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Inspection on 13/12/07 for Victoria House

Also see our care home review for Victoria House for more information

This inspection was carried out on 13th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

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

Residents and relatives who returned questionnaires and those spoken with during the inspection were happy with the care that they received and the staff that care for them. Many of the staff and residents` have been at Victoria Road for many years and good relationships have developed between staff and residents and their relatives. Staff were supportive of residents and understanding of their anxieties regarding the planned temporary move to a new home. Visiting arrangements are flexible and visitors are greeted and made welcome by staff. There is a programme of activities, which includes visits from external musical entertainers and also some motivation sessions. Residents were looking forward to the visit from the hairdresser on the day of the inspection. They also talked about some of the Christmas preparations that they had been involved in such as making a Christmas cake and making decorations. All residents spoken with were happy with the meals provided and confirmed that they were offered choices.

What has improved since the last inspection?

Significant improvements have been made since the last inspection. The shortfalls identified appear to have been taken seriously by the organisation and action has been taken to address them. All eleven requirements set at the last inspection have been met. These included areas such as information about the services, the adequacy of the care planning to support staff in meeting residents` needs, monitoring of health care needs and the management of medication. Staff report that the new care plans are much easier to use and they are able to find information about residents needs more quickly. New medication procedures have been introduced to improve the handling of medicines and senior staff are checking to ensure that staff are following them. Requirements were also made about staffing and the storage of dental cleansing tablets which have been addressed. Improvements have been made in all areas, which has improved the standard of care and support and reduced the level of risk to residents.

What the care home could do better:

While medication records are generally good for the receipt, administration and disposal of oral medication, carers do not always record the application of prescribed creams. Recommendations have also been made about the monitoring of storage temperatures for medication, use of inhalers and the need for regular medication audits to check policies and procedures for the safe management of residents medication are followed by all staff.

CARE HOMES FOR OLDER PEOPLE 77 Victoria Road Care Home 77 Victoria Road Rushden Northants NN10 0AS Lead Inspector Kathy Jones Unannounced Inspection 08:45a 13 December 2007 th 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.V354346.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.V354346.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 0AS 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 ****Post 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.V354346.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 10th August 2007 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. It is planned for residents to move to Thornton House in Kettering for a period of several months while building and refurbishment work is carried out to upgrade the facilities at 77 Victoria Road. A firm date had not been set at the time of the inspection though it was anticipated that it would be sometime in January 2008. 77 Victoria Road Care Home DS0000060005.V354346.R01.S.doc Version 5.2 Page 5 The fees are paid at a rate negotiated with Northamptonshire County Council who funds the placements. The rates are dependent on assessed needs and at the time of the inspection in August 2007 the fees were quoted as £405.40, £420.40 or £435.40 per week. The above fee covers accommodation, personal care, meals and laundry. 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. Information about the services provided are detailed in the service user guide and a copy of the most recent inspection report is available in the home. 77 Victoria Road Care Home DS0000060005.V354346.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. The report of the last inspection, which was carried out on the 10th August 2007 was reviewed. An improvement plan had been submitted by Shaw Healthcare, which detailed the actions that they were going to take to address the requirements made following the last inspection. The focus of this inspection was to check that action had been taken to address the shortfalls and reduce the risk to residents. Surveys were sent to a random sample of residents, relatives, staff and health professionals. One survey from a resident, four from staff and three from relatives were received. The comments have been taken into account as part of the inspection. The unannounced inspection visit covered the morning and afternoon of a weekday. A Pharmacist Inspector accompanied the Lead Inspector for part of the inspection and carried out a sample check of the management of residents’ medication. 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’ and staff during the inspection to ascertain their views. No new staff had been employed since the last inspection therefore staff files were not checked; however the adequacy of recruitment procedures in safeguarding residents’ were discussed. 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. 77 Victoria Road Care Home DS0000060005.V354346.R01.S.doc Version 5.2 Page 7 Verbal feedback was given to a temporary manager in charge of the home at the time of the inspection. What the service does well: What has improved since the last inspection? Significant improvements have been made since the last inspection. The shortfalls identified appear to have been taken seriously by the organisation and action has been taken to address them. All eleven requirements set at the last inspection have been met. These included areas such as information about the services, the adequacy of the care planning to support staff in meeting residents’ needs, monitoring of health care needs and the management of medication. Staff report that the new care plans are much easier to use and they are able to find information about residents needs more quickly. New medication procedures have been introduced to improve the handling of medicines and senior staff are checking to ensure that staff are following them. Requirements were also made about staffing and the storage of dental cleansing tablets which have been addressed. Improvements have been made in all areas, which has improved the standard of care and support and reduced the level of risk to residents. 77 Victoria Road Care Home DS0000060005.V354346.R01.S.doc Version 5.2 Page 8 What they could do better: 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.V354346.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.V354346.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 assessed, as intermediate care is not provided. Quality in this outcome area is good. 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 and information is available to help people make more informed decisions. EVIDENCE: A survey received from a resident confirmed that they received enough information about the home before moving in to help them decide that it was the right place for them. Copies of the statement of purpose and service user guide, which provides information about the home and services provided, were available in the foyer and also in residents’ rooms. A copy of the most recent inspection report was available in the foyer. 77 Victoria Road Care Home DS0000060005.V354346.R01.S.doc Version 5.2 Page 11 A sample check of the information available identified that there is information relevant to helping people make decisions about their care. Advice has been given to provide clearer information about the fees. One of the weekly fees quoted appeared to be the fee once any benefit entitlements had been deducted, however this was not clear in the information. It is recommended that more information about the fees is included to help people compare and make informed decisions about their care. No new residents have been admitted since the last inspection in August 2007. At the time of the inspection there was a policy not to take planned admissions due to the fact that all residents are going to be moved to a temporary location while building work is carried out. The previous inspection confirmed that prior to admission an assessment of needs is carried out and that sufficient information had been gathered about their needs to ascertain if their needs could be met in the home. This helps to ensure that the needs of people admitted to the home can be met. 77 Victoria Road Care Home DS0000060005.V354346.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 good. This judgement has been made using available evidence including a visit to this service. The care provided is good and the improvements that have been made in the care planning and risk assessment systems provide staff with better information to meet residents needs. The management of medication has also improved with better procedures in place, however improvements are still needed in record keeping in relation to prescribed creams and inhalers. EVIDENCE: A survey received from a resident stated that they usually get the care and support that they need and always get the medical support that they need. Three surveys from relatives identify that they also feel that residents get the care that they need and one stated, “on reflection they do very well on all matters”. A sample check of residents care plans and care records identified that there had been a big improvement in the documentation to identify residents care 77 Victoria Road Care Home DS0000060005.V354346.R01.S.doc Version 5.2 Page 13 needs and the support that they need to meet those needs. The care plans appeared to be reflective of residents needs and there was evidence that their needs were reviewed and also that the quality of the care planning was being reviewed. Staff were aware of the importance of keeping the care plans up to date, particularly with the pending move to Thornton House to ensure all staff are aware of residents current needs. A survey received from a member of staff identified that the new care plans contain information in a more simplified format making it quicker to access. The accessibility of the information is particularly important in helping to ensure that staff are able to consistently give the care that a resident needs. There had also been an improvement in relation to the assessment and monitoring of residents’ health care needs. Where a visit is requested fro a General Practitioner the reason for the visit and the outcome with any advice given, which helps to ensure residents health care needs are met. Assessments had been carried out to identify residents who are at risk of pressure ulcers and those at nutritional risk. A District Nurse spoken with during the inspection had no concerns about the care provided and confirmed that staff refer any concerns promptly to the District Nurse. Records for a resident with a pressure ulcer confirm regular visits by the District Nurse. The handling of medicines has improved and good detailed records are kept to show the receipt, administration and disposal of medication particularly tablets and capsules. Carers gave clear, detailed answers when asked about medication for individual residents. There is a new procedure where carers put a dot on the record sheet before taking medication to residents and then sign the record after they have seen residents take the medicine however not all carers are following this new practice. Administration records are less accurate for inhalers and skin preparations. Records for the administration of inhalers that are prescribed for regular use showed gaps or the code ‘not needed’ recorded. Junior carers apply prescribed creams and ointments, which are kept in individual baskets in a locked cupboard. Accurate records are not being kept to show that carers have checked which creams and ointments need applying and signed afterwards to confirm correct application. One carer said that she had not signed the record for the creams she had applied on the morning of the visit. Information about medication for individual residents has improved with details kept about changes made by health professionals and information about the use of medicines included in care plans. However there is still a lack of detail to 77 Victoria Road Care Home DS0000060005.V354346.R01.S.doc Version 5.2 Page 14 inform carers about medicines prescribed for ‘when required’ use, medicines used for certain conditions and where residents said they did not need or want them. Medicines are kept securely but maximum and minimum temperatures are not being taken for medicine fridges and no records are kept of clinic room temperatures to show that medicines are stored within the temperature range recommended by the manufacturer. There are also medicines kept in the fridge that do not need fridge storage. 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.V354346.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: Residents spoken with were happy with their lifestyle at 77 Victoria Road and they confirmed that the routines are relatively flexible in that they are able to get up and go to bed when they want. Breakfast was observed to be served as and when residents got up. Two residents spoken with were looking forward to having their hair done on the day of the inspection. There is a programme of activities, which includes visits from external musical entertainers and also some motivation sessions. One resident talked about some of the recent activities that they had taken part in which included making Christmas decorations and a Christmas cake. The resident said she was also going to be making some Christmas cards. 77 Victoria Road Care Home DS0000060005.V354346.R01.S.doc Version 5.2 Page 16 Visiting arrangements are flexible and residents said they can have visitors as and when they wish. A survey received from a relative said that they were kept informed of any significant issues affecting the well being of a resident. Residents are offered a choice of meal and staff were heard discussing options with residents. Staff were aware of individual preferences and residents all said that the food was very good. Nutritional assessments are carried out to identify those residents who need additional support and monitoring. 77 Victoria Road Care Home DS0000060005.V354346.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 (CSCI) have received no complaints directly about the service since the last inspection. However were made aware of concerns about pressure area care for a resident, which were reported to social services under safeguarding adult procedures. The concerns were being appropriately investigated by the organisation and pressure area care and care planning had been reviewed to protect residents. Information received in surveys from relatives and a resident and discussion with residents during the inspection identified that they had no concerns but were aware of who to speak to if they were unhappy with the care. A copy of the complaints procedure was available with information in the foyer and also in residents’ rooms. Contact details are given for the head office of Shaw Healthcare in case people do not wish to raise concerns directly with the manager. Advice was given to include contact details for social services who have a responsibility for ensuring that the care they purchase for residents is of a good quality. 77 Victoria Road Care Home DS0000060005.V354346.R01.S.doc Version 5.2 Page 18 It was identified at the inspection in August 2007 that training records confirmed that staff had received training in safeguarding vulnerable adults during April and May 2007. Discussion with staff confirmed that they are clear about their responsibilities towards the vulnerable people in their care. This helps to protect residents. 77 Victoria Road Care Home DS0000060005.V354346.R01.S.doc Version 5.2 Page 19 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: There are plans to rebuild and refurbish the whole building and improve the facilities provided. in order to meet residents’ needs. Since the home was originally built the needs of people coming in to residential care have increased and it has been acknowledged that the building does not adequately meet the needs of all residents. For example 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. 77 Victoria Road Care Home DS0000060005.V354346.R01.S.doc Version 5.2 Page 20 Residents will be relocated to Thornton House in Kettering for several months while the building work takes place. Residents appeared well informed about the planned move, though as would be expected expressed some anxieties. Staff were quick to provide residents with reassurance about the move and the fact that they would be able to take their belongings with them. A sample tour of the premises identified that the home was clean and comfortable. A survey from a resident confirmed that the home is always fresh and clean. It was identified at the time of the inspection in August 2007 that some wheelchairs were not being serviced and maintained creating a risk to residents. This has been addressed and there was evidence that wheelchairs had been serviced and they looked in much better condition. 77 Victoria Road Care Home DS0000060005.V354346.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. The additional staff training and development is helping to ensure that staff have the necessary knowledge and skills to meet the needs of residents EVIDENCE: Observations during the inspection confirmed that there was enough staff to meet residents’ needs. Comments in surveys received from staff identify that it is sometimes necessary to use agency staff sometimes at short notice, which is not the same as having permanent staff familiar with residents and their needs. However discussion with staff on duty at the time of the inspection confirmed that where possible the same agency staff are used in order to have some consistency. A survey from a resident identified that they felt that they usually get the care that they need and that staff listen and act on what they say. Surveys from staff identify that there are some long serving experienced staff working at the home. Two surveys identify the need for improved teamwork but all feel that a good standard of care is provided and that the reputation of the home is good locally. 77 Victoria Road Care Home DS0000060005.V354346.R01.S.doc Version 5.2 Page 22 Discussion with staff, a temporary manager and a company trainer identified that a lot of training has been provided recently. It was evident through discussion that a review of staff training needs has been carried out and training planned to address identified shortfalls based around meeting residents needs. A requirement was made following the inspection carried out in August 2007 about the need for a more thorough recruitment process to protect residents. It was identified that no staff have been employed since the last inspection, however discussion with a temporary manager confirmed that she was aware of what is required. 77 Victoria Road Care Home DS0000060005.V354346.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The additional management support has helped to improve standards 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. However the adequacy of the management arrangements, are considered a key aspect of ensuring that residents receive appropriate care and are therefore commented on. 77 Victoria Road Care Home DS0000060005.V354346.R01.S.doc Version 5.2 Page 24 The Acting Manager was on sick leave at the time of the inspection and the home was being managed by one of two temporary managers who have been providing additional management support. The Commission for Social Care Inspection were also informed following the last inspection that other senior staff from the organisation have worked in the home alongside staff to help address identified shortfalls in specific areas and to ensure that company policies and procedures are implemented. This inspection has confirmed that considerable improvements have been made particularly in relation to the management of medication, and care planning which have a direct impact on the standards of care provided. Although 77 Victoria Road is due to close for refurbishment shortly, it is important that the improved standards are maintained throughout the temporary move to Thornton House. Quality assurance documents were not reviewed during this inspection, however discussion with the Area Manager following the last inspection confirmed that the organisation had become aware of the need to consider the adequacy of the quality assurance systems to ensure any decline in standards is identified. Small amounts of money are held on behalf of some residents to help them to pay for things such as hairdressing and chiropody treatment. The management of this money was looked at during the inspection in August 2007 and good systems, which protect residents, were found to be in place. Changes to the storage of dental cleansing tablets had been made since the last inspection reducing the risk of asphyxiation to residents with dementia. No health and safety concerns were identified during the inspection. Discussion with staff confirmed that they receive training in safe working practices such as movement and handling, food hygiene and first aid. 77 Victoria Road Care Home DS0000060005.V354346.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 3 X 3 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 3 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 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 77 Victoria Road Care Home DS0000060005.V354346.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 OP9 Regulation 13 (2) Requirement Accurate, complete and up to date records must be kept to show the administration of all medication including skin preparations and inhalers. Timescale for action 30/01/08 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. Refer to Standard OP9 Good Practice Recommendations The arrangements for the monitoring of storage temperatures should be reviewed to ensure that medication is kept within the temperature range specified by the manufacturer. Regular medication audits should be undertaken to ensure that all carers who administer medication are following the current medication policies and procedures. Information relating to medication in care plans should be reviewed to ensure that there is sufficient detail relating to DS0000060005.V354346.R01.S.doc Version 5.2 Page 27 2. OP9 3. OP9 77 Victoria Road Care Home medicines prescribed for when required or as directed use and where residents are refusing medicines to ensure that all medicines are used safely and correctly. 77 Victoria Road Care Home DS0000060005.V354346.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Midland Regional Office Unit 7 Interchange 25 Business Park Bostocks Lane Nottingham NG10 5QG 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.V354346.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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