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Inspection on 30/05/08 for Victoria Cottage Residential Home

Also see our care home review for Victoria Cottage Residential Home for more information

This inspection was carried out on 30th May 2008.

CSCI found this care home to be providing an Adequate service.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There are good arrangements to promote residents health and well being, including accessing healthcare services when needed. Staff are told how to respect residents` privacy and dignity which ensures that residents are cared for in a way that respects their privacy and dignity. Residents are able to take part in organised activities and individual activities can be arranged. Visitors are welcome and can take residents out. Where able residents can go out by themselves. Residents are provided with a varied diet with a choice of main meal and further alternatives are available. Residents sometimes have a cooked breakfast. There is a complaints procedure in the home and residents are aware of how to make a complaint.The home is kept clean and tidy and there are measures in place to prevent the spread of infection. The home provides a minimum of 2 staff on duty. There are staff who work in the kitchen and keep the home clean. This ensures that staff are available to see to residents needs. New staff can only start work when the required checks have been carried out, including a satisfactory Criminal Records Bureau or Protection of Vulnerable Adults check and obtaining satisfactory references. This ensures that residents are cared for by people who are suitable to look after them. There is a suitably qualified and experienced manager in post. This ensures that the home is properly run in the best interest of residents. Residents are able to express their views on how the home is run through talking with staff and completing questionnaires which ensures that residents can have a say in how the home is run. The home will hold money for residents so they can make any purchases they want to. All transactions are signed for by 2 people. This ensures that residents financial interests are safeguarded. Regular checks and tests are carried out on the building and equipment, including the fire alarm to protect the health and safety of residents.

What has improved since the last inspection?

Care plans describe how residents` needs are to be met and staff uses these so they provide the care that residents require. These are kept under review. Medication is given out following the recommended safe procedures to make sure that residents are not put at risk when being given their medication.

What the care home could do better:

More details about the needs of any new resident must be collected as part of the assessment, including details of their ethnic origin and any significant relationships. Assessments should be dated to show when completed and signed to show who had carried out the assessment. Medication must be stored in an approved cabinet that meets current safety guidance. A record must be made of all food provided.Staff must be fully aware of the procedures to follow to ensure that residents are safeguarded. The must be a plan prepared to show how and when they physical condition of the home will be improved. Improvements must be made to the bathing facilities in the home so that residents can receive the support they require in a safe and dignified manner.

CARE HOMES FOR OLDER PEOPLE Victoria Cottage Residential Home 13 Station Road Lowdham Nottingham NG14 7DU Lead Inspector Stephen Benson Unannounced Inspection 30th May 2008 09:00 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.V365507.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.V365507.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 0115 966 4165 suncarehomes@hotmail.com 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.V365507.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th December 2007 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. The manager said on 30/05/08 that the fees for the service range from £295 £360 per week depending on dependency needs. There are additional charges for hairdressing and chiropody. Further information about the home is available in the brochure and service user guide a copy of the latest inspection report is available in the office and there is a notice in the entrance inviting people to read it. Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was our first visit to the home since 1st April 2008. Prior to the visit an analysis of the home was undertaken from information gathered over the last year including that from the Annual Quality Assurance Assessment they completed. The visit centred on looking at the key National Minimum Standards for older people. The site visit lasted for 6 hours and the main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the manager, staff on duty and care practices were observed. A district nurse were spoken with during the visit. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. Survey forms sent to the home by The Commission for Social Care Inspection had been completed by 4 residents and 3 relatives were seen. What the service does well: There are good arrangements to promote residents health and well being, including accessing healthcare services when needed. Staff are told how to respect residents’ privacy and dignity which ensures that residents are cared for in a way that respects their privacy and dignity. Residents are able to take part in organised activities and individual activities can be arranged. Visitors are welcome and can take residents out. Where able residents can go out by themselves. Residents are provided with a varied diet with a choice of main meal and further alternatives are available. Residents sometimes have a cooked breakfast. There is a complaints procedure in the home and residents are aware of how to make a complaint. Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 6 The home is kept clean and tidy and there are measures in place to prevent the spread of infection. The home provides a minimum of 2 staff on duty. There are staff who work in the kitchen and keep the home clean. This ensures that staff are available to see to residents needs. New staff can only start work when the required checks have been carried out, including a satisfactory Criminal Records Bureau or Protection of Vulnerable Adults check and obtaining satisfactory references. This ensures that residents are cared for by people who are suitable to look after them. There is a suitably qualified and experienced manager in post. This ensures that the home is properly run in the best interest of residents. Residents are able to express their views on how the home is run through talking with staff and completing questionnaires which ensures that residents can have a say in how the home is run. The home will hold money for residents so they can make any purchases they want to. All transactions are signed for by 2 people. This ensures that residents financial interests are safeguarded. Regular checks and tests are carried out on the building and equipment, including the fire alarm to protect the health and safety of residents. What has improved since the last inspection? What they could do better: More details about the needs of any new resident must be collected as part of the assessment, including details of their ethnic origin and any significant relationships. Assessments should be dated to show when completed and signed to show who had carried out the assessment. Medication must be stored in an approved cabinet that meets current safety guidance. A record must be made of all food provided. Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 7 Staff must be fully aware of the procedures to follow to ensure that residents are safeguarded. The must be a plan prepared to show how and when they physical condition of the home will be improved. Improvements must be made to the bathing facilities in the home so that residents can receive the support they require in a safe and dignified manner. 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.V365507.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Assessments do not contain all the information to ensure residents needs can be met or when they were completed. The home does not offer an intermediate care service. EVIDENCE: It was stated on the Annual Quality Assurance (AQAA) that, ‘A pre assessment of all new residents is undertaaken so all needs of residents are taken into consideration. A copy of nursing or any other assessment is obtained’ A sample of care files were seen and these contained pre admission assessments. These were not dated and did not state who had completed the assessment or where it took place. Information is not gathered about the Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 10 residents’ ethnic orientation or any detail of any significant relationship they may have had. There was a Local Authority assessment seen in the care file for a recently admitted resident which was dated prior to the resident moving into the home. The manager said that prospective new residents are encouraged to come and look round when she will assess them. If they do not come to the home the manager said that she will go to see them where they are, for example in hospital. Staff said that prospective residents come and look round and they complete a form with their particulars on. Staff said they check information they are given, particularly what medication they are on. Staff said they always know in advance when someone is moving into the home. In survey forms completed by residents, 4 residents said that they received enough information about the home before they moved in. A resident said, “I came and had a look round before moving in. I was assessed by a social worker from Newark”. There is no arrangement made for the home to provide an intermediate care service. Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 11 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ health, personal and social needs are met by care practices in the home. EVIDENCE: It was stated on the AQAA that ‘Our service users are encouraged to maintain control of their personal care where possible.’ A sample of 3 care files were seen and these were reasonably well organised, although could be better ordered. There were personalised care plans which were clearly written giving details of the suppoprt residents require and where they are able to do things for themselves. Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 12 Plans were reviewed on a monthly basis and some documentation seen was signed by the resident and/or their realtive, however the care plans seen were not. There were care plans seen for a variety of needs including short term memory loss, self neglect ands personal hygiene. Care plans referred to promoting residents privacy and dignuity and to resident’s personal preferences, for example one plan seen stated ‘discussed personal preferences, prefers a strip wash or shower.’ There were risk assesments seen for a range of potential risks, including falls, wandering and poor vision. The manager said she had been updating the care plans using more up to date formats. Staff said that the manager prepares the care plans and they write up the daily logs. Staff said the care plans help to ensure that everyone does what they are meant to do. In survey forms completed by residents, 4 residents said that they always receive the care and support they need. A resident said, “They treat me as family, which is very nice indeed. I do things for myself, I can see to my own shower”. Comments from relatives on survey forms included, “My mothers care is always first class. She is always neat, her room is kept clean and fresh. Her weight is stable’ and ‘If my mother is unwell I am contacted immediately. I met regularly with her health care team. Any changes however small are always discussed with me.’ It was stated on the AQAA that, ‘All clients have acccess to outside services’ and that ‘Nutritional food is served’. A record is made of any healthcare appointment in the care file. The manager said that they access healthcare services, which come into the home. A visiting district nurse said that the residents appear well cared for and staff always have residents ready for them when they visit. Staff said they promote residents healthcare through asking how they are and attend to any ailments they say they have. Staff said they watch for any signs of pressure sores and make sure residents have their glasses, hearing aids and dentures at the start of the day. Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 13 In survey forms completed by residents, 4 residents said that they always receive the medical support they need. A resident said, “Staff have been treating mew for wax in my ears, the district nurse is coming to syringe it next week. Medication is stored in a secure cupboard in a locked room, however this does not comply with the recent guidance for the storage of controlled drugs and an approved drugs storage arrangement is required. The manager said that a lot of work has gone into improving the medication systems in the home and the Medicine Administration Records seen were fully completed. There was a record made of any new or changed medication. Staff described good practices in giving out medication and said that one resident continues to her own eye drops and apply cream. This had been risk assessed. A resident said, “I’m given my medication, they make sure I take it, they give it to me one at a time”. The manager said that staff are given guidance about promoting residents privacy and dignity and this is discussed in staff supervision. Staff said they give residents options if they want any help and described good practices to protect and promote their modesty. A resident said, “What I can do on my own I like to do, I can manage my own shower. Staff always knock on the door”. Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 14 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have opportunities to satisfy their social and recreational interests. Residents are helped to exercise choice and control over their lives and receive a wholesome and balanced diet. EVIDENCE: It was stated on the AQAA that, ‘We strive to provide activities to suit different preferneces’ Staff and residents were seen talking and laughing together. A quiz took place in the morning and this involved several residents. This was done informally and residents made a number of references to other quizes and activities they had taken part in. The manager said that they do a quiz most days as residents enjoy these and that there is an exercise class every month. Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 15 Staff said they are meant to record when residents take part in activiites but they sometimes forget to do this. In survey forms completed by residents, 2 residents said that activities are arranged by the home they can take part in and 2 said they usually are. A resident said, “We have good fun, I enjoy the quizzes”. It was stated on the AQAA that, ‘We encourage family and friends to have an input and any suggstions are taken on board.’ The manager said that one resident goes out to church and communion is held in the home. Staff said that there is one resident who goes to a local club and another has a volunteer who takes her out for a walk. Staff said they will take residents with them to the shop or chemists if they are going to give them a chance to be outside. A resident said, “I go walkabouts when it’s nice. My daughter comes and fetches me.” The home does not have a fixed menu. The main meal is at lunchtime and recent dishes include poached salmon, sausage and onion plait, liver and onions, scampi and casseroles. There is a different type of fish on Fridays and a roast dinner on Sundays. A lighter meal is had at tea time with a choice of a hot dish or sandwiches. A pudding is provided at lunch and teatime and fresh fruit is available. The cook was seen going round asking each resident what they wanted for lunch and tea. Residents made different choices and one resident said he did not fancy lasagne but would like a welsh rarebit. This was added as a further choice for tea. Staff said they always ask residents what they want and don’t take it for granted what they will have. There is a book to record all meals served, however there is one resident who is a vegetarian an d a record is not made of the food provided for her. A resident said, ”We have a cooked breakfast on Friday mornings and I said that it was lovely but spoiled because there was no black pudding. The next week it was there and we had it again today.” Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents feel able to complain if they are not happy about something. The procedures for safeguarding adults are not yet properly in place. EVIDENCE: It was stated in the AQAA that, ‘We clearly display our complaints procedure in the front conservatory. We have not had any complaints.’ There was a log to record any complaints in, however no complaint have been rcorded. There have not been any complaints sent to us since our last visit to the home. The manager said that she needed to look at making more use of the complaints procedure as there may well be things that get resolved but not seen as complaints. Staff said there have not been any complaints made and anything said would be taken seriously. Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 17 In survey forms completed by residents, 4 residents said that they knew who to speak to if they were not happy and they knew how to make a complaint. One resident commented, ‘Never had reason to complain but I know the routine.’ A resident replied when asked if he had seen the complaints procedure, “I had it explained to me. If anything is wrong I will go and see the manager”. Information provided on The AQAA showed that there have not been any safeguarding referrals made and no safeguarding investigations have taken place. There have not been any referrals made to the Protection of Vulnerable Adults list. There was information seen about some recent training provided to staff called ‘Adult Protection basic awareness (POVA)’ however this training did not include information about current safeguarding practices and staff said it did not make them aware of the current safeguarding and adult protection procedures. The ‘Nottingham and Nottinghamshire Safeguarding Adults Policy, Procedure and Guidance for Alerters and Referrers’ could not be located, although there were some information posters about the process displayed in the kitchen and office. The manager confirmed after the visit that she has now obtained the booklet and has arranged fro further training. Staff were aware of the whistleblowing policy and showed some knowledge of safeguarding practices, but were not fully clear about them. A resident said when asked if he felt safe at the home, “No doubt about that”. Victoria Cottage Residential Home DS0000063057.V365507.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, 21 and 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some areas of the home are in need of decoration and the bathing arrangements could be improved. The home is kept clean and tidy. EVIDENCE: There décor in some areas of the home looked a bit ‘tired’ and in need of sprucing up. The manager said the main lounge is due to be decorated and have some new curtains. Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 19 Staff said that the building is cosy, but has some limitations, such as narrow corridors, but they make the best of it. Staff said they felt things would be improved with some decoration. It was stated on the AQAA, ‘Some carpets and chairs have been replaced’. A relaitve commented on our survey form, ‘The fixtures and fittings are not palatial but after all it is the care that matters and the care is excellent”. A resident said when asked what he thought of the decor, “It would be nice to see it brightened up”. The bath and shower areas have not been upgraded to take into account the increasing frailty of some residents and do not easily allow for residents to be assisted. There is a step up to enter the shower cubicles and these are not easy for staff to assist residents to turn round in or use a shower chair. Staff said they would be better able to promote residents’ dignity when bathing if there was a wet room and could use a shower chair. The manager also thought this would be a benefit. It was stated on the AQAA, ‘We also encourage to make cleanliness a priority’. A domestic was seen working in the home and areas of the home seen were clean and free from any odour. Staff said they had received infection control training and were seen using protective clothing. In survey forms completed by residents 4 residents said that the home is always fresh and clean. A relaitve commented on our survey form, ‘It does not smell like an institution, it is kept fresh and clean.’ A resident said, “They keep it clean. They will do your washing for you if you want them to”. Victoria Cottage Residential Home DS0000063057.V365507.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are sufficient and suitably trained staff employed at the home, ensuring that residents needs can be met. Residents are supported and protected by the home’s recruitment policy and practices. EVIDENCE: It was stated on the AQAA that, ‘We have a fairly constant and non changing workforce mandatory training goes on. staff are in the process of completing NVQ 2. All staff work welt together as a team.’ The manager has assessed the minimum staffing levels to be 2 care staff during the day, with a third on duty from 7.00 am until 11.00 am, and 2 care staff at night. In addition the home employs a cook and cleaner. In survey forms completed by residents, 4 residents said that staff are available when you need them. A resident said, “I think there are enough people on duty”. Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 21 The manager said that 3 staff have completed their National Vocational Qualification level 2 or higher and another is enrolled to do it. One member of staff said they had completed their National Vocational Qualification and another said they had been offered to do this but it was not part of her future plans. It was recorded on The AQAA that all people who have worked in the home in the past 12 months had satisfactory pre employment checks. Staff files seen showed that the correct recruitment practices are followed. The home follows their equal opportunities policy in the recruitment of new staff. Staff said new staff couldn’t work at the home until checks have been done. The manager said she was arranging dates for updates on mandatory training and the district nurses have agreed to provide training on diabetes. A resident said, “As far as I know they know what they are doing”. Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 22 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, 33, 35 and 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are suitable management systems in place for the smooth running of the home and to protect residents. Residents express their views on how the home is run. The health and safety of residents is promoted. EVIDENCE: The manager has been in post since 2004 and has completed National Vocational Qualification level 4. Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 23 Staff said the home is run very well and everyone is very close, it is like being one big family. Staff also said that maybe they should be pulled up more often if they let the paperwork slip. One resident commented on a survey form, ‘Victoria Cottage is run by a hands on manager who is always available to residents and families.’ A resident said, “She (the manager) speaks to everyone”. It was stated on the AQAA that, ‘Good communication between the manager, staff, residents, relatives, and other professionals.’ There is a system of seeking residents and relatives views through completing survey forms. Some recently completed forms were seen and these made positive comments about the care received. The home will hold money for residents to pay for hairdressing, chiropody and other incidentals. A record is made of each transaction and signed and witnessed. Receipts are kept when available. The manager said that all the required health and safety checks are carried out at the required frequency and there are service contracts in place for servicing all the equipment. It was stated on the AQAA that equipment is tested or serviced as recommended by the manufacturers or other regulatory body. A sample of these were looked at and found to be correct. A new fire alarm panel has been fitted as a problem was identified with the previous one. A resident said, “The fire alarm is often tested.” Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14(1)(a) Requirement More details about the needs of any new resident must be collected as part of the assessment, including details of their ethnic origin and any significant relationships. Assessments should be dated to show when completed and signed to show who had carried out the assessment. Medication must be stored in an approved cabinet that meets current safety guidance. A record must be made of all food provided. Staff must be fully aware of the procedures to follow to ensure that residents are safeguarded. There must be a plan prepared to show how and when the physical condition of the home will be improved. Improvements must be made to the bathing facilities in the home so that residents can receive the support they require in a safe and dignified manner. Timescale for action 01/07/08 2 3 4 5 OP9 OP15 OP18 OP19 13 (2) 17 schedule 4(13) 12 (1)(a) 23(2)(d) 01/08/08 01/07/08 01/08/08 01/08/08 6 OP21 23(2)(n) 01/03/09 Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Victoria Cottage Residential Home DS0000063057.V365507.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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.V365507.R01.S.doc Version 5.2 Page 28 - 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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