Inspection on 28/06/05 for Victoria Care Home

This inspection was carried out on 28th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Victoria Care Home 18/03/09

Victoria Care Home 21/11/07

Victoria Care Home 28/11/06

Victoria Care Home 10/05/06

Victoria Care Home 25/11/05

Victoria Care Home 02/02/05

Victoria Care Home 29/09/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Victoria Care Home Victoria Street Rainford, St Helens Merseyside WA11 Lead Inspector Diane Sharrock Debbie Corcoran Unannounced 28th June 2005 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 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 F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Victoria Care Home Address Victoria Street Rainford St helens Merseyside WA11 8DA 01744 886225 01744 886193 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Tamaris Healthcare (England) Ltd Mrs Ahern Care Home 53 Category(ies) of DE - Dementia registration, with number DE(E) - Dementia over 65 of places OP - Old Age Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 23 OP and up to 30 DE(E) 2. Service users to include up to 3 DE (out of 30 DE(E) category) Date of last inspection 2nd February 2005 Brief Description of the Service: Victoria Care Home is owned and managed by Four Seasons Health Care and is a two storey detached premises set in a residential area close to the centre of Rainford Village. A bypass is near by with links to motorways and the east Lancashire road. The home is registered to accommodate older people with nursing needs (Alexandra Unit) and Older people who experience mental health problems and also require nursing care (Emily Unit). Theses two categories of care are provided on separate floors. The Responsible Person for the Company was Mrs Sue Bevans however CSCI were informed 19/7/05 that she has now submitted a letter of resignation.The home s Manager seen during the previous inspection has left and the Company have provided a temporary Manager Mr Keith Garside , although CSCI were informed 19/7/05 that there was no guarantee that the Company can have Mr Garside stay at the home until a new Manager was recruited but would like the arrangement to continue. Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 6 hours and was unannounced with 2 Inspectors being present. A further unannounced visit has taken place 13/7/05 to investigate an anonymous complaint regarding reduced staffing levels and staff living in. Company Representatives have met with the CSCI following this inspection on the 19/7/05 and have agreed to submit a further staffing proposal for the home and provide appropriate evidence and rationale that the proposed Staffing levels would be suitable to provide the necessary care and support for all Residents currently living at the home. A partial tour of the premises took place and staff training records and Resident care plans and various other records were inspected. Approximately 7 Staff on duty, 8 Residents and 5 relatives and one GP had a chat with the Inspectors and a selection of comment cards were left. The current temporary Manager Mr Keith Garside represented the home. All areas of the inspection and findings were discussed with the Manager at the end of this inspection. The Regulatory process was discussed with the Manager especially in relation to outstanding requirements regarding the company’s reduction in staffing levels and the current use of Staff living in empty Resident bedrooms. Company Representatives have met with the CSCI following this inspection on the 19/7/05 and have agreed to submit a further staffing proposal for the home and provide appropriate evidence and rationale that the proposed Staffing levels would be suitable to provide the necessary care and support for all Residents currently living at the home. What the service does well: During this unannounced inspection, feedback from most people was positive about the care Staff but some comments from Relatives identified a high turn over of staff and the Staff themselves explained that levels of staffing had been reduced since the previous manager had left. The Home’s Staff provide nursing care for older people, and involve members of the multi-disciplinary team for clinical support and input. Long standing members of staff are honest about the changes over the last few months concerning different managers but some want to build on the improvements to the home and have a sense of pride to their role. Maintenance and decorating of the home was looking of a good standard including the dining areas. Training is now offered on a regular basis. Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Full feedback was given to the Manager at the end of this inspection including the need for the Owner to provide evidence that they are complying with the outstanding requirements of regulations made at the previous inspection in February 2005. Especially in relation to Staffing levels, including requirements for updates needed to the homes statement of purpose/staff living in the registered care home building and some odours noted to the EMI unit. Other areas of development were mainly in showing evidence of a planned management approach in various areas, and showing evidence that all parties are included in the overall management and organisation of the home. Supervision of Staff, records to show that Staff have individual training records including paid days for training and that they are updated/ a planned maintenance and decorating plan/ staff identify training needs in Dementia care/staff turnover including the management of the home/staff and resident meetings need to be developed/an activities budget should be identified / internal audits should continue to be implemented especially for care plans and medicines/bedding needs to be replaced/ the returned drugs book needs to be updated. Care practices should be reviewed by the Company in light of comments made. Choices can be developed further by developing menus reviewing the use of the bain marie and care staff “washing dishes” and providing regular notices for activities and include menus and ongoing developments of the home at future Residents meetings. Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1.3 Staff carry out detailed assessments of each new Residents needs so that the appropriate care can be provided. The Statement of Purpose does not meet the standard and needs to be updated. EVIDENCE: The care records for assessments for new Residents showed a detailed assessment carried out by Staff. The Manager acknowledged that following the previous inspection the home can now admit Residents to both units however the only restriction to date would be that they would not admit any Resident with Insulin required diabetes. The Statement of Purpose was displayed at the front entrance however this document needed to be up to date and had staffing levels listed that did not reflect the staffing levels on the day of inspection, and there was no evidence that Staff and Residents had been consulted about the reduced Staffing levels. Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 7.8.9.10 There continues to be progress made within care plans which include details for health, personal and social care needs of Residents. Medication procedures were found to be in good order with a well organised medical room. The company are required to stop Staff living in the home. EVIDENCE: Residents and Relatives were happy with the care provided at the home, but one concern was the high turnover of staff which was also supported by Staff comments and one GP. Some Staff also felt the reduced staffing levels affected the care e.g. in their opinion some residents could not be showered some had to be rushed with their meals, these points were raised with the manager. The care records seen had detailed information and had improved since the last inspection. The home has its own medication store room which is now kept locked. This area is managed by the Nurses at the home and was found to be much improved and well organised, however Staff explained that due to new legislation they are trying to contract with a licensed agency to take old supplies of medicines away from the building. Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 11 The “returned drugs book was not updated and Staff acknowledged they still needed to records all drugs stored and waiting for a return. During the inspection one Staff member was living in an empty registered bedroom, as well as an infringement of privacy to Residents living at the home it is also a breach of the Care Standards act and associated regulations. Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 12.13.15 Social activities are now being developed and need further work to meet all parts of the standard and to reflect the Resident needs and requests. EVIDENCE: The home employ an Activities Organiser Mon to Fri 10am to 2pm.The activities organiser would greatly benefit from further training especially for activities for older people and those with dementia. Both Residents, relatives and Staff all report an increase to activities with the introduction of this person. At present Staff are unaware of any type of activity budget which needs reviewing so staff can plan a suitable programme of events specific to Residents needs and requests. Some Residents explained that they had never been outside and staff acknowledged that for many years there had never been any outings and the organiser is attempting to arrange trips to bingo for some people. Staff also explained that they are restricted in accompanying Residents due to the reduction in Staffing levels. Staff ask each Resident the day before what meal they would like and a choice of 2 meals are offered daily, the accessibility of menus should be developed for various Residents needs. Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 13 Comments from Staff regarding the inappropriate use of the Bain Marie should be reviewed by management especially as they feel that sometimes it can affect the quality of the food. Some staff state they sometimes have to wash dishes in the kitchen to assist kitchen staff, again these comments should be reviewed by management as in the previous inspection the company response was clear that staff should not be carrying out this role. Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 16.18 The home has a complaints policy. Staff are trained in “Abuse Awareness” and know about the policies that should be carried out this standard was met. EVIDENCE: Staff described their policies and what they would do if there was a problem. The complaint record book had no record of complaints. The Staff on duty all described their recent training for making them aware of abuse and what steps to follow if they needed to carry out the policy. The homes complaint record book was also seen and noted to follow the homes own policy. An unannounced inspection took place on the 13th July 05 to investigate an anonymous complaint around lowered staffing levels and staff living on the premises, these were founded on this occasion. Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19..26 The environment is well managed and kept clean and tidy. Areas of odours smells noted on the EMI unit and are not eliminated and (still need further review to eliminate all smells.) Sufficient equipment is available for the Staff to use in ensuring that the good hygiene and cleanliness levels are maintained. The Company are required to develop a maintenance and decorating plan. Some bedding needs replacement EVIDENCE: The home was mainly found to be very clean and tidy especially the sample of areas seen. The areas of smells were mainly noted on the EMI unit and addressed a need for further review of these areas. Bedding in some bedrooms was noted to be worn and thin and in need of replacement for the benefit of Residents. It has to be acknowledged that there is a general improvement to the décor and the environment of the home. The outside gardens had been tidied but do have potential to provide a developed area for all categories of Residents. Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 16 Risk assessments were also seen and gave detailed information about any identified risks, these records would also benefit from updates. The home did not have a maintenance and decorating plan to show a planned approach to all parts of the home which would keep the Residents and Staff informed of changes to the home, it should be developed as previously discussed to show compliance and to provide a structured development plan for the Manager to use for future planning of the home. Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27.30.29 Some Residents and Relatives say they are very happy with the care provided by care Staff. They acknowledge the turnover of Staff and managers to the home and the instability of seeing different faces. There is no written assessment nor rationale as to why Staffing levels have been reduced. This has to be addressed and all parties should be included to elicit their opinions to the proposed Staffing levels by the company. Training records are much improved and should be updated to show ongoing evidence to meet this standard. Personnel files of all staff must be in place as per the requirements of the Care Home Regulations 2001. EVIDENCE: Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 18 Following the previous inspection in Feb 05 the Company produced the following Staffing commitment for the home based on full occupancy for each unit which was published in the previous inspection report. Ground Floor General Nursing Unit 1 Trained Nurse per 24 hours AM shift- (8-2) 4 care staff PM shift-(2-8) 4 care staff Night shift-(8-8) 1 carer First Floor EMI unit 1 Trained Nurse per 24 hours AM shift- (8-2) 7 care staff PM shift-(2-8) 6 care staff Night shift-(8-8) 3 carer The CSCI had not received any notification of any proposed reduction to the Companies previous staffing commitment which was published and measured during 2 monitoring visits in April and May 05. During the unannounced inspection on the 28th June 05 the Inspectors met the Companies Peripatetic Manager Mr Garside who explained he would be managing the home temporarily until a new Manager had been employed . The Staffing levels were found to be Ground Floor unit 14 Residents 1 RGN over 24 hours and 8am –2pm 2pm –8pm 2 carers 2 carers night 1 carer First Floor unit 30 Residents 1 Trained Nurse over 24 hours 8am-2pm 4 carers 2pm-8pm 4 carers night 2 carers The above Staffing levels reflect a reduction to the original levels . Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 19 The Manager Mr Garside explained that the staffing levels witnessed during this inspection had always been in place since he commenced and he did not have any evidence to produce regarding the rationale as to the numbers of Staffing reflected the dependency of care. The Staffing rotas examined showed an outstanding issue from the previous inspection in Feb 05 were the homes Care Staff levels are short staffed on various shifts. There was no assessment or rationale as to why the levels had changed. Staff acknowledged they did not have formal supervision but the Manager acknowledged that this would be developed and that he had started individual staff questionnaires with each member of Staff. Residents and Relatives say the care staff are lovely, they acknowledge the high staff turnover and seeing new faces every day. Staff interviewed were very proud of their work but acknowledged yet another change to the manager and felt deflated when the previous manager left as she was beginning to help moral and improve the home, they acknowledge that the present Manager was very good but they felt moral was dropping again due to more unrest, more new staff and faced with lowered staffing levels. Some Staff felt that they were very busy and stretched to do the work and made comments that residents were rushed with food and sometimes they were not always able to shower people. The training records give individual records for all Staff so that the home can give written evidence of each individuals training to date, however some of these records were in need of being updated. Staff were very positive about the training they had been on and looked forward to further training. These records and Staff interviews identified further training needing to be implemented for some individuals in i.e. dementia, activities, and further development to evidence trained staff competencies as some records were not in place which had been see partially completed at the last inspection. The Manager acknowledged that Staff were still being supported in assessing and requesting GP visits, were by the Manager has continued reviewing each request, competencies of Staff were identified as a need to continue to evidence. During a further unannounced visit to the home on the 13/7/05 a sample of personnel files were reviewed and found to be in need of necessary records being in place e.g. Up to date CRB, references from a previous employer and an updated CV. Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31.32.33.36.38 The Management of the home has been affected by the number of different Managers and this now needs to be reviewed to provide a consistent and stable effect to the home. Staff and Resident are benefiting from the current Manager but recognise that he is temporary. Residents have not been consulted about reduced staffing levels and staff living on the premises so this standard needs to be reviewed and developed. Supervision is not fully met but developments are in place to implement this standard in full. Risk assessments should be reviewed and updated including staff working in excess of 48 hours per week. EVIDENCE: During the previous inspection the previous manager developed a staffing structure so the home will eventually have a senior carer on each shift and also a unit Manager for each unit, i.e. the nursing unit and the EMI unit. At present the home has one unit manager on the EMI unit and has not yet managed to employ a unit manager for the ground floor and at present the home has a Peripatetic manager in place as a temporary position until they employ a new manager. Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 21 During a recent meeting with Company Representatives 19/7/05 they are hoping they have recruited a person who may commence employment shortly. Staff recognise that the Manager is having a positive influence on the home but they recognise that he is only there for a temporary period of time and they expressed concerns about the number of Managers to the home. The home was found to have 5 staff living in the unit and this has since been identified to the company that this was not acceptable under the terms of the care standards act 2000 and associated `regulations 2001. A recent incident was identified as needing reporting on a regulation 37 which the Manager agreed to submit. One member of Staff was noted to be working in excess of 60 hours a week again the Manager recognised a need for this to stop and explained that the recruitment of overseas staff would help accommodate this. During this inspection some Staff on duty discussed various issues and opinions with the Inspector which were also noted in the inspection in February and yet improvements to moral were also note during the previous management which was pointed out by Staff also, Various comments included “Staff moral is very low, Staff feel that Staffing levels are too low and that Service Users care is affected…that Staff are asked to carry out kitchen duties It was noted there were no recent minutes of Staff or Resident meetings however the manager acknowledged a need to increase staff moral and relationships with local GPs who comment on the turnover of staff to the home. Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 2 2 x x 2 x 2 Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 23 yes 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 1 Regulation 23 1)a) 2)a)? Requirement The Responsible Person Must take appropraite action so that the home is not used for any staff member to live on the premises. To inform the CSCI of the date members of Staff discontinue living at the home. Timescale for action (The company Respresent ative has agreed a date for the 20/7/05 for this regulation to be met. (this is a repeated requiremen t made at the previous inspection 8/8/05 2. 21 1) 2( 32 The Responsible Person must submit a detailed action plan to the Commission stating the action taken by the Company following the comments disclosed by all Staff members during the homes unannounced inspection on the 28th June 05 Some Staff felt that they were very busy and stretched to do the work and made comments that residents were rushed with food and sometimes they were not always able to shower people. “Staff moral is very low,..Staff feel that Staffing levels are too low and that Service Users care is affected…that Staff are asked to carry out kitchen duties F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Victoria Care Home Version 1.30 Page 24 3. 18 1 a 27 The Responsible Person must ensure that the staffing of the home meets the ongoing needs of the Service Users, and submit evidence to the CSCI describing the actions taken to meet this regulation and carry out a written assessment to show written evidence that the Staffing levels are appropriate at all times. 4. 19 9 c 29 5. 18 1 a 2 b 27 6. 16 2) n) 12 The Responsible Person must ensure all personnel files are in line with Schedule 2 of the Care Home Regulations 2001 and submit an action plan to the CSCI, Describing the actions taken to meet this regulation... The Responsible Person must provide documentary evidence to the Commission that all Staff at the home will be suitably qualified, competent and experienced to meet the needs of the Service Users , and submit a detailed action plan to the Commission stating what actions will be taken by the company to meet this regulation. The Responsible Person must consult Residents about the programme of activities to enable the developments in the activities programme to meet this regulation especially in providing support for EMI care, and submit a detailed action plan to the Commission stating what actions will be taken by the company to meet this regulation. F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc (this is repeated requiremen t made at the previous inspection) The company Respresent ative has agreed a date for the 26/7/05 for this regulation to be met. ) 8/8/05 (this is a repeated requiremen t from the previous inspection 9/8/05 8/8/05 Victoria Care Home Version 1.30 Page 25 7. 4 6 1 The Responsible Person must submit an updated and accurate Statement of Purpose to CSCI so that all parts of this regulation will be met. 8/8/05 8. 9. 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 38 15 30 Good Practice Recommendations To implement dates and signatures to all risk assessments to ensure they are all up to date. To develop the choices offered with menus and the accessibilty of suitable menus and review the current use of bain maries. To continue developing and updating training records and provide evidence of 3 days paid training for all Staff each year and review the accessibility of training in dementia and activities. To continue the developments in the activities programme to meet this standard .To continue developing areas in the home suitable to the Residents needs including the garden areas . The Responsible Person should produce an updated maintenance and decorating plan so that effective consultation and information can be provided for all parties., To continue with ongoing Staff meetings and develop the implementation of supervision and appraisals To develop ongoing and regular minuted staff and Resident meetings and develop areas of open discussions with all parties to keep them informed of all matters within the home.. To replace worn bedding throughout the home. 4. 12 5. 19 6. 7. 32 31 8. 9. 26 Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Burlington House, South Wing, 2nd Floor Crosby Road North Waterloo, Liverpool L22 0LG 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. Extracts may not be used or reproduced without the express permission of CSCI Victoria Care Home F53 F03 S5474 Victoria Care Home V242629 280605 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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