Inspection on 10/08/07 for Victoria House

This inspection was carried out on 10th August 2007.

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

The inspector 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 House 03/03/09

Victoria House 13/12/07

Victoria House 11/10/06

Victoria House 24/11/05

Victoria House 23/06/05

Victoria House 11/11/04

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE 77 Victoria Road Care Home 77 Victoria Road Rushden Northants NN10 0SA Lead Inspector Kathy Jones Unannounced Inspection 10th August 2007 08:40 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 77 Victoria Road Care Home DS0000060005.V340865.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. 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 77 Victoria Road Care Home Address 77 Victoria Road Rushden Northants NN10 0SA 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) 01933 417950 01933 417951 VictoriaRoad.Manager@shaw.co.uk www.shaw.co.uk Shaw Healthcare (de Montfort) Ltd Vacant Care Home 45 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (45), of places Physical disability over 65 years of age (6) 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. All re-development work detailed in the refurbishment plan submitted to the Commission on 25.04.04 must be completed by March 2009. The home may continue to accommodate 2 named service users who fall within the registration category MD(E) No one falling within the category of DE(E) may be admitted into the home where there are 8 service users who fall within the category of DE(E) already accommodated within the home No one falling within the category of PD(E) may be admitted into the home where there are 6 service users who fall within the category of PD(E) already accommodated within the home A total of 45 in the category of old age, not falling within any other category (OP) A total of 6 in the category of mental illness over 65 years of age MD(E) Maximum number of service users is 45 4. 5. 6. 7. Date of last inspection 11th October 2006 Brief Description of the Service: 77 Victoria Road is a residential care home currently owned by Shaw Healthcare. The home provides care for up to 45 Service Users over the age of 65 years. Within the homes total of 45 Service User up to 8 older people with dementia and up to 6 people with physical disabilities can be provided with personal care. The Home is situated within walking distance of Rushden town centre, has extensive gardens and all facilities are located on the ground floor. Service Users have easy access to local facilities and amenities. All bedrooms are single occupancy rooms with easily accessible communal areas. The home is made up of several smaller units, each with their own lounge, dining area and kitchenette as well as a central larger lounge and bar area. The fees are paid at a rate negotiated with Northamptonshire County Council who funds the placements. The rates are dependent on assessed needs and are currently £405.40, £420.40 or £435.40 per week. The above fee covers accommodation, personal care, meals and laundry. 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 5 Additional costs will include items such as private chiropody treatment and hairdressing, which are external, services which can be arranged. Currently chiropody treatment is £14 and hairdressing ranges between £7 for a shampoo and set and £20 for a perm. Other costs would be personal items such as toiletries, clothing and newspapers. 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. Standards identified as ‘key’ standards and highlighted through the report were inspected. The key standards are those considered by the Commission to have a particular impact on outcomes for residents. Inspection of the standards was achieved through review of existing evidence, pre-inspection planning, an unannounced inspection visit to the home and drawing together all of the evidence gathered. The pre-inspection planning was carried out over the period of a day and involved reviewing the service history, which details all contact with the home including notifications of events reported by the home, telephone calls and any complaints received. Reports of the last main (key) inspection carried out on the 11th October 2006 and two more focussed (random) inspections carried out on 11th January and 13th February 2007 to monitor compliance with requirements were reviewed. An annual quality assurance self assessment (AQAA) was reviewed as part of the inspection, however as this was not received prior to the inspection it did not form part of the planning. No questionnaires were received from relatives or residents on this occasion as this is prompted by information within the AQAA. The unannounced inspection visit covered the morning and afternoon of a weekday. The inspection was carried out by ‘case tracking’, which involves selecting samples of residents’ records and tracking their care and experiences. Observations of the homes routines and care provided were made and inspectors spoke with residents’, visitors and staff during the inspection to ascertain their views. The management of a sample of residents’ medication was checked. And a sample of staff files reviewed to check the adequacy of the recruitment procedures in safeguarding residents’. Communal areas and a sample of residents’ bedrooms were viewed and observations were made of residents’ general well being, daily routines and interactions between staff and residents. Verbal feedback was given to the Acting Manager throughout the inspection. The Inspector also spoke with the Area Manager following the inspection about the findings of the inspection and plans for improvement. 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: It would be helpful to prospective residents’ and their families if more information was provided within the service user guide to help them in making an informed decision about their care. Care plans need to be improved to ensure that they give detailed instruction to staff about how residents’ physical and mental health needs are to be met. The care plans are important documents in helping to ensure that residents’ receive consistent and safe care according to their individual needs. While staff appeared aware of changes in residents’ health, improvements are needed in the monitoring of residents’ health care, through better record keeping in relation to visits and advice given by doctors and other health 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 8 professionals. This helps to ensure that all staff are kept informed and aware of any specific advice given. Medication storage for controlled drugs and prescribed creams and the general management of the administration and checking of creams need to be reviewed to reduce risks. There also needs to be better recording in relation to medication to ensure that there is a clear audit trail and any discrepancies can be identified quickly and easily. In the run up to the transfer of residents’ care needs to be taken to ensure that equipment and premises are properly and safely maintained. A full review of the premises taking into account health and safety issues needs to be carried out to ensure residents are properly safeguarded. This needs to include making sure that all wheelchairs in use are safe and that products such as steradent which pose a risk to residents’ with dementia are safely stored. Staffing arrangements to include staffing levels need to be sufficient to meet the needs of residents’. A recommendation has been made to consider the adequacy of the quality assurance processes as although the shortfalls are now being identified and acknowledged there is evidence that some of the shortfalls are long standing issues. 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. 77 Victoria Road Care Home DS0000060005.V340865.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 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, standard 6 was not applicable, as intermediate care is not provided. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The admission process provides assurances that the needs of residents entering the home can be met. However additional information is needed to help people make more informed decisions. EVIDENCE: Information about the services provided was available in the foyer in the form of a statement of purpose and service user guide. Residents’ spoken with could not recall the information that had been made available to them prior to moving in to the home. However discussion identified that further information is required. For example, the Acting Manager agreed that a copy of the most recent inspection report would be made more accessible and be included with the information in the service user guide. This information is important in helping people to make decisions about moving into the home or about the care that they receive. 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 11 Information about fees is not included in the service user guide making it difficult for people to compare with other services. This again is important information to help people make decisions about their care. Review of the records for a recently admitted resident confirmed that there was sufficient information gathered about their needs to ascertain if their needs could be met in the home. The information gathered also included assessments carried out by the placing authority. This helps to ensure that the needs of people admitted to the home can be met. 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The shortfalls in the planning of residents’ care and management of medication have the potential to put them at risk. EVIDENCE: Residents and relatives spoken with during the inspection were happy with the care that they received. Staff conversations heard during the inspection indicated that staff were observing changes in a resident’s health and reporting this to senior staff. Requirements were made at the last main (key) inspection in October 2006 relating to care planning. Due to ongoing none compliance with requirements a targeted (random) inspection was carried out and from a sample check of care plans the requirements were found to have been met. However a sample check of care plans during this inspection identified continuing concerns about care 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 13 planning which are similar to those highlighted in the report of the inspection carried out in October 2006. For example the pre-admission assessment identified that the resident had a sacral sore. The inspector noted that a pressure mattress and a pressure cushion were in place reducing the risk of pressure ulcers. A care plan was developed at the beginning of June, which identified that the district nurse would visit to dress the sore. However there was no evaluation of the care plan and staff spoken with were not aware of the resident having a sacral sore or if the district nurse was still treating the sacral sore. A care plan for a resident with dementia was sample checked. Daily notes identified incidents where the resident had hit staff. Records showed that the Community Psychiatric Nurse had visited recently however there was no information about the outcome of the visit. There was no care plan in place to guide staff in managing the behaviours or meeting the residents mental health needs. There was evidence in residents’ records that health professionals are contacted on behalf or residents’ and one file reviewed indicated that staff were continuing to contact the General Practitioner regarding changes that they had observed in a residents’ health. Some of the records of health professional visits were poor in that the outcome of the visit was not always recorded and District Nurse visits did not appear to be always recorded making it difficult to check when a resident last had any treatment or of any specific advice given for staff. A sample check of the management of residents’ medication was carried out in one of the units during the inspection. This identified an issue in relation to the safe storage of medication. A small quantity of controlled drugs were held, which were stored in an appropriate locked cabinet, however they were not within a locked room as required for safe storage. The sample check of medication indicated that residents’ prescribed medication was available and records were in place to confirm administration of medication. The controlled drugs in one unit checked corresponded with quantities recorded in the register. However for other prescribed medication there was no record of medication, which is carried forward to the next medication cycle making it very difficult to carry out an effective audit of the medication. For medication with a short shelf life once opened such as eye drops, some containers were marked with the date of opening while others weren’t making it difficult to ascertain if the medication was still effective and safe to use. A sample check of residents’ bedrooms identified that the practice was to store prescribed creams in residents’ rooms. Several different creams were found 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 14 beside the sink in two bedrooms occupied by residents’ with dementia. There was no evidence of a risk assessment in place or of the safe handling of the creams. For example there was no stock rotation, consideration of contamination, or shelf life. One prescribed tube of cream had no lid to prevent contamination and part containers of cream dating back to 2004 were found. Residents’ spoken with did not have any concerns about how they were spoken to by staff and staff were observed to be mindful of residents’ dignity. 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Visitors are encouraged and welcomed into the home and residents’ confirmed that they were happy with the food and activities provided. EVIDENCE: There is a programme of activities in place, which includes in house activities. On the day of the inspection some residents’ were enjoying a glass of sherry and a game of bingo in the central area of the home. Twice a month there is musical entertainment provided by an outside entertainer and once a month there is a session, which includes physical and mental exercise. Staff and residents’ said that some residents’ like to go out on short outings. The activities organiser confirmed that she is trying to arrange some pub lunches for the end of August. Activities that residents’ have been involved in are recorded as part of the care records, though currently individualised care planning for activities is limited. 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 16 The annual quality assurance assessment acknowledges the need to involve all staff in supporting residents’ in daily activities and there are plans to provide additional training with this. This should help to enhance the daily lives of residents. Visiting arrangements are flexible which relatives spoken with confirmed this and staff were seen to be welcoming in their approach to visitors. Some of the visitors visit on a regular basis and are encouraged to do so which helps to enhance the daily lives of residents. The level of choice and control that residents’ have over their lives is largely dependent on their ability to voice their wishes. This is an area that could be developed as part of the care planning. The cook said that each day she checks with residents’ what they would like for their meals. Residents’ confirmed that they are offered a choice of meal and were satisfied with the food provided. Lunch on the day of inspection was fish, chips and mushy peas. Discussion with a resident identified that individual preferences are taken account of and she was going to have boiled potatoes with the fish. The cook said that another resident had asked for a burger, which was being arranged. This confirms that individual preferences are taken into account and respected. The main meal looked and smelt appetising and an alternative was quickly provided for desert, as the sponge was not properly cooked. 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are investigated appropriately and staff are aware of their responsibilities for protecting the people in their care. EVIDENCE: The Commission for Social Care Inspection have received no complaints about the service since the last inspection. Information held at the home identified that two complaints had been received directly by the service in this period. Letters of response were reviewed and these indicated that the issues raised had been investigated and responded to appropriately. In both cases the complaints appeared to have arisen through poor communication and is an area to be addressed. Residents’ and relatives spoken with had no concerns about how residents are treated and a resident spoken with said they felt able to raise any concerns that they might have. Training records identify that staff received training in safeguarding vulnerable adults during April and May 2007 and a staff member spoken with appeared clear about her responsibilities towards the vulnerable people in her care. This helps to protect residents. 77 Victoria Road Care Home DS0000060005.V340865.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, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and comfortable, however it is need of the planned redevelopment and refurbishment to provide more appropriate facilities to meet the needs of residents’. EVIDENCE: A sample tour of the premises identified that the home was clean and comfortable, though showing signs of wear and tear. For example following the last inspection some attempt had been made to place pictures on the bedroom doors of people with dementia to help them recognise their rooms. However some of these were in poor condition, were not easily recognisable and gave a poor visual impression. 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 19 There are plans to completely refurbish the whole building and improve the facilities provided. However in the meantime while people are living in the home it is important that standards are maintained to enable residents’ to live in a pleasant and safe environment, which meets their needs. Some of the bedrooms are very small with built in vanity units and wardrobe restricting the ability to accommodate a resident who requires a hoist for movement and handling. The annual quality assurance assessment identifies that there is a programme of servicing for things such as electrical equipment, emergency call systems and wheelchairs. It was however identified that at the time of the inspection there was a problem with staff having to use wheelchairs, which belonged to particular residents’ for other residents’ as some of the wheelchairs had not been regularly maintained. Poor maintenance of equipment poses a risk to residents’. 77 Victoria Road Care Home DS0000060005.V340865.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, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements are needed in the staffing arrangements in order to meet the needs and provide better safeguards for residents’. EVIDENCE: Residents’ and relatives spoken with were positive about the staff team and confirmed that they had no concerns about any of the staff and the care provided. There is an established staff team who have worked at Victoria Road for many years and know residents’ and their relatives very well. Discussion with staff, residents and relatives identified that staffing levels are variable and that there are not always sufficient staff to fully meet the needs of the residents’. On the day of the inspection there was a shortage of care staff partly due to sickness and staff were observed to be supporting and helping each other to meet the needs of the residents. The annual quality assurance self assessment completed by the Acting Manager acknowledges the need to review and revise the staff rota to make it more appropriate to meeting the needs of the residents’. Discussion with the Acting Manager confirmed that review of the rota is being prioritised. 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 21 Information received in the quality assurance self assessment identifies that only a small percentage of staff (15 ) of care staff have achieved a National Vocational Qualification (NVQ) at level 2 or above in care. It is considered important that at least 50 of staff have this training in basic care practices to help in understanding and meeting the needs of residents. There were however indications that some staff are keen to further their knowledge through training. For example two staff are currently working towards an NVQ in dementia care, which will help to give them an understanding of people with dementia. Two other staff are also keen to work towards this qualification. Discussion with staff and the Acting Manager indicated that training needs are being reviewed and training is being arranged to meet specific identified shortfalls. For example some care planning training has taken place and more is planned due to identified shortfalls in the planning of care to support residents’ needs. A sample check of staff files was carried out to check the adequacy of the recruitment process in protecting residents. Records confirmed that references and criminal record bureau checks are carried out. In one case where a staff member had started work before the criminal record bureau clearance had been received, there was evidence that a check had been made against the protection of vulnerable adults register and that the staff member had worked under supervision until the clearance had been received. As detailed above references are obtained, however review of one file identified that more care needs to be taken to review the information received as this indicated that a full employment history had not been declared. Due to the vulnerability of residents’ it is particularly important to check all information thoroughly. 77 Victoria Road Care Home DS0000060005.V340865.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, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The proposed concentrated period of additional management support working alongside the Acting Manager to review, improve and monitor care practices should help improve outcomes and reduce risk to residents. EVIDENCE: Standard 31 relates specifically to the registered manager and their experience and qualifications. At the time of the inspection there was no registered manager in post. Due to this no scoring has been given for this standard in the scoring of outcomes section. 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 23 However the adequacy of the management arrangements, are considered a key aspect of ensuring that residents receive appropriate care and are therefore commented on. There was no record of the Commission for Social Care Inspection being informed that the Registered Manager had left which raises some concerns about communication with the regulatory body. The Acting Manager who had been in post for four months at the time of the inspection has previous experience of managing a care home for people with similar needs. The Acting Manager demonstrated through discussion a good knowledge of current standards and good care practices. It was also evident from discussion throughout the inspection that the Acting Manager has in the time she has been in post, identified areas for improvement and begun to address the issues. The need to submit an application for registration was discussed. This inspection has identified various shortfalls in standards and indicates the need for a full review of all aspects of the service to ensure that residents are properly supported and safeguarded. Some additional management support had already been allocated to Victoria Road and the Area Manager has given verbal assurances that this support will be properly planned and focus on improving and sustaining improvements in specific areas such as the management of medication. This will allow the Acting Manager to concentrate on other areas and improve outcomes and reduce risk to residents’. An annual quality assurance self assessment submitted prior to the inspection did not fully reflect the extent of the shortfalls. Discussion with the Area Manager indicated that the extent of the shortfalls at Victoria Road had only recently become apparent to the organisation. This indicates the need to look closely at the adequacy of the quality assurance systems. Reports of unannounced visits by an Area Manager are part of the organisations quality assurance tools and are particularly important for monitoring standards in individual homes for which the organisation is responsible. A recent report (June 2007) seen during the inspection appeared quite comprehensive and appeared to be open about the areas where standards were not being met. Review of responses to previous inspection reports and recent discussions indicate a more honest and open approach, which gives more confidence that issues will be addressed. Good systems are in place to monitor the administration of resident’s pocket money accounts. Records and money held for one resident were checked and no discrepancies identified. Audits are carried out which help to safeguard residents’ monies. 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 24 There was evidence that review of equipment, staff practices and movement and handling need to be carried out to ensure that the health and safety of staff and residents’ is properly protected. Two tubes of “steradent” a dissolvable cleaning agent for false teeth were found beside the sink in the bedroom of a resident who has dementia. This poses a serious risk of asphyxiation to someone who may take this mistakenly. The movement and handling needs of a resident were discussed with staff and the movement and handling plan reviewed. Discussion identified that although the resident had moved rooms there were still difficulties for staff in carrying out safe movement and handling which protects them and the resident. Review of the movement and handling plan identified that this did not give staff sufficient guidance in how to safely transfer this resident or consider how the risks could be reduced. A sample check of records relating to staff training indicated that staff receive training in safe working practices such as movement and handling, food hygiene and first aid. 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score N/A X 2 X 3 X X 2 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 26 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 5 (1) (bb, bc, bd, d) Requirement A copy of the most recent inspection report and information about fees must be available within the service user guide to help people make informed decisions about their care. Care plans must be reflective of residents’ current care, physical and mental health needs and be sufficiently detailed to guide staff in providing appropriate and consistent care. Records relating to visits from health professionals must include the outcome of the visit in order that staff can implement any advice given regarding treatment or care. The room where the cabinet containing controlled drugs is stored must be locked as part of the arrangements for safe storage. Quantities of medication carried forward from the previous month must be recorded as part of an audit trail. This is to assist in monitoring safe practice in relation to the management of DS0000060005.V340865.R01.S.doc Timescale for action 30/09/07 2. OP7 OP8 12 (1) (a, b), 15 30/10/07 3. OP8 12 (1) (a, b) 30/09/07 4. OP9 13 (2) 07/09/07 5. OP9 13 (2) 30/09/07 77 Victoria Road Care Home Version 5.2 Page 27 6. OP9 13 (2) 7. OP19 23 (2) 8. OP27 18 (1) (a) 9. OP29 19 (1) (b) schedule 2. 6 10. OP38 13 (4) (c) 11. OP38 13 (5) residents’ medication. Review of the arrangements for managing prescribed creams must be carried out to ensure that they are safely stored, there is no risk of contamination and that they are used within the recommended timescale. A full review of the premises and equipment must be carried out to ensure that equipment and the appearance of the premises are maintained to a good and safe standard in the period up to the transfer of residents’ prior to refurbishment Staffing levels must be maintained at a level that ensures residents’ needs are met at all times. A more thorough check of information supplied as part of applications for employment must be carried out to ensure that all information including a full employment history has been declared. This is to help safeguard residents’. Steradent and other similar products must be stored securely to reduce the risk to a resident with dementia who may swallow the tablet. Individual movement and handling plans must be reviewed and revised to ensure that staff have clear and detailed guidance about how to transfer residents who require assistance safely. 30/09/07 30/09/07 30/09/07 30/09/07 07/09/07 30/09/07 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP28 Good Practice Recommendations Care plans should guide staff in supporting residents’ to have more choice and control over their lives. Efforts should be made to increase the number of staff who hold a qualification of at least National Vocational Qualification level 2 or equivalent to provide a higher ratio of trained staff. The adequacy of current quality assurance systems should be reviewed to ensure early identification of poor standards. 3. OP33 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 77 Victoria Road Care Home DS0000060005.V340865.R01.S.doc Version 5.2 Page 30 - 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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