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Inspection on 11/07/06 for Victoria Care Home

Also see our care home review for Victoria Care Home for more information

This inspection was carried out on 11th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

What the care home does well

New residents are assessed by a senior member of staff from the home to ensure their needs can be met. There are appropriate arrangements in place for meeting the healthcare needs of residents, which vary depending upon their age. This helps residents maintain good health. There are good practices employed to promote the privacy and dignity of residents. The home provides a full activities programme for the older persons and residents on Champion Crescent have individual programmes to follow, designed to support their rehabilitation into the community. Residents therefore have opportunities to participate in appropriate activities, which they enjoy. The home is well laid out and suitable for use as a residential home. The home was clean and well maintained making a pleasant environment. Residents on Champion Crescent are responsible for the cleaning of the unit, helping them re learn domestic skills. The home adjusts staffing levels to reflect occupancy. Staff are expected to take part in appropriate training so they are able to meet the needs of residents. The home is well managed with the manager continuing to undergo training for her own development so she can ensure best practices are followed in the home. The home is subject to an annual audit to identify the strengths and weaknesses of the service and an action plan is prepared to address weaknesses. Residents are asked to complete a questionnaire on the services provided so their views can be taken into accountAll required health and safety checks are undertaken at the correct timescale making the home a safe environment.

What has improved since the last inspection?

The home has tightened up on the drug administration procedures to ensure that residents are kept safe by the medication practices. The home`s complaints procedure has been developed so that there is a complaints book in each unit making it easier for residents and their relatives to use the procedure if they want to. Each member of staff has their own training records, which they are expected to complete after any training so that staff can be kept up to date with training so that residents are cared for by trained staff. All records are now kept in a locked room so that residents` privacy is maintained and they are not at risk from a breach of confidentiality.

What the care home could do better:

The newly introduced care plan system sets out residents needs but in some cases these did not have all the required information and were not signed. All care plans must have the required information and be signed so that staff are able to fully meet residents needs. Staff restrict residents access to cigarettes on Champion Crescent to help them make them last the week, but this is not recorded. Any restriction imposed on residents must be recorded to prevent them having their rights restricted inappropriately. All residents have the same menu, which is designed to meet the needs of the older people and does not take into account younger residents preferences of meals. All residents` dietary preferences should be accommodated so that everyone is able to have meals they prefer. Any incident which results in a resident receiving an injury must be reported through the Adult Protection Procedures to ensure that residents are protected from abuse.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Victoria Care Home Memorial Avenue Worksop Nottinghamshire S80 2BJ Lead Inspector Stephen Benson Key Unannounced Inspection 11th July 2006 09:30 X10029.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 DS0000024666.V303066.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 and Care Homes for Adults 18 – 65*. 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 DS0000024666.V303066.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Care Home Address Memorial Avenue Worksop Nottinghamshire S80 2BJ 01909 476416 01909 476089 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) Dukeries Health Care Limited Diane Shirley Barnes Care Home 87 Category(ies) of Dementia (21), Dementia - over 65 years of age registration, with number (29), Old age, not falling within any other of places category (37) Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. No more than 37 persons falling within the category OP should be accommodated within Victoria Care Home Dementia over the age of 65 years DE(E). No more than 29 persons over the age of 65 years with Dementia should be accommodated within Victoria Care Home Dementia for adults aged between 40 and 65 years of age (DE). No more than 21 persons between the ages of 40 and 65 should be accommodated within Victoria Care Home. This should be restricted to persons with Korsakoff Syndrome and such persons should be accommodated in Champion Crescent which is a separate wing within Victoria Care Home To accommodate the persons with Korsakoff Syndrome named in application number V32696 and application number V32688 who are under the age of 40 years, to Champion Crescent within Victoria Care Home The maximum number of persons to be accommodated within Victoria Care Home is 87 2nd November 2005 4. 5. Date of last inspection Brief Description of the Service: Victoria Care Home is a care home providing personal care and accommodation for 88 older people. The current registration categories are older people, dementia and people with dementia bought about through alcohol related brain injury (Korsakoffs syndrome). There are three units accommodating residents over 65 years old (Lancelot for people with dementia, Guinevere and Camelot for old age not falling within any other category) and one unit for people with Korsakoffs syndrome (Champion Crescent) The home provides short and long term care and will accept emergency admissions. A respite service is available if required. The home is owned by Dukeries Health Care, which is run as a small business. The home is located in a residential area of Worksop close to shops, pubs, the post office, library and a church. There is also a park opposite. The home was opened in 1996 and was purpose built. The home is split in to four separate units. All of the homes bedrooms are single and have en-suite facilities. Bedrooms are located on 2 floors and there is a passenger lift. The home has 2 gardens that are well maintained and easily accessible, one of which is enclosed. There is ample car parking available. The manager said on 12/07/06 that the fees for the service range from £334 £420 per week for those over 65 years old depending on dependency needs and from £450 to whatever needs are assessed at on Champion Crescent. There are additional charges for hairdressing and chiropody. Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first visit to the home since 1st April 2006 by The Commission for Social Care Inspection. The inspection lasted for 6 hours and the main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the manager, care staff on duty and care practices were observed and relatives were spoken with. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. What the service does well: New residents are assessed by a senior member of staff from the home to ensure their needs can be met. There are appropriate arrangements in place for meeting the healthcare needs of residents, which vary depending upon their age. This helps residents maintain good health. There are good practices employed to promote the privacy and dignity of residents. The home provides a full activities programme for the older persons and residents on Champion Crescent have individual programmes to follow, designed to support their rehabilitation into the community. Residents therefore have opportunities to participate in appropriate activities, which they enjoy. The home is well laid out and suitable for use as a residential home. The home was clean and well maintained making a pleasant environment. Residents on Champion Crescent are responsible for the cleaning of the unit, helping them re learn domestic skills. The home adjusts staffing levels to reflect occupancy. Staff are expected to take part in appropriate training so they are able to meet the needs of residents. The home is well managed with the manager continuing to undergo training for her own development so she can ensure best practices are followed in the home. The home is subject to an annual audit to identify the strengths and weaknesses of the service and an action plan is prepared to address weaknesses. Residents are asked to complete a questionnaire on the services provided so their views can be taken into account. Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 6 All required health and safety checks are undertaken at the correct timescale making the home a safe environment. What has improved since the last inspection? 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. Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 (older people) and 2 (Adults 18 – 25) Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. New residents are assessed prior to moving into the home to ensure that their needs can be met. The home does not offer an intermediate care service. EVIDENCE: The manager said that all prospective residents are assessed prior to admission, unless the admission is a rapid response when an assessment is obtained from the placing authority and the resident is then assessed at the home. Staff said that prospective residents are visited and assessed before admission. Care files seen included assessments carried out by a Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 9 representative from the home and were dated prior to the admission date. Residents from the older people’s accommodation confirmed that they had been visited by someone from the home before they moved in and some residents on Champion Crescent talked about the manager coming to visit them in hospital whilst others could not remember whether they were visited or not. There is no arrangement made for the home to provide an intermediate care service. Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 (older people) and 6, 9, 16, 18, 19 and 20 (Adults 18 – 25) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents health, personal and social care needs are set out in an individual plan of care. Residents’ health care needs are fully met. Residents are protected by the homes procedures for dealing with medicines. Residents feel they are treated with respect and their right to privacy upheld and their wishes are acted upon. Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 11 EVIDENCE: The manager said that a new care planning system has been introduced and training has been provided to staff on completing these, and more training is to be provided. The same system is used in each unit. The system uses generic plans as a base/guide and these are then built upon to tailor them to individual needs. Plans seen were well structured and included personal information, assessments, risk assessments, care plans and evaluations, doctor and hospital appointments and daily records. Plans seen were not being signed by representatives from the home or the resident and/or their relative. The evaluation of plans was not occurring monthly and some were being archived whilst still active. A recent audit undertaken highlighted that not all care plans are being signed. On Champion Crescent there is a system in place to manage residents cigarettes so they do not chain smoke leaving themselves none for later in the week, however this restriction is not recorded within the care plan. Residents from the older people’s accommodation said that they were able to talk to staff about the care they wish to receive and some residents on Champion Crescent talked about short and long term goals they were working towards, whilst others said they could not remember discussing their care. The manager said that arrangements on the older people’s accommodation are made for healthcare to be provided at the home and visiting professionals include doctors, district nurses, chiropodist and optician but those on Champion Crescent are expected to access services within he community. Due to problems accessing dental services referrals are being made through the local hospital when required. Staff on Champion Crescent said they have been trained to monitor one resident’s blood level and staff from the older people’s accommodation described systems to ensure healthcare needs are met including chiropody. Entries in the care plan showed that one resident on Champion Crescent had arrived without his glasses and new ones had been got from a local optician. A resident from the older people’s accommodation said that she was waiting for a visit from a doctor and had seen the district nurse. Residents on Champion Crescent said they had been out to visit the doctor. The manager showed a new system that has been introduced for assessing whether staff are competent at administering medication. Each unit administers their own medication in a manner suitable to the needs of the residents. Each unit, with the exception of Champion Crescent and newly admitted residents, had photographs of residents attached to the Medicine Administration Records. The manager said this was in the process of being done. Staff spoken with said that they had received training in the administration of medication and were clear of their responsibilities to observe residents actually take the medication. Residents from the older people’s accommodation said that staff bought them their medication and residents on Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 12 Champion Crescent said that they have to go to the office to be given their medication. Staff said that there are polices and procedures concerning the privacy and dignity of residents and described practices that promoted this. All bedrooms are single enabling any support required in private. Staff were seen closing doors when assisting residents and residents from the older people’s accommodation said that staff were very good at helping. Staff said that they switch on a light over residents doors when assisting them. The majority of residents on Champions Crescent do not require any personal support, but one who does praised staff for the assistance that they give. Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 14 and 15 (older people) and 12, 13, 15 and 17 (Adults 18 – 25) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents find the lifestyle experienced in the home matches their expectations. Residents maintain contact with family and friends. Residents are helped to exercise control over their lives. Residents receive a wholesome and balanced diet, although not always suited to the preferences of those on Champion Crescent. Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 14 EVIDENCE: There are two activities coordinators employed in the home, who provide the activities for the older people. A programme of activities is displayed and this showed that a morning and an afternoon activity is provided everyday. Activities take place in different parts of the older people’s accommodation to encourage participation and there are some activities arranged specifically for those with dementia. A music session was one of these taking place during the inspection and a music to movement session was taking place in the afternoon. Some residents said they had enjoyed watching the recent World Cup together and another said he did not join in activities as she preferred to be in her room, although she did enjoy going to the nearby park, which he had done the previous day. One recently admitted resident said that he would like to be able to play dominoes and member of staff said that she would make sure he knows when this is taking place. There are separate arrangements for activities on Champions Crescent so that activities appropriate to residents ability, age and understanding can be provided on an individual basis. Residents receive a weekly allowance to enable their individual interests to be pursued. Some residents have worked in the garden and were growing some plants, including tomatoes in a small greenhouse. Residents on Champion Crescent are provided with opportunities to go into the local community, with a member of staff unless they have been assessed as being able to leave the home safely unescorted as one resident does, to go to purchase a daily newspaper from a local shop. Residents on Champion Crescent have some opportunities to participate in work related daytime activities. One resident assists the administrator with some admin duties and others work on allotments, attend MIND activities such as painting and varnishing and attend local support meetings. The opportunities that may be available through local colleges has not been explored and it is recommended that this is pursued. Staff said that visitors are welcome to visit at any time and a number of visitors were seen at the home. Those spoken to said that they can visit at anytime and are made welcome. Staff were seen telling relatives of toiletries required for one resident. The manager said that residents on Champion Crescent are allocated two slots a week for use of the rehab kitchen where they can buy, prepare and cook their own meals. Information was seen on the nutritional content of different foods to help with meal planning. The timetable seen did not include all residents and records of meals cooked by residents could not be found. Meals for all units are prepared in a central kitchen and delivered to the unit in a heated trolley. There is a choice provided at each meal and residents are asked to complete a menu sheet the day before as to their choice of meal. One recently admitted resident said that he had not enjoyed the meal he had Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 15 and could not remember selecting this. Staff said that this could have been changed if he had said so. It should be taken into account that a number of residents suffer with memory loss and cannot remember something they selected the previous day. All units have the same menu, which is designed to meet the needs of the older people. The residents on Champion House are considerably younger and include different dietary preferences. These preferences must be catered for. Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 (older people) and 22 and 23 (Adults 18 – 25) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident that their complaints will be listened to. The correct procedures are not followed to protect residents from abuse. EVIDENCE: Following a requirement at the last inspection the manager has introduced a complaints book onto each unit, which she inspects on a monthly basis. All the books seen contained entries in and stated action taken. Staff were aware of these books. Residents from the older people’s accommodation and Champions Crescent said there was nothing to complain about. The manager said that the majority of staff have been provided with training on adult protection and a further course is planned shortly. There have not been any allegations of abuse inn the older persons’ accommodation, although a report was seen on Champions Crescent, which described an incident where a resident was restrained by a member of staff and both the resident and member of staff received minor scratches. Although this incident was documented it had not been notified to the manager, the Adult Protection Unit or The Commission for Social Care Inspection. Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) 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 and 26 (older people) and 24 and 30 (Adults 18 – 25) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-maintained environment. The home is clean, pleasant and hygienic EVIDENCE: The home is a suitable building for its purpose and is well maintained. The manager said that there are plans to decorate part of the building in the near Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 18 future. The home employs a handyman to carry out routine repairs and maintenance. Staff said that they found the building suitable to carry out their duties in and residents from the older people’s accommodation said they were happy with the accommodation. A resident on Champions Crescent said that he and his wife have 2 rooms, one that they use as a private sitting room. There is a well equipped laundry room where all the laundry for the older people’s accommodation is done. There are two small laundry rooms on Champions Crescent where residents are expected to do their own laundry. The home was clean and hygienic and staff described good practices to ensure this is maintained. Residents and relatives from the older people’s accommodation said the home is always very clean. Residents on Champion Crescent are responsible for cleaning the unit and were seen vacuuming and wiping tables. Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 (older people) and 32, 34 and 35 (Adults 18 – 25) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents needs are met by the numbers and skill mix of staff. Residents are in safe hands at all times. Residents are supported and protected by the home’s recruitment policy and practices. EVIDENCE: The manager said there is a set number of staff for each unit and these numbers are always maintained. The manager said that the older person’s accommodation is staffed to the maximum due to occupancy levels and there is a guide in Champions Crescent showing when staffing is adjusted along with occupancy. Staff said they felt there were enough staff on duty to allow them to fulfil their duties. Residents and relatives from the older people’s accommodation said Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 20 they thought the staff were very good and took residents out, attended to their needs and generally spent time with them. Residents on Champion Crescent said that staff were always to hand if they wanted something. All senior staff are required to have National Vocational Qualification level 3 and all other care staff National Vocational Qualification level 2. The manager has applied for funds for housekeeping staff to also study towards a National Vocational Qualification level 2. Staff spoken with confirmed that they have completed National Vocational Qualification level 2. Residents said they felt staff knew their jobs. A selection of staff files were seen and these contained the required information. The manager showed an example of a staff training record. These are kept on each unit and staff are responsible for taking them to courses they attend and getting them completed. The audit undertaken highlighted some staff not attending courses and this is being addressed through the action plan. Staff spoken with said that they had undertaken mandatory training and they have regular training opportunities. Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) 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 and 38 (older people) and 37, 39 and 42 (Adults 18 – 25) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a suitable manager employed to run the home. Residents have opportunities to express their views on how the home is run. Residents’ financial interests are safeguarded. Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 22 The health, safety and welfare of residents are protected. EVIDENCE: The manager has worked at the home for 10 years and been the registered manager since 2005. The manager has completed a Diploma in nursing, is a National Vocational Qualification assessor and is currently working on the final unit of the Registered Managers Award. She has also enrolled on a manager’s course. The manager said that she is well supported in her position. An annual home audit prepared by the head of clinical governance for Dukeries Healthcare was undertaken in June and a detailed report has been produced highlighting both areas of excellence and weakness in complying with key indicators. The report included an action plan, which the manager is working to achieve. Staff bought the manager some questionnaires completed by residents on Champion Crescent and the manager said she will be producing a report on the outcome of these. The home will help residents who require assistance manage their personal allowances. This is done on the unit in Champions Crescent, and by the administrator for the older people’s accommodation. The manager said that all routine health and safety checks and tests are carried out and that the hot water system in place does not need temperature testing to prevent legionella. Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Victoria Care Home DS0000024666.V303066.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP7 YA6 Regulation 15 Requirement Timescale for action 01/09/06 2 YA6 12 3 4 YA17 OP18 YA23 16 12 The registered person must ensure that care plans include all relevant and current information and are signed The registered person must 01/08/06 ensure that all restrictions placed on residents are done so as a result of an assessment and recorded in the care plan The registered person must 01/09/06 ensure that all residents’ dietary preferences are catered for. The registered person must 01/08/06 ensure that any incidents or allegations of abuse are dealt with through the Adult Protection procedures 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 YA15 YA15 Good Practice Recommendations The registered person should explore opportunities available through local colleges to residents on Champion Crescent The registered person should make greater use of the rehab kitchen on Champion Crescent DS0000024666.V303066.R01.S.doc Version 5.2 Page 25 Victoria Care Home Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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