Inspection on 15/12/06 for Victoria Cottage Residential Home

This inspection was carried out on 15th December 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Victoria Cottage Residential Home 28/04/09

Victoria Cottage Residential Home 30/05/08

Victoria Cottage Residential Home 11/12/07

Victoria Cottage Residential Home 14/05/07

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 Key Unannounced Inspection 09:30 15th December 2006 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.V301439.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.V301439.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.V301439.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 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, which are well maintained and easily accessible. Fees range between £279-£350 a week. This information was provided by the manger, in the Pre- Inspection Questionnaire received at the Commission Social Care Inspection on 24/11/06. No information was provided of how service users can access a copy of the previous inspection report on the home. Victoria Cottage Residential home DS0000063057.V301439.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 seven daytime hours, including lunchtime. The main method of inspection used was called ‘case tracking.’ This involves selecting three residents and looking at the quality of the care they receive by talking to them, 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. The residents who were “case tracked” were not all able to help by giving an opinion about the care provided. Residents who could express opinions were spoken with and one relative who was visiting the home and one service users representative by telephone, their views are included in the report. Five 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 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 Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 6 family/friends, representatives and local community as they wish and exercise control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. A relative said of the manager “I am very Impressed with the dedication of the manager who obviously sets a high standard and is an excellent role model to the staff. I feel mum is looked after and loved” A representative said “The staff are very helpful, pleasant and very obliging, if I was ever in a position requiring the care and attention, which is given at Victoria Cottage I would not hesitate to put myself in the hands of the staff there.” 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. Comments also included that “staff emanate warmth and a breath of fresh air”. “Entrusting your loved one to other people is hard but I have complete faith in everyone at Victoria Cottage” Service users needs appear to be met by the number and skill mix of staff, however a staffing review should be undertaken in conjunction with health and safety protocols for infection control and duties of staff. 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 and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon and feel safe. Service users are protected from abuse. Service users live in a comfortable and clean environment and service users own rooms meet their needs, with their own possessions around them. Comments from relatives were made as follows: “Mum is occasionally incontinent but every effort is made to make her room smell fresh.” The home is always fresh and clean-excellent” Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Not all service users have the information they need to make an informed choice about where to live, neither have they written confirmation or a contract that the home can meet their needs, their needs are assessed before the move into the home but the home has admitted service users it is not registered for. 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. There were a number of health and safety hazards identified in the home and which are included in the Environment section of the report and in relation to training updates for staff in manual handling practices and first aid. The registered Provider must ensure that the manual handling operations Regulations 1992 are complied with and therefore consultation with the Environmental Health Officer is imperative in this area. Quality assurance monitoring within the service was weak. There was no evidence of provider visits as required by regulation 26 and there was no evidence of health and safety audits being carried out. The homes recruitment practices are not robust currently and do not protect service users fully. Staff are not appropriately supervised. Service users, where appropriate are responsible for their own medication, but are not fully protected by the homes policies and procedures for dealing with medicines. Victoria Cottage Residential home DS0000063057.V301439.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. Victoria Cottage Residential home DS0000063057.V301439.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.V301439.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3,4, 6, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all service users have the information they need to make an informed choice about where to live, neither have they written confirmation or a contract that the home can meet their needs, their needs are assessed before the move into the home but the home has admitted service users it is not registered for. 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. The home does not provide an intermediate care service. EVIDENCE: The statement of purpose available did not quite meet with Schedule 1 of the Care Home Regulations although the manager reported that she thought she had an updated copy this could not be located. Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 11 The Service user guide available on the day of the inspection contained a copy of the previous inspection report, but service users and relatives/representatives spoken with had not been provided with information about how to access a copy of the report A relative said that they had been issued with a copy of the service user guide on admission but a representative said they had not. 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. There were no completed contracts available for inspection, details of terms and conditions were seen in the Statement of Purpose, but this did not identify the room number or contain a section for signatures. Service users must have written conformation that the home can meet their needs. Three service users personal files were examined, including a service user admitted two days earlier. 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. No care plans had been devised for the newly admitted service user. The manager informed the inspector that it was her intention to complete them on the day of the inspection and reported that she would commence these as soon as she could. Staff were observed to have knowledge about the service users nutritional needs and confirmed that communication between the manager and each other was very good. 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. One service user who had been admitted in 2004 was noted to have a primary diagnosis of Dementia on admission despite the home not been registered to Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 12 provide a service for people with Dementia and a relative said that her mother had been diagnosed with Dementia prior to being admitted to the home. On speaking with the manager she said she was aware that the home could not admit service users with a primary need of Dementia, and that the home had no confirmation of the diagnosis of Dementia for one of them and the other service user had been admitted prior to the change in the regulation. The manager was informed that the Registration Regulations had been implemented since 2001; therefore the home is therefore in breach of these Regulations. That said there was no indication that the service users needs were not being met at this time. Service users must not be admitted to the home outside of the registration category it is registered for. Intermediate care is not provided at the home, this standard is not applicable. Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 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. Improved documentation in respect of service users healthcare monitoring is recommended to improve outcomes for service users. Manual handling practices require urgent attention to ensure the health and safety of service users and staff is fully protected and promoted. Service users feel they are treated with respect and their right to privacy upheld. Service users, where appropriate are responsible for their own medication, but are not fully protected by the homes policies and procedures for dealing with medicines. EVIDENCE: Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 14 Care plans and associated risk assessments, although basic, were in place for two out of three of the personal files examined, which informed staff of how the service users individual needs were to be met. The manager informed the inspector that she was intending to change the format to a new system and that the detail would be improved in this process. Service users and a relative spoken with confirmed that they were involved in their care plans and that the manager spoke with them at least monthly to review the plans of care and that they had signed the care plans. The care plans examined did not reflect this practice however, there was evidence of regular review and where service users needs had changed, care plans had been revised promptly. The National minimum standards state that care plans should be devised within five working days. The inspection took place only two days after admission of the new service user, however it is good practice to implement interim care plans for priority areas until detailed care plans can be completed. The manager commenced the care plans during the inspection. Completed copies should be forwarded to the inspector. 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. The health care of service users appeared well promoted and access to healthcare services promptly addressed. Evidence within the daily notes, care plans and comments made within the questionnaires, and by service users and a relative spoken with, confirmed that appropriate action is taken to obtain medical and specialist input for service users as required. Continence appeared well managed and the manager and staff confirmed that charts are implemented when there are areas of nutritional or pressure area concern. 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. There was good records of professional involvement such as GP visits, it is recommended that details of the actual consultation is documented with the record rather than in the progress notes to ensure a running history of information is present within the notes and not archived. Service users care plans contained risk assessments for mobility and manual handling and identified where there is a history of falls. Running records were not evident in respect of incidents of falls and accidents. Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 15 Weight records were not kept for everyone and not kept up to date monthly and this is needed to enable staff to fully evaluate the health and well being of service users on a regular basis. On the day of the inspection the inspector witnessed a service user take a fall and was able to observe the care provided. The manager and staff acted promptly and reassured the service user, however a full body check was not carried out prior to moving the service user to assess if there was any injury or whether the service user was in any pain. The manual handling techniques used by staff were observed not to be consistent with current good practice and it was identified that it had been at least two years since staff had undertaken refresher manual handling training and that first aid training updates was overdue. A requirement to address this urgently has been made. A relative commented” The staff have recognised when mum is unwell or needing a medication change” I have spoken personally on a number of occasions to the GP caring for my mum” Medication management was partly assessed as the manager reported that a pharmacist audit is expected. The medicine cupboard was kept locked and currently the home uses Lloyds Pharmacy Nomad system. Although there was some evidence that the administration and disposal of medication was appropriate, this was not provided in respect of safe storage and receipt of medication. The storage temperatures of medication are not being monitored neither was there any record of medicines received in the home or any method to audit trail the stock. There were no controlled drugs in use on the day of the inspection. One service user self medicates, however an appropriate risk assessment had not been carried out, nor was the individuals medication stored securely and this must be addressed urgently. The Medication Administration Record Charts [MAR] were not examined at this inspection. Staff have undertaken appropriate 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. Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 16 A number of dressings, a prescription cream, massage oil, Vaseline and surgical spirit were being stored in a set of drawers in a the main hallway, which was not appropriate. The manager removed these during the inspection. A 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. The manager reported that a pharmacist audit is to be undertaken in the next few days. A copy of the report must be sent to the Commission for Social Care Inspection 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. Staff spoken with confirmed that they knew how to treat service users with respect at all times and how described how this was promoted. Observations made of interaction between staff and service users on the day of the inspection supported this also. Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 17 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): 12, 13, 14, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 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 local community as they wish and exercise control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: Service users and representatives spoken with confirmed that they were happy with the level of activities provided. Staff, were observed playing table games with service users and reading the newspaper on the day of the inspection. Service users and relatives praised the staff for their efforts to escort them out and about within their local community. Trips were said to local pubs, shops, and events in the village. Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 18 Other 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. Records held in the home did not justify what was clearly being provided and therefore this should be developed. Service users and staff stated that they have a laugh together and that this was important to them. 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 relative said that staff, go the extra mile for everyone and said that staff had been there to support her with her relatives changing needs and deterioration in health and also particularly when her father died. Comments also included that “staff emanate warmth and a breath of fresh air”. “Entrusting your loved one to other people is hard but I have complete faith in everyone at Victoria Cottage” “I can always talk to someone about mum, I can ring if I’m anxious about her or unable to visit at a time I had arranged” 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. Mail was reported, to be, given unopened and rooms were very personalised. Service users handle their own affairs for as long as they wish to. One representative said, “The staff are excellent” Mealtimes were observed to be relaxed and the food provided appeared nutritious and varied. There is not a pre- devised menu but the cook plans this daily and service users are offered a choice of two options at lunchtime and a wide range of sandwich fillings at tea - time or something on toast. One service user is vegetarian and a special option is provided for this individual. It was recommended that all service users be offered vegetarian options also. Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 19 There were no service users on special or soft diets otherwise on the day of the inspection but one service users needs dietary supplements. 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. Service users confirmed that drinks are provided regularly and when requested and a relative stated that she was satisfied that her relative received adequate hydration and nutrition. Service users confirmed that they can take meals in their room should they need to. Adequate food stocks and food safety storage was noted to be satisfactory. Fresh fruit and vegetables were observed in the home and service users and relatives reported that extra snacks and treats are provided. It is recommended that menus are pre-devised and displayed in the dining room. Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 20 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): 16,18 Quality in this outcome area is good. 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. Service users are protected from abuse. 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, but as there was not sufficient evidence that service users had been issued with this document, the Registered Person should ensure that a copy is distributed. That said service users said that the manager asks them if they have any complaints and likes to know they are happy with everything. There were no complaints recorded in the complaints book and no complaints have been made to the Commission for Social Care Inspection. The complaints procedure needs updating to CSCI [Commission for Social Care Inspection] as still refers to NCSC [National care Standards Commission] The manager reported that she was familiar with Safeguarding Adults Protocols as she had previously had to follow these. Staff confirmed knowledge in what Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 21 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. Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 22 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): 19-26 Quality in this outcome area is poor. 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 many areas identified which require attention to improve the environment for service users. There are some identified areas, which may present a risk to service users health and safety, which the Registered Provider must address urgently. Service users have sufficient and suitable lavatories and washing facilities but an assessment of equipment and support rails is recommended. Service users own rooms meet their needs, with their own possessions around them. EVIDENCE: Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 23 The home was decorated up for Christmas on the day of the inspection and Christmas tapes playing which provided a festive and homely atmosphere. The home was clean and smelled fresh, but some areas were identified to the manager that would benefit from a spring clean and/or redecoration. The manager explained that the Provider has recently purchased the home and is working towards some refurbishment and redecoration. Some areas had recently been redecorated and a new office is being completed. There is outdoor space for service users, which is paved, however many of the slabs were raised and present a trip hazard. A requirement has been set for these to be levelled and made safe. One of the dining tables was unsafe as it moved about on its legs. Staff removed this from use at the inspector’s request. The manager reported that she had requested a new table from the Provider. 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. There were also some trailing cables, which could present trip hazards and square five socket adaptors were being used, which are not deemed safe. Toilet and bathrooms were clean but the support rails around the toilets were not secure and 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. The handrail in the ground floor shower requires replacement as the enamel has rubbed off. It is recommended that when the floor covering in the bathroom and toilets is replaced that non-slip type flooring is used. Some windows did not have restrainers fitted and these were identified with the manager for action. There were a number of bottles of toiletries left out in bathrooms, which should be kept in service users rooms or stored away in cupboards. Some flooring in the laundry and one service users en suite requires attention/ re –painting. Some light fittings in the bathrooms had missing shades/globes. Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 24 A light fitting in the bathroom on the first floor had exposed wiring, which needs urgent action. Service users bedrooms were personalised and homely and service users said they were comfortable and that they had everything they needed. Room 18 had plaster cracks, which need attention. Radiators were guarded. Several fire doors were wedged open and there was no fire risk assessment evident in the home. The Registered Person must consult urgently with the Fire authority to ensure that the home is compliant with the Fire Authority Regulations. The manager reported that the water outlets were regulated to safe temperatures, a sample check confirmed water was supplied at safe temperatures, however there was no records of sample water testing temperatures being monitored or evidence that systems were in place for the prevention of legionella. The manager had kept records of shower disinfection only. The laundry although small had a washer with sluice facility and drier. Outside drying facilities are also provided. An Ariel clothes drying rack is sited in a communal walkway, which is not appropriate, and consideration should be made to remove this. Liquid soaps and paper towels were observed and disposable gloves and aprons sited around the home. There was no antibacterial hand scrub noted to be in use and this is recommended. Only one small first aid box was seen in the home, which did not contain any dressings. It is recommended that a person be given responsibility for ensuring first aid supplies are adequate and stored appropriately. Staff confirmed what was documented that they had received training in hand washing MRSA and other infectious disease in the last twelve months but it is recommended that colour coding of apron use and isolation of care staff from the kitchen is implemented to improve infection control practices in the home. Staff were observed to wear the same tabards/aprons in the laundry, kitchen and dining room and when supporting service users. The kitchen area appeared to meet food safety standards but care staff were observed to wander in and out at various times. The manager stated that the Environmental Health Officer had approved for the kitchen door to be left open, however this was not evidenced in writing on the day of the inspection. Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 25 The Registered Person must consult with the Environmental Health officer in respect of ensuring suitable arrangements for maintaining satisfactory standards of hygiene in the care home. Comments from relatives were made as follows: “Mum is occasionally incontinent but every effort is made to make her room smell fresh.” The home is always fresh and clean-excellent” Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 26 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): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users needs appear to be met by the number and skill mix of staff, however a staffing review should be undertaken in conjunction with health and safety protocols for infection control and duties of staff. The homes recruitment practices are not robust currently and do not protect service users fully. Staff are trained to do their jobs but refresher training in Manual Handling, first aid and equalities and diversity would improve outcomes for service users. EVIDENCE: The staffing numbers provided appear to meet the minimum staffing levels for the number of service users, however a breakdown of staffing hours is needed and should be sent to the inspector, which demonstrates at least 210 care hours between 7am and 10pm are provided and in addition 36 hours catering hours and 36 hours for laundry and domestic hours. The manager reported that the home does not employ its own handyman and that the person previously contracted is not able to undertake maintenance work for them, which reflects perhaps why there were so many issues identified in relation to maintenance at this inspection. Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 27 Care staff are expected to undertake domestic and laundry duties and this may compromise the attention service users may need and this way of working also conflicts with infection control practices. Care staff were also observed to work in the kitchen during the inspection. Clearly there is a blurring of roles, which needs to be reviewed. That said service users and relatives said that there is always adequate staff around and that their needs were met. The manager had difficulty locating rotas requested for examination and although it is recognised that the office was in the process of transfer, organisation of records needs to be improved. Information provided by the manager in the pre –inspection questionnaire indicates that thirteen care staff are employed and one ancillary staff. Four staff have been identified as having NVQ level 2 or above. A copy of The General Social Care Code of Conduct was seen in the home and a copy of a blank induction and a completed induction for one staff member. Four staff personal files were examined and although it appears that staff have not commenced work prior to Protection Of Vulnerable Adults Checks and Criminal Records Disclosure checks, one staff member had only one reference evidenced on file, two had no application forms and three had no identification or photograph. Two staff had been employed from overseas and no police checks had been obtained from their country of origin. The Registered Person is therefore in Breach of Regulation 19 Schedule 2 and Schedule 4 of the Care home Regulations. There was no record of induction on the files, no record of supervision or appraisal but training records were seen to be kept. The manager did not appear to keep well organised records and improved practice is recommended to ensure all appropriate documentation is available for inspection. Training records were examined but these were not easy to always follow. Staff confirmed what was seen on records that they had undertaken training in Food hygiene, health and safety, infection control, fist aid, medicine management, abuse awareness and fire safety. Manual Handling and first aid training refreshers are needed to ensure staff are kept up to date with appropriate good practice. Staff should undertake training in equalities and diversity. Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 28 Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 29 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): 31,32, 33, 35, 36, 37, 38 Quality in this outcome area is poor. 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 person fit to be in charge, of good character and which has a staff team who are respectful of the manager. Staff are not however appropriately supervised and quality monitoring is weak, despite some evidence that the home is run in the best interest of service users. The health and safety and welfare of service users and staff are not fully promoted and protected, several requirements have been made in this area, some of which are for urgent action. EVIDENCE: Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 30 The manager has been registered with the Commission for Social Care Inspection has completed the Registered Managers Award. A relative said of the manager “I am very impressed with the dedication of the manager who obviously sets a high standard and is an excellent role model to the staff. I feel mum is looked after and loved” A representative said “The staff are very helpful, pleasant and very obliging, if I was ever in a position requiring the care and attention, which is given at Victoria Cottage I would not hesitate to put myself in the hands of the staff there.” 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 within the service was weak. There was no evidence of provider visits as required by regulation 26 and there was no evidence of health and safety audits being carried out. There was evidence that the manager verbally asks service users if they are happy and one service user thought a survey had recently been undertaken, however the manager could only locate blank questionnaires and not any completed surveys or state what the result of the survey was. There are no resident relative meetings held currently. 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 but there was no indication of appropriate supervision or appraisal as required by regulation. Many records requested by the inspector could not be located, including accident records, rotas, staff information, surveys, risk assessment, equipment servicing, water temperature check test records, contracts, etc, the manager said this was due to the office being in a mess and the move to a new office, however those records that were examined were disorganised, not fully completed or not sufficient to provide supporting evidence to meet the regulation or national Minimum standards. The manager had informed the inspector in the pre-inspection questionnaire that there had been two deaths in the home, in the last twelve months but had not notified the Commission For Social Care Inspection as required under Regulation 37. Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 31 There were a number of health and safety hazards identified in the home and which are included in the Environment section of the report and in relation to training updates for staff in manual handling practices and first aid. The registered Provider must ensure that the manual handling operations Regulations 1992 are complied with and therefore consultation with the Environmental Health Officer is imperative in this area. Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 32 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 1 2 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 3 2 2 X 3 2 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 1 1 1 Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 33 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 Requirement The Registered Person must ensure the Statement of Purpose available meets with Schedule 1 of the Care Home Regulations 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. Service users must have written conformation that the home can meet their needs. The Registered Person must not admit service users outside of the Registration Category Timescale for action 15/02/07 2 OP1 5 15/02/07 3 4 OP2 OP4 14 14 15/02/07 15/02/07 5 OP9 13 The Registered Person must 15/01/07 ensure that arrangements are in place for the recording, handling, safekeeping and administration and disposal of medicines received into the care home. 1, The storage temperatures of medication are not being monitored. Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 34 2, neither was there any record of medicines received in the home or any method to audit trail the stock. 3, One service user self medicates, however an appropriate risk assessment had not been carried out, nor was the individuals medication stored securely and this must be addressed urgently. 6 7 OP9 OP19 17 13,23 Urgent Action Provide CSCI with a copy of the outcome of the pharmacy audit. 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 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. There were also some trailing cables, which could present trip hazards and square five socket adaptors were being used, which are not deemed safe. 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. 9 OP19 13,16,23 Support rails around the toilets must be made secure 15/02/07 15/01/07 15/01/07 8 OP19 13,23 15/02/07 Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 35 10 11 OP19 OP19 13,23 13 The handrail in the ground floor shower requires replacement as the enamel has rubbed off. Ensure all windows have restrainers fitted Ensure the light fitment in the bathroom on the first floor, which has had exposed wiring, is repaired. Urgent Action 15/02/07 15/01/07 12 OP19 23 Several fire doors were wedged open and there was no fire risk assessment evident in the home. The Registered Person must consult urgently with the Fire authority to ensure that the home is compliant with the Fire Authority Regulations. Urgent Action The Registered Person must consult with the Environmental Health officer in respect of ensuring suitable arrangements for maintaining satisfactory standards of hygiene in the care home. Including water temps and prevention of legionella Recruitment The Registered Person is therefore in Breach of Regulation 19 Schedule 2 and Schedule 4 of the Care home Regulations. The Registered Person must ensure training is provided for staff in Manual Handling and first aid. The Registered Person must ensure Quality monitoring systems are in place, that service users are consulted about the care provided and that DS0000063057.V301439.R01.S.doc 15/01/07 13 OP26 13 15/02/07 14 OP29 19 schedule 2,4 18 15/02/07 15 OP30 15/02/07 16 OP33 24, 26 15/02/07 Victoria Cottage Residential home Version 5.2 Page 36 17 OP36 18 18 OP37 17,37 visits are made and recorded under the requirements of Regulation 26 The registered person must ensure that staff receive appropriate supervision and records are kept for this. The Registered person must ensure that records are available for inspection at all times. The registered person must provide written notification of the deaths identified during the inspection and of all incidents identified under Regulation 37 thereafter. 15/02/07 15/02/07 19 OP38 13[4][a] 20 OP38 13[5] The Registered Person must 15/01/07 ensure that all parts of the home are so far as reasonably practicable free from hazards to their safety Urgent Action 15/02/07 The Registered person shall make suitable arrangements to provide a safe system for moving and handling service users. The registered Provider must ensure that the manual handling operations Regulations 1992 are complied with and therefore consultation with the Environmental Health Officer is imperative in this area. 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 Good Practice Recommendations DS0000063057.V301439.R01.S.doc Version 5.2 Page 37 Victoria Cottage Residential home 1 2 3 Standard OP1 OP2 OP3 4 OP7 5 6 OP8 OP8 7 8 OP16 OP22 9 OP27 Provide information to service users and their representatives how to access a copy of the inspection reports for the home Ensure service users contracts are provided and available for inspection, details of terms and conditions, identify the room number or contain a section for signatures. 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. 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. Weight records were not kept for everyone and not kept up to date monthly and this is needed to enable staff to fully evaluate the health and well being of service users on a regular basis. The complaints procedure needs updating to CSCI [Commission for Social Care Inspection] as still refers to NCSC [National care Standards Commission] 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. Undertake a staffing review in relation to blurring of roles and responsibilities and to ensure minimum staffing hours are provided. Provide evidence of this to the Commission for Social Care Inspection. Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Victoria Cottage Residential home DS0000063057.V301439.R01.S.doc Version 5.2 Page 39 - 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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