CARE HOMES FOR OLDER PEOPLE
Victoria House 2 Victoria Road Poulton Le Fylde Lancashire FY6 7JA Lead Inspector
Christine Marshall Unannounced Inspection 09:45 13 March 2006
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 Victoria House DS0000009714.V281536.R01.S.doc Version 5.1 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 House DS0000009714.V281536.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Victoria House Address 2 Victoria Road Poulton Le Fylde Lancashire FY6 7JA 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) 01253 892400 Mrs June Patricia Wilkinson Mrs Pauline Elliott Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Victoria House DS0000009714.V281536.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The service is registered to accommodate a maximum of 15 service users in the category OP (older persons 65 and over) 13th June 2005 Date of last inspection Brief Description of the Service: Victoria House provides residential care and is registered to accommodate 15 residents of either sex, aged 65 years and above. The home is situated in a residential area of Poulton-le-Fylde and is close to shops and local amenities. The home is run in a homely manner with a friendly, informal atmosphere. It is also situated on a bus route and is close to the railway station. Residents are encouraged to retain their links in the community and help is given to ensure that relationships, hobbies and interests are pursued. Relatives, friends and visitors are made welcome at any time. Communal accommodation is situated on the ground floor and the bedrooms are situated on the ground and first floors. A lift and chair lift is installed to assist those residents who cannot manage stairs. Victoria House DS0000009714.V281536.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the second of two inspection visits, scheduled from 1st April 2005 to 31st March 2006. This unannounced inspection took place over two hours during the morning. A tour of the home included bedrooms, lounge and dining areas and bathrooms. The people who live at the home told the inspector that they would like to be referred to as residents. Residents and relatives were spoken to, and all said that they were comfortable and happy. The registered provider, manager, kitchen staff and carers were spoken to. Everyone was very friendly, welcoming and co-operative throughout the visit. What the service does well:
This home provides good care for its residents, many of whom suffer from some confusion. Victoria House provides a friendly informal atmosphere where staff encourage visits and contact with family and friends in the community. Many family members visit daily and spend time with residents in their own rooms, some go out for part of the day, mealtimes then become quite flexible, lunch or dinner can be “saved” until the resident returns to the home. Meals are varied with an alternative choice available. The chef will also prepare cooked snacks for residents. Those spoken with said they likes living at the home and felt well cared for. Comments from residents included “This home has everything I need, I couldn’t wish for more.” “Everything is lovely.” “I am well looked after, I get up and go to bed when I want.” Victoria House DS0000009714.V281536.R01.S.doc Version 5.1 Page 6 One relative said, “I am more than happy with the care that my mother receives, and I am always made to feel welcome.” Another relative said “ My mother’s care changes along with her changing needs, which is really good.” What has improved since the last inspection?
The new manager has worked very hard to make improvements to the home and the owner has fully supported her in this. The home has achieved the Investors in People (IIP) quality system and all of the paperwork for the home, for example letterheads, brochures and invoices, have the IIP logo on, so that any prospective or existing resident can see the quality mark. A new medicine cupboard has been fitted to the wall outside of the kitchen, for safe storing of medicines. A portable air-extractor has been purchased for the smoking area of the home and this reduces the affects of cigarette smoke for other residents who do not smoke. Staff training programmes have been prioritised and all of the home’s staff have now undertaken the mandatory training of Moving and Handling, Health and Safety, First Aid, Fire and Elder Abuse Awareness. This makes sure that the residents are cared for by staff who are trained properly. The dining room has been redecorated and this looks very light and attractive for the residents to have their meals. New signs for the Home have been fitted outside and in and this improves the look of the home. New garden decking and seating has been purchased so that the residents can enjoy the garden during the warmer months. A new Statement of Purpose has been developed to show the name of the manager, her qualifications and those of the staff who work at the home: This gives any prospective resident good information about the manager and her staff. Care plans are signed by the resident or their relative when they are first developed and then on each review; this shows that there is agreement about the care that is being given by the home. Victoria House DS0000009714.V281536.R01.S.doc Version 5.1 Page 7 A new washing machine has been purchased that has a sluicing programme on; this will make doubly sure that laundry is sterilized and clean before it is put on any resident’s bed. 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. Victoria House DS0000009714.V281536.R01.S.doc Version 5.1 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 House DS0000009714.V281536.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No judgement has been made. EVIDENCE: These standards were assessed on the previous inspection visit and were met. Victoria House DS0000009714.V281536.R01.S.doc Version 5.1 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8&9 Residents’ health care needs are fully supported and their welbeing is protected by safe medication systems. EVIDENCE: The residents’ care plans showed that they have access to the chiropodist, dental care and district nurses; they are registered with the GP of their choice and residents and relatives confirmed this. The medication system is the Nomad where daily doses of tablets are put in a cassette and popped when it is time to take them. One resident is responsible for taking her own medicines and has signed a disclaimer for this. The supplying chemist recently checked the home’s systems and found that there were no problems. Checks on the records for giving medicines showed that these are signed and dated properly by the staff: Those members of staff who give medicines have all been given training for this. Victoria House DS0000009714.V281536.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 14 Lifestyles for the residents are flexible at this home and there is an open door policy for relatives and friends. EVIDENCE: A number of residents and relatives were spoken to and each said that they had full choices of their daily activities. When they went to bed, or got up was their own choice as was when they want their breakfast, lunch or tea. Social activities are provided by the home and these include clothes parties, Tai Chi armchair exercises, outings and one to one spontaneous activities such as manicures or reminiscence. An extra member of staff is on duty each Tuesday and Thursday to accommodate the activity programme. Talking books are provided for the residents who have sight difficulties and the manager and her deputy act as key-workers for the residents’ personal needs such as toiletries, clothing, sweets and keeping the bedroom wardrobes and drawers tidy. One resident said “I can do whatever I want.” and another said “You can’t get better than here.”
Victoria House DS0000009714.V281536.R01.S.doc Version 5.1 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): No judgement has been made. EVIDENCE: These standards were assessed on the previous inspection visit and were met. Victoria House DS0000009714.V281536.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The residents live in a safe, clean, warm and comfortable environment and are supported in their personal preferences. EVIDENCE: The residents’ bedrooms are very personalised and individual and are kept very clean and tidy. The furnishings are of a good standard and many had the resident’s own items of furniture. Residents and their relatives said that they were very happy with the bedrooms and one resident said “I have plenty of space in here and a nice big bed for my comfort.” The manager is currently doing a risk assessment in each resident’s room to see who might need an extension lead for their call bell. Victoria House DS0000009714.V281536.R01.S.doc Version 5.1 Page 14 There is a refurbishment programme that is ongoing with plans to paint the outside of the home in the Summer and to provide a new dishwasher for the kitchen. Victoria House DS0000009714.V281536.R01.S.doc Version 5.1 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Staff have the appropriate training, qualifications and experience necessary to give a good care service to the residents. EVIDENCE: The new manager has focused on the staff induction, training and supervision programmes and these were very well recorded. Each staff file that was looked at showed the training programmes that had been done and the ones that were planned for the future. The deputy manager and a carer confirmed that they have had all of the mandatory training, with the deputy manager also being the home’s Fire Marshall and Health & Safety officer. Victoria House DS0000009714.V281536.R01.S.doc Version 5.1 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 & 38 The home makes sure that the best interests of the residents are protected in that there are regular health and safety checks that focus on the quality of care that is provided. EVIDENCE: There is a quality monitoring system for the home and this means that the home is a preferred provider for the local social services. These systems involve residents and relatives’ surveys and the results of these are included in the two-monthly newsletter that is produced for the residents and their relatives. The home does hold some personal monies for residents. These were checked and found to be accurately recorded; however the total monies in the cash tin was over the amount recorded on the balance sheets and it was advised that
Victoria House DS0000009714.V281536.R01.S.doc Version 5.1 Page 17 the residents monies be kept in individual envelopes so that these can be checked for correct balances on each deposit and withdrawal. The manager readily agreed that this would be a better method and will implement this immediately. All health and safety checks are done including fire drills and current safety servicing certificates are in place. Victoria House DS0000009714.V281536.R01.S.doc Version 5.1 Page 18 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x 3 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 Victoria House DS0000009714.V281536.R01.S.doc Version 5.1 Page 19 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. Standard Regulation Requirement Timescale for action 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 3 Refer to Standard OP19 OP31 OP35 Good Practice Recommendations Residents with restricted mobility should have extension leads fitted to their call system in their bedrooms. The registered manager should be NVQ level 4 qualified by July 2006 Personal monies kept at the home should be in individual envelopes and should have the balance checked on each deposit or withdrawal. Victoria House DS0000009714.V281536.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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