CARE HOMES FOR OLDER PEOPLE
Victoria Care Home Memorial Avenue Worksop Nottinghamshire S80 2BJ Lead Inspector
Stephen Benson Unannounced Inspection 2nd November 2005 09:30 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.V264829.R01.S.doc Version 5.0 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.V264829.R01.S.doc Version 5.0 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 Mr Paul Levack Vacant Care Home 88 Category(ies) of Dementia (22), Mental disorder, excluding registration, with number learning disability or dementia (22), Old age, of places not falling within any other category (88) Victoria Care Home DS0000024666.V264829.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Up to 22 beds may be used for DE Of the total number of beds a maximum of 22 beds may be designated MD Service users shall be aged 48 years or over. Date of last inspection 23/06/05 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 subject to an application to vary to 77 older people, 40 of whom have dementia and a further 11 for people aged over 40 with dementia bought about through alcohol related brain injury (Korsakoffs syndrome). 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 three 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. Further information about the home can be obtained from the manager. Victoria Care Home DS0000024666.V264829.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was the second of two unannounced inspections carried out between April 2005 and March 2006. The inspection focussed on the key standards not inspected last visit and on the requirements that were set. The inspection lasted for 4 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 care staff on duty, the manager and care practices were observed. Relatives were spoken with as well as a visiting district nurse. 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: What has improved since the last inspection?
An assessment is obtained for all new residents prior to moving into the home to ensure their needs can be met. The care planning system is in the process of being changed and a sample one was seen. This contained clear details of the care to be provided. A district nurse described a good working relationship with the home and that there is a system in place to aid communication. Staff were aware of the correct procedures for moving and handling and a resident said that she was happy with the assistance she receives. A resident who had previously been restrained for fears for her safety is now able to sit without the use of any restraint.
Victoria Care Home DS0000024666.V264829.R01.S.doc Version 5.0 Page 6 More attention is paid to the appearance of residents ensuring that they are well presented. Staff have received training on the adult protection procedures and are aware of the home’s policy on whistleblowing. 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.V264829.R01.S.doc Version 5.0 Page 7 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.V264829.R01.S.doc Version 5.0 Page 8 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): 2 New residents are assessed prior to moving to the home. EVIDENCE: A requirement was set at the last inspection to ensure that there is an assessment held for all new residents. The file for a recently admitted resident was seen which contained an assessment that had been completed prior to the resident moving to the home. Victoria Care Home DS0000024666.V264829.R01.S.doc Version 5.0 Page 9 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 and 10 The delivery of health and personal care has improved since the last inspection. EVIDENCE: A new system of care planning is currently being introduced. And a sample one of these was seen. This was more detailed than the previous system and this clearly indicated the support that each resident needed. A discussion was had with a resident on the Carenza unit who understood the reason for her placement and discussed the support that she is receiving. A district nurse spoken with said that there was a good working relationship with the home and that there is communication book to use for passing messages. There is equipment available to assist with moving and handling and a resident who requires assistance to move said that she is happy with the way that she is helped. A requirement was set at the last inspection to assess a resident who was being restrained when sat in a chair for fear for her safety. This has been done and it was established that the resident could be cared for without the use of
Victoria Care Home DS0000024666.V264829.R01.S.doc Version 5.0 Page 10 the restraint and was seen sitting in the lounge without the use of any restraint. Medication is given out separately in each unit within the home which each has their own medication trolley. Staff responsible for giving out medication were spoken with and all were aware of the correct procedures to follow, however on one unit the medication trolley was seen left open and unattended whilst a member of staff dealt with another matter, and tablets were being given to residents but they were not observed taking these. There was not a risk assessment completed indicating that these residents had been assessed as able to take responsibility for administering their own medication. The manager has introduced a drug administration and storage audit form. At the last inspection it was noted by the appearance of some residents that they had not had their personal needs met properly. Residents seen at this inspection were properly attended to and said that they receive the help they need in the mornings when getting up. The manager said that all staff had been made aware of the need to ensure that residents had received the proper attention. Victoria Care Home DS0000024666.V264829.R01.S.doc Version 5.0 Page 11 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): 14 Where able residents are able to make choices and have control over their lives. EVIDENCE: Information is displayed around the home informing residents of what is happening in the home and how to access other services and support. Residents are able to choose how they spend their time and can use their rooms or communal areas as they please. Keypads are fitted to the doors of the dementia unit to prevent those residents from wandering. Other residents were seen using the grounds and residents said they have been on trips out of the home. Residents were seen spending their time in a variety of ways, and apart from using communal areas watching television or listening to music or spending time in their rooms, some were having their hair done and others playing dominoes. Staff were observed giving residents choices where able, including things like what they wanted for breakfast and where they wanted to be taken to. Residents said that they are able to choose how they spend their time and staff regularly offer them choices. Victoria Care Home DS0000024666.V264829.R01.S.doc Version 5.0 Page 12 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 Any complaints should be dealt with on the residents unit initially. EVIDENCE: The home has a complaints procedure, which a copy of is displayed in the entrance hall. There is a book for recording complaints in, one remains unresolved since July 2005 and the manager is waiting for a reply from head office. Through discussion with staff it was felt that it would be preferable if each unit managed their own complaints record as minor complaints tends to be resolved on the unit and recorded in the daily notes but not then included in the homes central complaints record. Victoria Care Home DS0000024666.V264829.R01.S.doc Version 5.0 Page 13 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): None EVIDENCE: Victoria Care Home DS0000024666.V264829.R01.S.doc Version 5.0 Page 14 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, 28, 29 and 30 There are sufficient staff on duty through out the day. Staff training records need to be improved EVIDENCE: Each unit is responsible for producing their own rota so that staff can be deployed where need is identified. Staff work on a designated unit and the minimum staffing levels the home operates to are: Dementia Unit AM PM Night 2 2 2 Carenza 2 2 1 Guinevere Camelot 5 3 2 2 2 Lancelot: 4 3 3 between both units Staff spoken with said that they have sufficient staff on duty and residents said that staff work very hard and have a lot to do, but they are attended to in good time. There is a system for recording all training undertaken by staff, however this record was not up to date.
Victoria Care Home DS0000024666.V264829.R01.S.doc Version 5.0 Page 15 The manager was interviewing for a waiting list for staff to come and work in the home. The manager described the recruitment process followed, which is in line with the required procedures. A sample staff file seen contained all the correct information. There have been some problems encountered by staff working towards their NVQ’s due to the departure of the college assessor. The manager said that arrangements are being made for staff to complete these. Staff at another college have completed their course and certificates for these were seen. Victoria Care Home DS0000024666.V264829.R01.S.doc Version 5.0 Page 16 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): 35, 37 and 38 Residents financial interests are safeguarded and measures are in place to protect their health and safety, apart from reducing the risk of Legionella. EVIDENCE: The home does not manage any residents’ finances, but does look after some personal allowances. A record is made of every transaction and this is accompanied by 2 signatures. Residents records are stored at nursing stations on each unit, however this does not provide the level of security required. All the required fire, water, gas and electrical safety checks are complied with except those for testing the storage of water to prevent the risk of Legionella. Victoria Care Home DS0000024666.V264829.R01.S.doc Version 5.0 Page 17 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 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 x X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X 2 2 Victoria Care Home DS0000024666.V264829.R01.S.doc Version 5.0 Page 18 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 2 Standard OP9 OP16 Regulation 13 22 Requirement Ensure that the correct drug administration procedures are followed Develop the procedure for managing complaints and ensuring that they are identified when made. Keep the records of staff training up to date Ensure records are securely and safely stored Carry out tests for the prevention against Legionella Timescale for action 05/10/05 02/02/06 3 4 5 OP30 OP37 OP38 18 17 13 01/01/06 01/12/05 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Victoria Care Home DS0000024666.V264829.R01.S.doc Version 5.0 Page 19 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
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