Inspection on 19/11/07 for Victoria Care Home

This inspection was carried out on 19th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Victoria Care Home 12/02/09

Victoria Care Home 11/07/06

Victoria Care Home 02/11/05

Victoria Care Home 23/06/05

Victoria Care Home 11/01/05

Victoria Care Home 20/07/04

Victoria Care Home 02/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Victoria Care Home Memorial Avenue Worksop Nottinghamshire S80 2BJ Lead Inspector Jayne Hilton Unannounced Inspection 19th November 2007 08:00 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 DS0000024666.V354293.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 DS0000024666.V354293.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Care Home Address Memorial Avenue Worksop Nottinghamshire S80 2BJ 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) 01909 476416 01909 476089 vch@dukerieshealthcare.co.uk 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.V354293.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 11th July 2006 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 Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 5 home has 2 gardens that are well maintained and easily accessible, one of which is enclosed. There is ample car parking available. The fee range in the service user guide is stated as between £334 and £745 depending on needs. There are additional charges for hairdressing and chiropody. Copies of previous inspection reports and the Service User Guide were on display in the home. Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection took place over 8. 5 daytime hours and was unannounced. Because people with dementia are not always able to tell us about their experiences, we have used a formal way to observe people in this inspection to help us understand. We call this the ‘Short Observational Framework for Inspection’ (SOFI). This involved us observing four people who use services for 2 hours and recording their experiences at regular intervals. This included their state of well being, and how they interacted with staff members, other people who use services, and the environment. The observation took place in the dining room and lounge in the ‘Lanceleot’ of the home. Our overall findings were that the service promises to deliver care to service users in a way, which respects their personal dignity and right to privacy and that this is how care is provided in practice. We found that there were high levels of staff interaction with the service users and the interactions, which were seen, were mostly of good quality to enhance the quality of life of the residents who were observed. We also spoke to the manager, three staff members and five people who use the service who were not part of the observation. We looked at records and documents, including two people’s care plans in detail. What the service does well: Service users have information about the home and can be assured the home will meet their individual needs and preferences and are supported well to settle into their new surroundings. The health, safety and welfare of residents are protected. Service Users live in a comfortable, homely, clean environment with a choice of communal areas Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 7 and personalised bedrooms. The up-to-date infection control policy is followed and maintains a safe environment. Service users are protected by the homes recruitment policies, however staffing numbers need to be reviewed. Staff receive training to enable them to meet the needs of service users. Service users know how to make a complaint and generally good systems are in place to protect them from harm. Three activities co-ordinators are employed and the home offers a range of activities including lots of bingo and dominos Service users find the lifestyle in the home generally matches their expectations and preferences and satisfies their dietary, social, cultural religious and recreational interests and needs Service users health, personal and social care needs are mostly set out in an individualised plan of care and their health needs mostly met. Service users are treated with respect and their privacy upheld. Through the observation process many positive interactions between service users and staff were demonstrated including warmth, holding, a relaxed pace and atmosphere, acknowledgement, genuiness, facilitation, enabling and belonging, which provided comfort, identity, attachment, occupation and inclusion, resulting in very positive outcomes for people with dementia. There were no times during this observation when the service users with Dementia showed negative mood states of being. What has improved since the last inspection? What they could do better: Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 8 The registered person must ensure that care plans include all relevant and current information and are signed. Ensure staff does not sign the medication record until visibly observing the service user has taken the medication. Ensure quality assurance surveys are undertaken to obtain service users and their representative’s views about the service Improve the systems for managing service users finances to ensure service users financial interests are fully safeguarded. Review staffing numbers to ensure the needs of service users are consistently met. Provide suitable stimulative activities for people who remain in bed or in their rooms to meet all service users individual needs and preferences. Further develop the personal life history profiles and the assessment documentation to further embrace the individual as a whole person. Provide sufficient equipment so that service users are not left waiting for attention. Cease the practice of monitoring blood pressure and temperatures of service users. Monitor the food temperatures, to ensure food is served at an appropriate temperature. Reviewed the garden areas to ensure there are no hazards for service users when accessing the garden/patio areas. All service users should offered a key for their room and lockable facilities unless risk assessment proves otherwise. If service users are expected to go outside to smoke, then a suitable weather shelter be provided. Three requirements and thirteen good practice recomemndations have been made in respect of the above. Please contact the provider for advice of actions taken in response to this Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 9 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. Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 10 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 DS0000024666.V354293.R01.S.doc Version 5.2 Page 11 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 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have information about the home and can be assured the home will meet their individual needs and preferences and are supported well to settle into their new surroundings. The home does not offer an intermediate care service. EVIDENCE: The home has produced a Service Users Guide and Statement of Purpose that describes how the individual needs of residents will be met but does not details the fees charged. A copy of the previous inspection reports on the home is displayed. Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 12 Two service users care plans were viewed. Pre-assessment visits are an integral part of the home’s pre-admission procedure. . Service users are supported and encouraged to be involved in the assessment process. The home has formal documentation in place for carrying out holistic needs assessment. The manager or senior member of staff who is trained and skilled in assessment techniques carries out the needs assessment, including that of individuals who are self-funding. Service users are supported and encouraged to be involved in the assessment process. There is less diversity within the service user’s catchments area. However person centred care is provided where the individual is the central focus which areas of diversity impact upon. Policies and procedures also ensure equality and diversity are promoted and incorporated into what they do. Religious needs are met through the local community either by the service users attending a place of worship, or the local clergy coming into the home. Dietary needs of certain religions are addressed pre-admission to ensure the home could meet the service user’s requirements. Through the observation process many positive interactions between service users and staff were demonstrated including warmth, holding, a relaxed pace and atmosphere, acknowledgement, genuiness, facilitation, enabling and belonging, which provided comfort, identity, attachment, occupation and inclusion, resulting in very positive outcomes for people with dementia. There were no times during this observation when the service users with Dementia showed negative mood states of being. Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 13 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. Service users health, personal and social care needs are mostly set out in an individualised plan of care and their health needs mostly met. Improved documentation is needed within the care plans and medication charts however to ensure service users needs are fully met. Service users are treated with respect and their privacy upheld. EVIDENCE: The care plans examined demonstrated that each service user is supported to make their own decisions, the home uses a person centered care planning approach, which is evaluated at regular intervals. Care staff confirmed that they are trained in giving choice to service users and in ways in which to facilitate users to make decisions, for example, what to wear and service users spoken with endorsed this. Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 14 The home operates a policy of knocking before entering a service user’s room to ensure privacy, dignity and respect, which practice was observed on the day of the inspection. Care plans and risk assessments were not in place to identify those at risk of pressure damage and what action is being taken to reduce the risk for example pressure relieving equipment. Care plans and risk assessments for identifying and acting upon service users at risk of malnutrition are in place. The home carries out risk assessments aiming to prevent falls and these are monitored, however the care plans viewed did not contain service users/and/or their representatives signatures. An audit undertaken by the community pharmacist in December 2006 showed generally good compliance with medication management in the home, however at that audit the trolley was left unlocked whilst unattended. At this inspection the trolley was not left unsupervised, however it was observed that a staff member signed for one persons medication, despite this not being fully taken and another staff member prompted the service user to take the medication after the staff member administering medication had left the room with the trolley. Staff told us and and the records confirmed that they have undertaken training in safe handling of medication. The home assists residents in planning for routine healthcare visits and keeping appointments, however one persons file care plan was lacking in information about the management of foot care for this individual and staff were unsure about what the actual arrangements were for the person. Service users spoken with stated they were happy, that their healthcare was looked after well. One service user commented that they had to wait an unnecessary length of time for the toilet because the home has insufficient equipment. [Only one hoist in the home that is suitable, which has to be used throughout.] Staff are undertaing blood pressure monitoring and temperatures of service users, but as this is a clinical procedure and the home is not registered to provide nursing care, this practice should cease unless a GP specifically requests this on an individual needs basis and then it must also be recorded in a care plan. Victoria Care Home DS0000024666.V354293.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users find the lifestyle in the home generally matches their expectations and preferences and satisfies their dietary, social, cultural religious and recreational interests and needs. More innovation with the activities provision would further enhance the lifestyle currently experienced by some people living in the home. EVIDENCE: The home has good links with the community so that service users can access local activities and the community can be involved in the home’s activities. The care home has regular service user/relative forums where ideas on improvements are discussed and taken on board by management. Minutes of meetings and feedback from satisfaction surveys evidenced this. Services users are able to make decisions on what they would like to see on the menus and activities programmes and service users stated they had Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 16 recently been consulted about menus and have full say about their daily routines and bedtimes etc. The home has open visiting arrangements and has areas where service users can meet with relatives/friends/professionals and not be disturbed. Service users are able to have their own private phone line into their rooms. The care home encourages services users to become involved in activities should they wish. The home will accommodate as much as possible of a service user’s personal possessions which they wish to bring with them into the home. The home offers three meals, including cooked breakfasts, together with snacks and drinks each day, special diets are catered for, for example diabetic diet. Soft diets were served in an appetising way and people were assisted to eat by staff in a sensative and enabling way. Service users were observed being asked which option they would like and being offered second cups of tea etc. Most service users spoken with said they were happy with the quality of the food, but one service user, commented that the days meal was cold and the meat tough. The acting manager reported that she samples the food on a regular basis to ensure it is served to a good standard. On checking the temperature of the food served on the day of the inspection, no records were kept of this. The food is transported in Bay Maries, from a central kitchen to each unit and it is recommended that a system is put into place for staff to ensure food is served at the correct temperature. Three activities co-ordinators are employed and the home offers a range of activities including lots of bingo and dominos, which service users spoken with said was popular, however it was identified that one to one time with service users, particularly those who remain in their rooms is not always provided. The home must provide suitable stimulative activities to meet all service users individual needs and preferences. It is also recommended that where service users refuse to participate in offered activities that this be fully documented. Victoria Care Home DS0000024666.V354293.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. 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. Service users know how to make a complaint and generally good systems are in place to protect them from harm. EVIDENCE: The Homes policies and procedures on complaints and suggestions for improvement are up to date. The service user guide has clear guidelines on how to make a complaint and the complaint procedure is displayed within the home. Service users and staff spoken with confirmed they knew how to make a complaint Five formal complaints had been recorded on Lancelot since the previous inspection. The previous manager had reported in the Annual Quality Assurance Assessment that ten complaints had been recorded for the whole home since the previous inspection, none being upheld. Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 18 As the complaints for each unit are held on the specific unit, these were not fully viewed at this inspection. In addition there is a communication book for anyone to raise concerns/complaints, which the manager respond in writing, for example, standatds of cleaning/hygiene, staff practices. The home has obtained the new procedures and guidance on safegaurding adults. Staff training records confirmed that all staff have been trained in in adult protection issues. Examination of procedures confirms that a robust whistle blowing procedure is in place and staff spoken with were fully knowldegeable about the contents this. There has been one reported safeguarding issue in the home in the previous twelve months, which was resolved satisfatorily Agreements are in place with risk assessments for the use of bedrails and staff are trained to deal with challenging behaviours. Victoria Care Home DS0000024666.V354293.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20,24,and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users live in a comfortable, homely, clean environment with a choice of communal areas and personalised bedrooms. The up-to-date infection control policy is followed and maintains a safe environment. EVIDENCE: The care home is maintained appropriately to reduce the risk of infection and cross infection. Antibacterial scrubs and protective clothing was observed to be in use at all times. Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 20 The care home provides infection control training to staff so that they are aware of the importance of prevention. A program of internal and external routine maintenance works is kept within the home. The home complies with the requirements from the local fire service and a risk assessment was viewed in the home. The home has outdoor space which is accessible to all servise users including those with mobility problems, however some paving slabs outside the dining room of Lancelot were slightly raised. It is reccomended that the garden areas be reviewed to ensure there are no hazards for service users when accessing the garden/patio areas, prior to the spring. The home has a nurse call system with an accessible alarm facility in every room. Observations on the day that the home is well maintained, clean, smells fresh and is safe and comfortable. Cleanliness and maintenance are discussed at service user meetings and any comments are acted upon. The homes contracts for maintenance by external contractors are up to date and the maintenance schedule has been followed. All service users should offered a key for their room and lockable facilities unless risk assessment proves otherwise. The Provider has decided to make the home a No smoking environment for service users and visitors. Information provided on the day, reported that not all service users and visitors were respectful of this and still used the previous smoke lounge provision. The acting manager was requested to address the situation in line with new legislation and if service users are expected to go outside to smoke, then a suitable weather shelter be provided. Victoria Care Home DS0000024666.V354293.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are protected by the homes recruitment policies, however staffing numbers need to be reviewed. Staff receive training to enable them to meet the needs of service users. EVIDENCE: Staff practices observed confirmed that all staff operates in a manner, which promotes liberty and enable users to feel safe and secure whilst promoting independence. Service users and a visitor said staff were marvellous, hard working and do their best, but felt that there was not enough of them, they also confirmed their needs had never been unmet. However one service user commented that they had to wait an unnecessary length of time for the toilet because the home has insufficient equipment such a suitable hoists. The home undertakes a robust recruitment process and carry out various checks on possible employees, for example, CRB, [Criminal Records Bureau] checks references and employment history. Three staff files were viewed and found to be satisfactory and; staff records showed staff, receive induction Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 22 training and regular updates. The manager provided information that 13 staff hold NVQ level 2 or above. One staff member reported that she had achieved NVQ`level 2 and was now undertaking level 3 All staff working within the home complete mandatory annual training, applicable to their role within the company, for example, manual handling, health and safety, food hygiene, first aid and fire safety. Most staff are only now undertaking training in Dementia Care or Alcohol and substance abuse, depending in which units they work, by distance learning. Some staff are undertaking training in equality and diversity. Some staff have undertaken specific training for example in diabetes care, but the training matrix does not include, details of this kind of training. . Examination of list of staff employed by the home and staff rotas confirms that there are mostly sufficient staff available at all times to meet the needs and aspirations of the service users. However, rotas showed that although four staff were on duty in Lancelot on the morning of the inspection and three in the afternoon, not all shifts were covered by this amount of staff. The manager reported that staff cover would be maintained to safe levels wherever possible and that the recent recruitment of bank staff was helpful. A service user said “there are sometimes only one staff member on in the unit at night, which makes me feel unsafe”. [Four staff are employed on nights for the whole building] Staff confirmed that rotas are sometimes not fully covered because of short notice absence, although they do try to cover where one unit may have surplus and another short. Staff demonstrated that they have a through understanding of the needs of service users and can deliver highly effective personal care and there are written records of the monitoring of staff performance. Information provided in the annual quality assurance questionnaire, stated that 41 people require two staff to assist them during the night. In view of all of the above information, a recommendation is made in respect of staffing levels being reviewed in line with dependency levels in the home. Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there is evidence that the home is run in the best interests of service users, quality assurance surveys would further support this. Improved systems are needed for managing service users finances to ensure service users financial interests are fully safeguarded. The health, safety and welfare of residents are protected. EVIDENCE: Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 24 The acting manager has worked at the home for only 4 months. She is an experienced manager but has not yet been registered with the commission for social care inspection and is currently undertaking the Registered Managers award. Service users, a visitor and staff praised the acting manager, said she was approachable and provided leadership for staff. A service user said they haven’t seen a lot of the manager around the home. Audits on the home are regularly undertaken by the head of clinical governance for Dukeries Healthcare. The manager reported that she has not yet undertaken any service user surveys, since being employed at the home. The home will help service users 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, however there is no policy in place for staff to follow, when shopping on their behalf, neither were receipts seen for hairdressing costs. Receipts are given for valuables stored in the safe, but as a duplicate copy of the receipt is not kept, this does not fully protect service users valuables, should the original receipt be lost or misplaced. 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. A random selection of records were viewed and found to be satisfactory. Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 2 3 X 3 Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 26 Yes partly Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The registered person must ensure that care plans include all relevant and current information and are signed. Partly met. Timescale extended in consideration of change in manager and introduction of new care plans. This will ensure that the individual service users needs are fully met. 2 OP9 13[2] Staff must ensure that they do 29/12/07 not sign the medication record until visibly observing the service user has taken the medication. Staffing levels should be 29/12/07 reviewed in line with the dependency levels of service users residing in the home. Timescale for action 19/01/08 3 OP27 18 Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP3 OP8 OP10 OP8 Good Practice Recommendations Further development of the personal life history profiles and the assessment documentation would further embrace the individual as a whole person. Specific care plans should be implemented with foot care arrangements for service users. Ensure sufficient equipment is available so service users do not have to wait an unnecessary length of time for assistance. Staff are undertaing blood pressure monitoring and temperatures of service users, but as this is a clinical procedure and the home is not registered to provide nursing care, this practice should cease unless a GP specifically requests this on an individual needs basis and then it must also be recorded in a care plan. Suitable stimulative activities be provided to meet all service users individual needs and preferences. Where service users refuse to participate in offered activities, this should be fully documented. A system should be put into place for staff to ensure food is served at the correct temperature. Provide napkins so service users do not use the tablecloth for wiping up splillages etc. It is reccomended that the garden areas be reviewed to ensure there are no hazards for service users when accessing the garden/patio areas, prior to the spring. All service users should be offered a key for their room and lockable facilities unless risk assessment proves otherwise. Address the situation raised about smoking service users, in line with new smoking legislation and if service users are expected to go outside to smoke, then a suitable weather shelter be provided. Provide details of all training provided on the training matrix, for example, diabetes, continence and pressure DS0000024666.V354293.R01.S.doc Version 5.2 Page 28 4 OP8 5 6 7 OP12 OP12 OP15 8 9 OP19 OP24 10 OP19 11 OP30 Victoria Care Home 12 13 OP33 OP35 area care Undertake, satisfaction surveys, with service users and visitors to he home. A policy should be put in place for staff to follow, when shopping on their behalf. A duplicate copy of the receipt should be kept for valuables held kept on behalf of service users. Ensure receipts are obtained for hairdressing costs. Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Victoria Care Home DS0000024666.V354293.R01.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!