Inspection on 14/05/07 for Victoria Cottage Residential Home

This inspection was carried out on 14th May 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 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 Cottage Residential Home 28/04/09

Victoria Cottage Residential Home 30/05/08

Victoria Cottage Residential Home 11/12/07

Victoria Cottage Residential Home 15/12/06

Victoria Cottage Residential Home 09/02/06

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 Cottage Residential home 13 Station Road Lowdham Nottingham NG14 7DU Lead Inspector Jayne Hilton Unannounced Inspection 14th May 2007 9:00 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 Cottage Residential home DS0000063057.V336688.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 Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Cottage Residential home Address 13 Station Road Lowdham Nottingham NG14 7DU 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) 0115 966 3375 Sun Care Homes Ltd Andrea Josephine Clark Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 2006 Brief Description of the Service: Victoria Cottage is a care home providing personal care and accommodation for 18 older people. The home is owned by, Mr Pancholi. The home is located in the village of Lowdham, close to shops, pubs and other local amenities. The home was opened in 1984 and consists of a converted 2 storey house with a newer purpose built extension. All the home’s bedrooms are single and 9 of the bedrooms have en-suite facilities. There is a passenger lift. The home has small gardens. Fees range between £283-£350 a week. This information was provided by the manger, in the Pre- Inspection Questionnaire received at the Commission Social Care Inspection on 30/04/07. No information was currently provided to service users their relatives/visitors how they can access a copy of the previous inspection report on the home. Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 5 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 two visits seven daytime hours on 14/5/07 and one hour on 23/5/07. Further time was spent on the 24/5/07 reviewing care notes. A total of ten hours was spent on this inspection. The main method of inspection used was called ‘case tracking.’ This involves selecting four residents and looking at the quality of the care they receive by talking to them, wherever possible, examining their care files and discussing how support is offered to them by staff members. Many of the people who live at this home have a very limited ability to understand and communicate. Therefore many judgements in this report are from observation and reading residents’ records and documents. Some of the residents who were “case tracked” were not all able to help by giving an opinion about the care provided. Eight questionnaires from service users and relatives were returned to the Commission for Social Care Inspection and the manager completed a pre – inspection questionnaire. Information obtained in these, have been used within the report also. Three members of staff and the manager were spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to residents. A partial tour of the building was undertaken. All communal areas were seen and a sample of bedrooms to make sure that the environment is safe, well maintained and homely. What the service does well: Service users live in a home, which is managed by a person fit to be in charge, of good character and which has a staff team who are respectful of the manager. Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 6 A relative said “They deliver holistic care to everyone, the home cant do anything better, the manager is a wonderful role model to all”. Care plans and associated risk assessments, although basic, were in place for all of the personal files examined, which informed staff of how the service users individual needs were to be met. The service users health, personal and social care needs are set out in an individual plan of care and service users healthcare needs are met. Service users feel they are treated with respect and their right to privacy upheld. Service users needs appear to be met by the number and skill mix of staff, Service users live in a comfortable and clean environment Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service user’s and representatives spoken with confirmed that they were mostly happy with the level of activities provided. What has improved since the last inspection? A new table has been provided in the dining room. There were no trailing cables. The handrail in the ground floor shower has been replaced. Toiletries were not left out in bathrooms. The missing shades/globes in bathrooms/toilets, have now been replaced/repaired. A light fitting in the bathroom on the first floor, which had exposed wiring, has been repaired. Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 7 Fire doors were kept closed. The manager reported that the Environmental Health Officer had visited and was happy that systems were in place for the prevention of legionella and that food safety practices were satisfactory. An ariel clothes drying rack, which was is sited in a communal walkway has been removed. What they could do better: The health and safety and welfare of service users and staff are not fully promoted and protected, requirements have been made in this area, some of which are for prompt action. Service users, where appropriate are responsible for their own medication, but are not protected by the homes policies and procedures for dealing with medicines. The homes recruitment practices are not robust and do not protect service users. Refresher training for staff in manual handling and first aid will ensure that staff have the necessary skills for safe practice. Ten requirements have been set, including the above issues. Some requirements set at the previous inspection have not been fully met and are therefore outstanding. Failure to comply with the new timescales set may lead to enforcement action being taken. Nine good practice recommendations have been made also. Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 8 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. The summary of this inspection report can be made available in other formats on request. Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have the information they need to make an informed choice about where to live, have written confirmation or a contract stating that the home can meet their needs, their needs are assessed before the move into the home. The home does not provide an intermediate care service. EVIDENCE: The statement of purpose was available but did not quite meet with Schedule 1 of the Care Home Regulations although the manager reported she was still working through the documentation. The Service user guide available on the day of the inspection contained a copy of the previous inspection report, but service users and Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 11 relatives/representatives spoken with had not been provided with information about how to access a copy of the report. The manager reported that the registered provider had ordered extra copies so these can be given to existing residents. It is recommended that information is posted in the home, which informs service users, their relatives and other visitors to the home, how they can access a copy of the inspection report. There was no other evidence that every service user or their representatives had been issued with a copy of the service user guide and non were observed in residents rooms. Both Statement of Purpose and Service user guide require updating to meet the regulations fully. Service users are issued with a contract and these were viewed, but this did not identify the room number or contain a section for signatures. A service user who had recently moved into the home had written confirmation that the home could meet their needs. Four service users personal files were examined. All contained assessments. Where social workers had been involved in the placement and Extended Community Care Assessment was present. The homes own assessment document meets standard 3.3 in relation to the areas of need covered, however it is recommended that the agenda of equality and diversity is further developed in the home in general and that the assessment document is expanded to identify any gender, sexuality, race and cultural needs of individuals and how these will be met. The assessment documentation should have a date when carried out and signature of person undertaking. The manager confirmed that she visited service users prior to admission wherever possible to undertake the assessment of need. Assessments were noted to be reviewed and care plans changed as required. Further development of the assessment document would ensure that equality and diversity needs of service users were fully identified and addressed and whether the service is registered to provide for the individuals primary needs. Intermediate care is not provided at the home, this standard is not applicable. Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users heath and personal care needs are generally met, however, service users are not fully protected by the homes policies and procedures for dealing with medicines. EVIDENCE: Care plans and associated risk assessments, although basic, were in place for all of the personal files examined, which informed staff of how the service users individual needs were to be met. Not all of the care plans examined showed that service users or their representatives were involved or had agreed to the plan of care. Progress notes are only made when significant information needs to be recorded. Although there was evidence of good monitoring of concern and Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 13 follow up it is recommended that notes are completed daily and address the holistic needs of service users and their daily routines and choices made. The health care of service users appeared well promoted and access to healthcare services promptly addressed. Medication management was assessed, as the expected pharmacist audit discussed at the previous inspection had not yet taken place. The storage temperatures of medication are now being monitored. There were no controlled drugs in use on the day of the inspection. One service user self medicates, now has an appropriate risk assessment in place and the individuals medication is now stored securely. Staff, have undertaken some training in Safe Handling of Medicines, but policies and procedures need to be developed in line with The Royal Pharmaceutical Societies Guidance on Medication Administration in Care Homes. During the inspection it was observed that both members of care staff had left the dining room, leaving two open baskets containing the medication for several residents on the dining table and unattended. A requirement was set for Compliance with Regulation 13 [2] at the previous inspection undertaken on 15th December 2006 by 15th January 2007. Two action points included in the requirement had been addressed satisfactorily however the issue of poor audit trail of stock was found to be unmet at the inspection on 14th May 2007 and therefore the breech of Regulation not fully complied with. An improved system for the safe storage and transportation of medication is required as the current system in use may place service users at risk. An improved system for re-ordering and auditing stocks of medication is required as the current system in use may place service users at risk if they do not receive their medication as prescribed. Immediate action must be taken to ensure service users receive their medication at the times prescribed. An immediate requirement is set that The Registered Person ensures that arrangements are in place for the recording, handling, safekeeping and administration and disposal of medicines received into the care home. Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 14 Service users and relatives/representatives confirmed that privacy and dignity was always respected by staff and praised the staff and manager highly for their dedication and kindness. Victoria Cottage Residential home DS0000063057.V336688.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. Most 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. EVIDENCE: Service user’s and representatives spoken with confirmed that they were mostly happy with the level of activities provided. Activities provided include live entertainment, singers, local choirs and schoolchildren, scout groups etc, raffles, quizzes, group discussion, bingo, church services and therapeutic care, hand, arm and foot massage. A relative commented that she has been able to set a bird table up outside of her mum’s window and plant a garden for her Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 16 Records held in the home about the activities provision, did not reflect what was clearly being provided and therefore this should be developed. Another relative commented “My relatives major complaint is they don’t talk to you meaning, no – one, staff or other residents stop for significant periods of time to make social conversation. I believe this is largely an unrealistic expectation of what is practicable to provided in a residential home but it does lead to a reduced quality of life and the general lack of stimulation, does not help preserve the will to overcome difficulties. My relative is bored. In addition to physical care and support a resident’s companion type service would be useful and we would be happy to pay extra for this if one existed”. It is recommended that the manager take the comments made on board and look at improving ways to engage with service users who need extra support with their leisure time and for staff to have quality time within their shift to sit and chat with the people who live in the home. Visitors are welcome at any reasonable time and a relative and representative spoken with confirmed that they are always made welcome and offered drinks. A resident said “Carers always help me to keep contact with my relatives by telephone.” Comments also included that “ the staff team provides general loving care for all residents and welcoming support for visitors and relatives” Service users confirmed that they had choice and control within their life at Victoria Cottage and that the manager liked them to be happy. Observation of staff on the day of the inspection supported this. Information of advocacy services was seen posted in the home and the Service users guide. Service users handle their own affairs for as long as they wish to. One representative said, “The staff are excellent” There were no meal times observed at this inspection due to time being spent on other issues but service users reported that the food is very nice, served at an appropriate temperature and that on Fridays a full cooked breakfast option is provided. One relative said “My relative enjoys the food at the home and spontaneously tells people they feed you well there”. Victoria Cottage Residential home DS0000063057.V336688.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: Service users and their representatives said they were confident that any complaints would be dealt with, but they had no reason to complain. Information on how to make a complaint was seen in the Statement of Purpose and Service User Guide. There were no complaints recorded in the complaints book and no complaints have been made to the Commission for Social Care Inspection. The manager reported that she was familiar with Safeguarding Adults Protocols. Staff confirmed knowledge in what to do should they be concerned about the way a service user is treated and that they have undertaken training in abuse awareness. Service users and representatives confirmed that they felt safe in the home. It is recommended that the policy for Safeguarding Adults be updated to reflect the agreed protocols for Nottinghamshire. Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 18 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, 22 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a comfortable and clean environment but there are some identified areas, which still present a risk to service users health and safety, which the Registered Provider must address urgently. EVIDENCE: The home was clean and smelled fresh. Some areas had recently been redecorated and a new office has being completed. Some of the repairs and issues identified at the previous inspection Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 19 had been achieved and the overall standard of the environment was noticeably improved. There is outdoor space for service users, which is paved, however many of the slabs were raised and present a trip hazard. A requirement had been set at the previous inspection for these to be levelled and made safe. The manager provided quotes for the proposed work and said she hoped the work would be completed in the next few weeks. A gas fire in the lounge was protected by a fireguard but this was not fully secured and presented a hazard for service users should they use it to steady themselves. A requirement was set at the previous inspection for this and therefore is not met. Toilet and bathrooms were clean but the support rails around the toilets were not secure and it is recommended once again that the Registered Person obtain an assessment of the aids and adaptations within the home to ensure that they meet the needs of the current service users. Service users bedrooms were personalised and homely and service users said they were comfortable and that they had everything they needed. In one bathroom upstairs a wooden, painted chair was placed next to the bath which was loose at the joints this presented a risk to service users and the home needs to look at the provision appropriate aids and adaptations to ensure all service users individual needs are being met. The manager agreed to remove this chair at once. Disposable gloves and aprons were sited around the home however there were no paper towels or dispensers for these in the staff toilet and the toilet opposite room 5 and there was no antibacterial hand scrub noted to be in use. It is recommended that the registered person seek advice from the environmental health officer in relation to ensuring adequate infection control measures are in the home. The manager stated that the Environmental Health Officer had visited the home on 29th January 2007 and that only one issue was raised in relation to some cracks in the ceiling of the freezer/dry store area, which had now been rectified. Comments from relatives were made as follows: “The fixture sand fittings are not palatial the care love respect and dignity are second to none it is the care that matters at the end of the day”. “The interior of the home could be updated but this is outweighed by the care and dedication of the manager and staff”. Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 20 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 poor. This judgement has been made using available evidence including a visit to this service. The number and skill mix of staff meets Service users needs, however refresher training for staff in manual handling and first aid will ensure staff have the necessary skills for safe practice. The homes recruitment practices are not robust and do not protect service users. EVIDENCE: The staffing hours, provided for the home were examined and found to meet service users needs. However care staff is expected to undertake domestic and laundry duties and this may compromise the attention service users may need. The Registered Provider has made arrangements for periodic high cleaning. Information provided by the manager in the pre –inspection questionnaire indicates that twelve care staff are employed and three ancillary staff. Four Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 21 staff has been identified as having NVQ level 2 or above which equates to 40 . A copy of The General Social Care Code of Conduct was seen in the home. Three staff member’s personal files were requested for inspection. These were staff listed on the pre-inspection information as people employed at the home. One file was not available for inspection. The manager stated that this person was a Director of the Company employed for occasional cleaning duties. One file did not contain a photograph or proof of Identification and there was no application form and therefore no details of the persons work history or any evidence that written verification had been obtained as to why the person had left their previous places of employment working with Vulnerable Adults. Two references had been obtained but the manager could not confirm fully that at least one of these was obtained from the previous employer. A Criminal Records Disclosure was seen on the file, which indicated that the person had been employed by a care home in 2003. There was no evidence that the home had obtained an up to date Criminal Records Disclosure or had undertaken a Protection of Vulnerable Adults list check prior to the employment of this staff member. The third staff member’s file did not contain any information of Proof of identification as required by Regulation 19 schedule 2. At the previous inspection on 15th December 2006 a requirement was made in relation to breech of Regulation 19 Schedule2. The timescale set of 15th February 2007 for The Registered Person to meet the Regulation has not been met. Training records were examined, these showed that staff have been provided with induction and training in Medication management, manual handling health and safety, fire safety, abuse awareness, dealing with aggression, Infection control, Dementia Care, First aid, pressure area, Equality and Diversity and food hygiene. Staff confirmed what was seen on records that they had undertaken the said training. Manual Handling and first aid training refreshers are needed to ensure staff are kept up to date with appropriate good practice. Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 22 The manager stated that she has found difficulty accessing the training. It is recommended that the manager explore other options/providers of this training. Victoria Cottage Residential home DS0000063057.V336688.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, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a home, which is managed by a Registered Manager, staff are not appropriately supervised and the health, safety and welfare of service users are not fully promoted and protected, EVIDENCE: The manager has been registered with the Commission for Social Care Inspection has completed the Registered Managers Award. A relative said “They deliver holistic care to everyone, the home cant do anything better, the manager is a wonderful role model to all”. Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 24 The staff and service users spoken with praised the manager highly and it was clear that the long established staff had a strong team ethic and were committed to their role. Quality assurance monitoring is undertaken. Copies of service user surveys and provider visits were viewed. The manager stated that the home does not deal with any of the service users finances and due to time spent on other issues this area was not examined further. Staff said that the manager speaks to them regularly and staff meetings are held, but there was little evidence of appropriate supervision or appraisal as required by regulation. Organisation of records was noticeably improved. A number of disposable razors were seen in the bathroom drawers, these may present risk to service users safety as they need to be treated as sharp\items and be kept for individual service users. The way the razors were stored suggest that these were not kept for personal use only of individual service user and present a risk of cross infection should they be communally used. It is also recommended that the storage of disposable razors be included in the policy on ‘ Sharps.’ Victoria Cottage Residential home DS0000063057.V336688.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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X 2 X X X 2 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 2 X 1 Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement The Registered Person must ensure the Statement of Purpose available meets with Schedule 1 of the Care Home Regulations Previous timescale 15/02/07 NOT MET. This will ensure service users have the information they need about the home. The Registered Person must ensure the Service User Guide available meets with Schedule 5 of the Care Home Regulations and ensure every service user or their representatives had been issued with a copy. Previous timescale 15/02/07 NOT MET. This will ensure service users have the information they need about the home. 3. OP9 13 The Registered Person must 15/05/07 ensure that arrangements are in place for the recording, handling, safekeeping and administration and disposal of medicines received into the care home. DS0000063057.V336688.R01.S.doc Version 5.2 Page 27 Timescale for action 15/08/07 2. OP1 5 15/08/07 Victoria Cottage Residential home • Medication must not be left unattended at any time. An improved system for the safe storage and transportation of medication is required as the current system in use may place service users at risk. • Ensure residents receive their prescribed medication at all times. An improved system for reordering and auditing stocks of medication is required as the current system in use may place service users at risk if they do not receive their medication as prescribed. • Ensure medication with a use by date is dated upon opening. All handwritten entries made on the medication record must contain all details of the prescription [dosage and details of administration] and be witnessed by two competent staff members as correct. • An improved system for the management of medication is required as the current system in use may place service users at risk if they do not receive their medication as prescribed. Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 28 Immediate action must be taken to ensure service users receive their medication at the times prescribed. By 3.30pm 15/5/07. 4 OP18 19 schedule 2,4 • You are required to ensure that documentary evidence is held at the Establishment, which confirms that a Criminal Records Bureau Disclosure has been obtained in respect of all individuals employed to work at the Home. With regard to individuals who are working at the care home and employed by the registered provider you are required to ensure that documentary evidence is held at the Establishment which confirms that all checks have been obtained in relation to these individuals as required by regulation 19(4) You are required to be able to evidence at the establishment that an employee has not commenced work until you have all of the information and documents in relation to that individual as specified in schedule 2 paragraphs 1-9 except for a criminal records certificate. 15/05/07 • • You are required to ensure that any individuals employed at the Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 29 home (following receipt of a Protection Of Vulnerable Adults check, but while awaiting receipt of a Criminal Records Bureau Certificate) are supervised by an appropriately qualified and experienced staff member. Previous timescale 15/02/07 NOT MET. Timescale for compliance: Immediate Action must be taken by 11.30am 15th May 2007 The outdoor space for service users, which is paved, has many slabs, which were raised and present a trip hazard. The Registered Person must ensure these are levelled and made safe. Urgent Action Previous timescale 15/01/07 NOT MET. 6. OP19 13,23 A gas fire in the lounge was protected by a fireguard but this was not fully secured and presented a hazard for service users should they use it to steady themselves. Previous timescale 15/02/07 NOT MET. The Registered Person must take action in relation to the above identified issues to ensure all parts of the care home are free from hazards. 15/06/07 5. OP19 13,23 15/06/07 7 OP19 13,16,23 Support rails around the toilets must be made secure DS0000063057.V336688.R01.S.doc 15/07/07 Victoria Cottage Residential home Version 5.2 Page 30 Previous timescale 15/02/07 NOT MET. These present a hazard for service users should they use them to steady themselves. The Registered Person must take action in relation to the, above identified issues to ensure all parts of the care home are free from hazards. 8. OP30 18 The Registered Person must ensure training is provided for staff in Manual Handling and first aid. Previous timescale 15/02/07 NOT MET. This will ensure that staff, have the necessary skills in safe practices which protect service users from harm. 15/07/07 9 OP36 18 The registered person must ensure that staff, receive appropriate supervision and records are kept for this. Previous timescale 15/02/07 NOT MET. This will ensure that staff are appropriately supported and their skills assessed. 15/06/07 10. OP38 13 [4a] The Registered Person must ensure that all parts of the home are so far as reasonably practicable free from hazards to their safety Urgent Action Previous timescale 15/02/07 15/06/07 Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 31 NOT MET. Ensure disposable razors are treated AS ‘SHARPS’ and appropriately stored and disposed of after use. Service users are placed at risk of Sharps items if they are not stored safely. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP1 OP3 Good Practice Recommendations Display information in the home, which informs service users, relatives and visitors to the home how they can access a copy of the inspection reports. It is recommended that the agenda of equality and diversity is further developed in the home in general and that the assessment document is expanded to identify any gender, sexuality, race and cultural needs of individuals and how these will be met. The assessment documentation should have a date when carried out and signature of person undertaking. Progress notes are only made when significant information needs to be recorded. Although there was evidence of good monitoring of concern and follow up it is recommended that notes are completed daily and address the holistic needs of service users and their daily routines and choices made. Ensure all service users or their representative have agreed to their care plan. It is recommended that nutritional screening is undertaken for all service users and tissue viability tools used to ensure any potential risk is identified and monitored. Where authorisation is obtained for bedrails, the care DS0000063057.V336688.R01.S.doc Version 5.2 Page 32 3. OP7 4 5 OP7 OP8 6 OP8 Victoria Cottage Residential home 7 OP22 plan/risk assessment should inform the service user or their representative of the possible risks of placing bedrails and be signed by all parties. It is recommended that the Registered Person obtain an assessment of the aids and adaptations within the home to ensure that they meet the needs of the current service users. Ensure paper towels are provided in all WC’s and bathrooms and provide antibacterial scrubs around the home to promote infection control. Organise resident relative surveys on specific topics and demonstrate any action taken as a result of these. 8 9 OP26 OP33 Victoria Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Cottage Residential home DS0000063057.V336688.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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