has been made with careplans it has still been identified through continued Local authorities, district nurse input, csci pharmacy inspection that the Health and Personal care needs are not always being met according to individuals Resident’s needs. Quality in this outcome area is poor. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: The care plans case tracked were detailed and have records in place to eventually meet the standards, the main issues are regarding the nurses records and use of them. One care plan for one Resident has a company wound chart in use then staff seem to suddenly stop using it 24/4/06 regardless of the care plan indicating the wound still there. A referral was seen by a nurse requesting the Doctor to review a Resident’s skin condition, the nurse queried if it was due to medication? However there was no record or reference to this in the Resident’s care plan or evidence in the care plan of monitoring the skin condition.
Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 13 Another care plan identifies a Resident’s challenging behaviour. The staff confirmed that they had identified a need for a Resident to require 1 to 1 support from staff. They confirmed they tried to give the support but they were not given any additional staff from the Company to do this, regardless of Staff identifying specific risks and needs. The Resident only received 1 to 1 support when the Local authorities agreed to fund the additional support. One Resident recently suffered a fracture. Staff confirmed they did not submit a regulation 37 report to CSCI, however this has now been submitted following this inspection and request to do so. The Staff member acknowledged they had not realised they would need to submit a regulation 37 report. This is a requirement of the care home regulations 2001. District Nurses are still visiting the home and providing support and review of Residents needs. The daily care records were actually stating when the District Nurses visits and advice given eg regarding wound care and diabetes. The Manager confirms that all requests for the GP visits are still reviewed by the on call rota to screen for the appropriateness of the requests from the homes Nurses. Staff minutes of meetings state clearly the care issues noted by the company that still need improvement on by staff, eg regarding supervision of the lounges, toileting regimes being too long 4hourly. No overall action plan was seen regarding what actions were to be taken by the Company to demonstrate any measured improvements to care practices. Especially since November 05 when initial concerns were identified by St Helens Social Services. A Company care audit was seen dated the 18th April 06 which read as an overall favourable report about the home, no action plans were seen following this review. The Local Authority and Primary care Trust still have ongoing reviews identifying actions specifically needing attention by the company. The Companies action plan was seen up to April 06. Internal care plan audits were also produced but none were seen for the last 2 months, however staff state they have been carried out. CSCI Pharmacy Inspector has carried out 2 recent inspections one dated 3/4/06 and recently 2/5/06 and found further repeated breaches of the previous requirements served and various residents still not getting medications as prescribed sometimes due to being out of stock and poor practice. A separate report has been produced for this inspection with a list of requirements and concerns around the competencies of Trained Staff. An enforcement notice has also been served to the company regarding these breaches of the regulations. Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 14 The above incidents highlight ongoing concerns from various bodies. A Company response must be developed to describe what overall strategies / resources will be put in place to address such serious ongoing concerns. Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12.13.14.15 Improvements have been made towards Resident’s choices for meals and activities, further actions should be developed to enable the home to fully meet the standards. Quality in this outcome area is good. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: There has been improvement in the menu since the last inspection when a menu wasn’t being followed. The new menu looks interesting and varied. The cook reported that there is normally an alternative lunch option but this was not available on the day. However, when served the residents did get a choice of two main meals. The desert was also different to that stated on the menu. Food storage was checked and there was a vast improvement in this area. All food (with the exception of frozen meat) is now being dated and labelled appropriately. There was a good amount and variety of fresh ingredients for meals. The kitchen was not clean in all areas. The kitchen needs to be cleaned thoroughly with particular attention paid to the cooker, wall tiles and floor. It was reported that an Environmental Health Officer had visited the home and given a ‘list’ of things to do but this was not available for inspection. Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 16 Mealtimes were noted to be unrushed and residents said that they enjoyed their food and appeared to enjoy it. One comment card stated there was still problems with the food. The Cook acknowledged that although they have menus in place she has not actually met with Residents to include them in the development and ongoing review of the menus. All residents now have the option of a cooked breakfast 7 days per week. A records of activities is kept for each of the residents. A sample of these were checked and indicated activities such as manicure, crafts, bingo, exercise and sing- a-long are taking place. The activities co-ordinator tries to provide as much support to the residents as possible and appreciates the importance of some one to one support to residents. However, this obviously takes her limited time away from other residents. A number of the residents commented favourably on the activities co-ordinator and this is clearly a resource which they value. One of the residents reported that they were out in the garden yesterday. Another resident reported the activities co-ordinator to be “very nice” and “takes us to the shops when it’s our turn.” Old music was noted to be playing around the home. The activities co-ordinator doesn’t have any information as to the budget for activities and therefore she is keeping costs to a minimum. This person may be able to make more of their work if given some indication of how much she can spend. There is no money allocated for day trips. The provider should identify what budget is available for social / leisure activities. Care staff are busy providing for the daily care needs of the residents and the fact that there is one activities co-ordinator and at present 35 residents means that some of the residents receive little support with activities. Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16/18 The home have not always managed complaints and the protection of Residents, thus putting Residents at risk with poorly applied policies. Quality in this outcome area is poor. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: The Manager confirmed that she had tried to trace records regarding complaints but couldn’t find any records of recent ones, there was a handwritten complaint in the file for Jan 06 but no one knows who the complainant was. CSCI advised the Manager to talk to all Staff to try and identify which Relative had made the complaint to ensure they have an acceptable outcome to their concerns. As mentioned previously the Statement of Purpose needs updating and several topics need to be included as listed in the standards and regulations. Staff could not locate a Service User Guide either which should provide an easily accessible complaints procedure and necessary information about the home. The Company must review all complaints procedures within the home to ensure everyone has the opportunity to openly express their views. Staff could not find records of previous Company investigations including one regarding the company investigation into care practices noted in the Nov /Dec 05 inspection with regards to beds being moved from nurse call systems and some rooms not having nurse cords. Recent Staff meeting minutes also describe concerns noted by management about care practices. The Company
Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 18 should produce evidence regarding what actions they took to these concerns and continued poor practices. There have been 2 long standing Adult Protection investigations from November 05 which are being dealt with currently by St Helens Social Services. Company Representaives have attended regular meetings with the Authorities and are aware of the failings of the home. During a meeting with representatives of the company on 16.3.06 the Local Authority identified a further 3 Residents for review under the Adult Protection referral policy regarding their care. An appropriate action plan that is effective and regularly measured would help to stop any further occurrences of poor practices. The current Manager and Residents at the home would benefit from a corporate plan of action that would assist continuity and ensure effective outcomes are achieved. Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19/26 There are improvements noted to the environment, and further actions should be developed to enable the home to fully meet the standards. Quality in this outcome area is adequate. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: The environment was much improved in that generally it had 2 domestics on duty on day one. General areas were clean and tidy; some areas of redecoration were noted to be needed. A couple of bedrooms were malodorous. There was no maintenance and decoration/ refurbishment plan for the home, to assist planning and continuity of upgrading the home. Environmental risk assessments were in place with some stating all radiators covered and wardrobes affixed to walls. The main lounge for residents on the ground floor is also a thoroughfare for visitors in to the home. This is compromising the privacy and dignity of the
Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 20 residents. One of the residents was in a night dress in this lounge and her privacy was being compromised. There were issues regarding the laundry arrangements at the previous inspection. These appear to have been resolved. There has also been some improvement in the amount and quality of linen at the home although there is still plenty of room for improvement particularly for new bedding for residents on the ground floor. Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27/18/29/30 The company have not evidenced that they are supplying suitably qualified and competently trained staff to meet the needs of the Residents. Poorly applied polices have potentially put Residents at risk. Quality in this outcome area is poor. This judgment has been made using available evidence including a site visit to the service. EVIDENCE: There is evidence of a varied amount of training provided to staff. Much of the training is provided through videos and workbooks. Currently moving and handling, fire training and abuse awareness are carried out by the use of videos and workbooks. The company should review the appropriateness of the current training to ensure that it meets the needs of the Staff and the Residents. The home currently employs a total of 23 care staff. Of these only 2 have attained an N.V.Q level 2 in care. The manager reported that 5 staff are undertaking this award. The home is clearly significantly below the target of 50 of care staff to be qualified to N.V.Q. There was no structured plan to evidence what actions the company was taking to ensure NVQ training would eventually meet the National minimum standards target. There was no training and development plan for the home. A staff training matrix has been produced, however the information in this did not coincide with information on staff training in the staff files. Training records were not up to date and there was no evidence of 3 days paid training for staff.
Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 22 A company training matrix for the home dated 25/4/06 gave numbers of staff who had attended training and numbers of staff still needing to attend training. For moving and handling 8 staff were outstanding or needing updating. For health and safety 39 staff were outstanding or in need of updating. For POVA 14 staff were outstanding or in need of updating. For fire awareness 10 staff were outstanding or in need of updating. For care planning and recordkeeping 1 nursing staff member were outstanding or in need of updating. For introduction to dementia 4 staff were outstanding or in need of updating. For Coshh 12 staff were outstanding or in need of updating. For diabetes 27 staff were outstanding or in need of updating. For medication 4 staff were outstanding or in need of updating. For continence 2 staff were outstanding or in need of updating. For falls 5 staff were outstanding or in need of updating. No Staff were recorded as attended training in the section for death and dying. One of the trained nurses only recently in post was noted to have no training file in place. Some staff, in reviewing the matrix produced, had still not received certain mandatory training but quite a lot of other staff had. There have been ongoing concerns around the competencies of staff following 2 adult protection investigations from November 05. Following this, St Helens PCT have supplied district nurses to the home to offer clinical support. Ongoing Care Manager reviews have taken place with all residents,some reviews had identified shortfalls in their care and care plan records. There didn’t seem to be any type of strategy from the company to demonstrate what actions were taken to evidence that Staff were competent and able to practice without the current resources and support of clinicians from outside bodies. Staffing Numbers seen and on duty rotas produced, were noted to be as follows, 1st floor (21 residents) - 4 carers, 1 nurse, Staff on the first floor reported that they now have time to support the residents appropriately due to the reduction in the number of residents and staffing ratio. Ground floor (14 residents) – 2 care staff and 1 nurse. Staff reported that they don’t feel that they can meet the needs of the residents due to staffing levels A copy of the staff rota was taken for the preceding 4 weeks. The Rota’s should clearly indicate which unit they are for. Two different rotas were provided stating Alexandra for day shifts and night shifts when one of these must have been for the Edward unit. Rotas must be clearly recorded with the correct name of the unit and correct date. Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 23 Staff commented that in their opinion of the care offered – they felt it was ‘basic’ due to time restraints. They stated they would like to see more staff and more activities. One resident said that they were waiting for the toilet but that “staff were busy seeing to other residents” and “there are others waiting before me.” In response to ongoing requirements in Dec 05 and January 06 the company stated in their responding action plan that they apply a staffing ratio of 1 to 5 in the day, there was no evidence to link this to the ongoing dependancies of Residents. Staff are not being provided with one to one supervision. This is evident in records and through discussions with staff. Staff described moral as good. They felt positive that there have been some improvements at the home and were positive about the new manager. In assessing the procedures for the recruitment and selection of staff 4 staff files were reviewed. The files reviewd included no evidence of (crb) police checks. One new Staff member had just 1 verbal reference,yet had commenced employment at the home. 7 police checks (crb) were found in the company safe for other staff, but Staff were unsure if this was for everyone and the sum total in place. This must be reviewed by the Company and action taken to ensure the recruitment and selection of all staff are in line with the care home regulations and are appropriately carried out to ensure the safety of Residents at the home. Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 24 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31/33/35/38 The Company must provide appropriate resources and expertise to evidence what actions they will take to demonstrate improvements needed to the ongoing management, health, safety and welfare arrangements within the home. Quality in this outcome area is poor. This judgment has been made using available evidence including a site visit to the service EVIDENCE: Currently the new manager has been in place 7 weeks and has not worked as a manager in a care home before. The Manager was very helpful and eager to assist and learn during this inspection. Currently a manager from a sister home gives support to the new manager 1 day per week. The regional manager visits one day a week to carry out work to be done and regulation 26 reports.
Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 25 The manager had not been given any type of overall action plan to address issues at the home or to demonstrate how the staff have been supported to evidence they are competent. The main focus from the company seemed to be on responding to the Local Authority’s action plan to improve care plans for individual residents. A Company care audit was seen dated the 18th April 06 no action plans were seen following this review. The Local Authority and Primary care Trust still have ongoing reviews identifying actions specifically needing attention by the company. The Company’s responding action plan was seen up to April 06. There was no provider self audit or any other type of evidence in place to demonstrate the company have measured themselves against the National minimum standards. There was some confusion as to where maintenance certificates were kept and staff were unable to find an up to date Electrical installation certificate, the one shown was dated 1996 and was for 5 years so currently the home may not have an up to date electrical installation certificate. Evidence of an up to date portable appliance check could not be found by staff. Other certificates were found and in date. The Manager acknowledged the organisation and management of maintenance certificates needed to be reviewed and improved upon. The local fire brigade have visited the home on the 21st April 2006 and the 5th may 2006. During the visit on the 21st April they identified a number of concerns about the fire safety arrangements in the home in particular that fire doors did not automatically close when the fire alarms went off during their inspection. The report for the visit 21/4/06 goes onto to list the fire brigades concerns with a list of advice for the home to implement to ensure the matter is corrected urgently to ensure a means of escape to the premises. The fire officer did not have access to the homes fire recording log book similar to the CSCI inspection in Dec 06. The fire brigade have confirmed that the company have subsequently carried out various work to improve the fire safety arrangements at the home. Resident’s finances were case tracked and found to be detailed and all computerized. The administrator confirmed that they do not act as appointee for any Resident. Currently most relatives pay monies to the home to pay for additional costs such as hairdressing. The money is then logged into a company residents personal allowance account. The administrator agreed to check some issues following this inspection regarding whether the account was, 1) interest generating? 2) were the most updated bank statement was, and did it have an accurate balance evidencing just residents personal allowances being managed in that account. The statement seen was not reflective of all the balances for every Resident at the home. Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 26 3) The administrator was to check the procedures for Residents wanting large amounts of money from their account at any time, they were unsure of the procedure as currently they access a petty cash amount, which can then be invoiced against the Residents account details. Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 27 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 1 X 1 1 X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X X X X X X 2 STAFFING Standard No Score 27 1 28 1 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 2 X x 1 Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 28 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. OP1 Standard Regulation 45 6 Requirement The Responsible Person must provide an accurate and accessible Service User guide and Statement of Purpose to Residents and all other parties so that it is openly accessible. Timescale for action 14/07/06 2 OP35 20 1) 14/07/06 The Responsible Person is required to provide evidence that all Service Users finances managed by the company will be reviewed and that their bank account offers an accurate an updated record to reflect Residents current financial balances and demonstrates that the account is solely used for Residents finances. 14/07/06 The Responsible Person is required to provide evidence that all Service Users will be provided with a detailed, accurate and appropriate care plan according to their needs. Please submit an action plan to the Commission detailing what actions will be taken to meet this regulation 3 OP7 15 1)2)b Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 29 4 OP16 22 The Responsible Person must provide an appropriate complaints procedure openly accessible to everyone at the home. The Responsible person must provide a statement containing a summary of complaints made during the past 12 months and the actions that were taken in response. 14/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP26 OP19 Good Practice Recommendations To replace worn bedding/linen throughout the home.( a repeated recommendation) Maintenance and decorating programme should be developed; this will enable all parties to be involved with plans for their home the garden areas should be maintained. Review of the current main lounge on the ground floor. The Company should look at ways of protecting Residents privacy as currently the main entrance leads straight through this area. The administrator should check the procedures for Residents wanting large amounts of money from their account at any time and ensure Residents are aware of the company procedure. then be invoiced against the Residents account details. 3 OP10 4 OP35 Victoria Care Home DS0000005474.V295188.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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