Inspection on 14/06/05 for Victoria House

This inspection was carried out on 14th June 2005.

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 07/08/08

Victoria House 08/08/07

Victoria House 15/06/06

Victoria House 13/12/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Victoria House 25 Victoria Avenue Brierfield Nelson BB9 5RH Lead Inspector Pat White Announced 14 June 2005 9.30 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 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 F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Victoria House Address 25 Victoria Avenue Brierfield Nelson Lancs BB9 5RH 01282 697535 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Delta Care Ltd Mrs Maxine George (awaiting registration) Care Home 15 15 Category(ies) of Older People registration, with number of places Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 2. The home is registered to provide personal care for up to 15 service users who fall in the category of Older People (OP) Date of last inspection 27 January 2005 Brief Description of the Service: Victoria House is an older type detached two-storey house, in a residential area on the outskirts of Brierfield. The home is registered to provide accommodation and care for 15 older people over the age of 65 yrs of age. Accommodation consists of single and double bedrooms on the first floor, two lounges and a separate dining room on the ground floor. Two stair lifts join the two floors. Various aids and adaptations were in situ; including hand rails and grab rails. There were two bathrooms providing assisted bathing, including a shower. There were no en suite facilities, but commodes were provided in each bedroom and there were sufficient communal toilets. Delta Care Ltd purchased the home in February 2005 and Mr Baki of this company was the Responsible Individual. Mrs Maxine George was the appointed manager and at the time of the inspection was undergoing registration with the CSCI. There was a deputy manager in post. Victoria House received the Investors in People Award in 2002. Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an announced inspection, the purpose of which was to assess important areas of life in the home that should be inspected over a 12 month period, check the progress of previous legal requirements and good practice recommendations, and check other matters in the home which came to the inspector’s notice. The inspection took 9 hours, 15 minutes and comprised of, talking to residents, a tour of the premises, looking at resident’s care records and other documents, and discussion with the manager and the owner. Eight residents were spoken with and others were observed in their routine daily activities. One relative was spoken with. Three residents and 4 relatives completed comment cards. What the service does well: The home was successful in meeting the needs of the residents and did not admit residents whose needs could be met in the home. The needs of the other residents were taken into consideration when making these decisions. There is a good atmosphere in the home and residents and staff get on well. Positive comments from residents and relatives have also consistently been made with residents praising the environment, the food and the care given by staff. At this inspection all residents spoken with and who completed comment cards praised every aspect of the home. One resident on respite care said she did not want to go back to her own home and said Victoria House was like “A five star hotel”. Relatives who completed comment cards stated they were highly satisfied with all aspects of care in the home. Staff were praised for their kindness and patience. The home provides pleasant and comfortable accommodation with a high standard of décor and furnishings which suits the residents’ needs. Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: The way in which residents’ needs, and the plans for meeting these needs, were recorded could be further improved. Assessments of prospective residents’ needs that have been undertaken by social workers must be obtained by the home and more details regarding health and medical matters should be recorded on the residents’ plans for care. Medication management and procedures must be improved with priority to ensure the safety and well being of the residents. Staff recruitment must be improved to meet legal requirements and to help ensure the protection of residents from unsuitable staff. The registered persons must act immediately to ensure members of staff do not commence work until Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks have been obtained. Failure to do so will result in enforcement action being taken by the Commission. In addition the home needs to develop a system for recording all the stages in the CRB/POVA check applications and the problems encountered. Some safety aspects of the home could be improved. The registered person must ensure as a matter of priority that residents are not at risk from broken sash windows, and windows that open wide, and that all staff attend fire drills. Please contact the provider for advice of actions taken in response to this Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 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 standard(s) 3, 4 & 5 Standard 6 was not applicable The home’s admission procedures; including information provided, pre admission assessments and prior visits by prospective residents and relatives to the home, helped to determine whether or not the home could meet people’s needs. However the home must obtain any social work assessment that has been carried out and include this in the decision making process. EVIDENCE: Delta Care had produced and updated a Statement of Purpose and a Service User Guide. These were not fully assessed at this inspection. Residents and relatives were given a Service User Guide in order to provide information about the home and its facilities. The home’s Terms and Conditions” were being revised following recent recommendations from the “Office of Fair Trading” regarding care homes’ fees. The viewing of residents’ records showed that the assessments and care plans of most of the existing residents had been updated, and that the manager had undertaken pre admission assessments with those residents recently admitted. Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 10 The registered person had confirmed in writing to prospective residents that the home could meet their needs, and there was evidence that the home would not admit people with needs that could not be met in the home. After a re assessment, a resident in hospital at the time of the inspection would not return to Victoria House. The social work assessment for one resident admitted recently under care management arrangements had not been obtained. This assessment must be acquired retrospectively. This was the subject of a requirement at the previous inspection, and the practice of admitting residents without obtaining a copy of the social work assessment must cease. The in house assessment documentation included all the matters listed in standard 3.3 All residents spoken with and all those who completed comment cards indicated that their needs were met. Residents stated that they were happy living in the home, that they were well cared for and that staff treated them well. One relative stated that she thought the overall care in the home was of a high standard and that staff “interact with the residents in a kind, friendly and humorous way”. The admission procedures allow prospective residents and relatives to visit the home and meet staff prior to admission and therefore help choices to be made. The most recent admission was classed as an “emergency admission” from hospital. The manager visited the prospective resident in hospital and the relatives visited the home Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 9 The system and documentation for recording how the residents’ needs were to be met had been improved, and most care plans had been updated since the previous inspection. This process could be further improved by recording more information about residents’ health and personal care needs on the care plans. Residents’ health care was monitored and promoted, but to further enhance this, medication management and procedures must be improved. EVIDENCE: The documentation for detailing the plans for meeting residents’ needs had been improved and the care plans of most residents had been updated. The care plans included all matters listed in standard 3.3, and there were comprehensive risk assessments on matters relating to mobility, moving and handling and the risk of falling. Vulnerability to pressure sores was identified on the risk assessment and the registered person was advised to consider the use of a specific detailed risk assessment for this condition. The registered person was aware that these care plans should be reviewed approximately once a month. Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 12 The inspection methods used showed that residents’ health was promoted and maintained and that residents had access to all necessary health care professionals. However more details regarding residents’ health and medical needs must be recorded on the care plans. This should include the medical conditions of one of the most recently admitted residents, and whether or not residents require help with oral care. There must be clear evidence that risk assessments have been carried out on whether or not bedrails should be used and evidence that residents, their representatives and appropriate professionals have been involved in the decision. The prevention of pressure areas and the promotion of continence were encouraged in the home. The intervention and advice of the appropriate district nurses was sought. Information about diet and food preferences was recorded on the care plans, and residents’ weights were regularly monitored and recorded. It is recommended that comprehensive nutrition assessments be undertaken. Some aspects of medication management must be improved. Some of these matters have been outstanding over a number of inspections and must be addressed as a matter of priority. Therefore a number of requirements have been made which are repeated from the previous inspection. Some other requirements have been made which include: Staff must not sign for medication that has not been given. MAR sheets must contain an accurate record of the current medication prescribed, and any changes in instructions regarding doses must be clearly recorded. The temperatures of the medication storage areas must be monitored regularly. There must be a recognised means of identification of residents and a staff signature list. Eye drops must be supplied and used for each eye separately to prevent cross infection. Staff administering medication must undertake appropriate training from a qualified body. Standard 10 was not fully assessed but all residents who were spoken with, and those who completed comment cards, stated that their privacy was respected by staff and that all staff treated them appropriately. Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 12, 13, 14 & 15 Routines in the home were flexible enough to suit individual choices and preferences. Residents were encouraged to maintain contacts with relatives and friends and the wider community and visitors were made to feel welcome in the home at any time. The meals served were wholesome, appetising and well served and appeared to meet the preferences and tastes of the residents. EVIDENCE: Routines of daily living appeared flexible enough to suit individual residents’ expectations and preferences. Some of these preferences were recorded on the care plan. All residents spoken with, and those who completed comment cards, stated that there were suitable activities, such as playing games and movement to music. Contacts with family, friends and the local community were encouraged. Four relatives who completed comment card confirmed that they could visit the home at any time and were made very welcome. One visitor said, “staff are always friendly and welcoming”. Residents had enjoyed a recent trip to Pendle Hill. Delta Care had a minibus with wheelchair access. Residents were encouraged to exercise choice in their lives and remain as independent as possible. They had choices regarding rising and retiring times, food and activities, doctors, chiropodists, hairdressers and religious Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 14 observation. Residents could bring small items of furniture and had access to their personal records. Residents enjoyed appetising and wholesome food with a choice of a cooked breakfast. The meals were well served in a pleasantly decorated and furnished dining room. Members of staff gave appropriate assistance to those who required it. Whilst the menus seen did not show a great deal of variation, and it was noted that salad was not listed on the menu, the meals appeared to satisfy the preferences and tastes of the residents. All who were spoken with and the three who completed comment cards stated that they enjoyed the food served. Comments such as the “food is very good” were made. Drinks and snacks were served throughout the day and at supper - time. Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 16 & 18 The home had a complaints procedure which was understood by residents and visitors. Residents felt safe living in the home and this was supported by policies and procedures for the protection of residents from abuse. EVIDENCE: The home had a simple complaints procedure. No complaints had been reported or investigated since the previous inspection. All residents spoken with stated that they had no complaints and several stated they would not hesitate to speak to the manager or the owner if they were unhappy about any aspect of their care. The 3 residents who completed comment cards stated that they knew who to speak to if they were unhappy about any matter in the home, and the 4 relatives who completed comment cards stated that they were aware of the home’s complaints procedure. The home had an adult protection policy that included a whistle blowing policy and stated step by procedures to be followed in the event of an allegation or suspicion of abuse. Staff would benefit from guidance on dealing with aggression from residents, and procedures should be developed, according to standard 18.6, which support the protection of residents’ money and valuables. There had been no recorded incidents, or allegations of abuse in recent years and residents stated that they felt safe living in the home. Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 16 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 standard(s) 19 & 26 Victoria House provided a pleasant, clean living environment for the comfort and appreciation of the residents. The home was well decorated and furnished. The safety aspects of some parts of the home could be improved EVIDENCE: The home was well decorated and furnished and provided pleasant accommodation for residents. Grounds to the rear of the home provided an attractive outlook. Some carpets would benefit from cleaning or replacing. Broken sash windows must be repaired and the practice of propping broken windows open must cease. Risk assessments on the need for window restrictors according to the bedroom occupants had not been completed, and this must be done as a matter of priority (see standard 38). It is recommended that regular audits of the premises be undertaken to ensure rapid identification of, and action on, parts of the premises which need repairs and renewals Residents stated that they appreciated the living environment and were satisfied with their communal and private accommodation. Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 17 The home was clean and free from offensive odours, and there were appropriate infection control policies and procedures. Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 The home had sufficient staff on duty to meet the needs of the residents and the staff training programme was being developed according to the needs of the residents and staff. However the home’s staff recruitment policies and procedures did not meet statutory requirements, nor do they assist in the protection of residents from the appointment of unsuitable staff. EVIDENCE: The inspection methods used, including the viewing of rosters indicated that staffing levels were sufficient for meeting the needs of the service users. The catering and domestic hours also ensured high standards of cleanliness and meals in the home. Staff appeared caring and kind to residents and these were words frequently used by residents to describe the staff. Members of staff were observed giving appropriate assistance. The atmosphere in the home was convivial with an apparent good rapport between staff and service users. Service users spoken with praised the care and attitude of the staff and stated that they were well treated by staff. 50 of staff was trained to at least NVQ level 2, and members of staff had undertaken training in moving and handling and safe handling of medicines. New members of staff undertake the home’s induction training and the registered person must ensure that those members of staff without relevant qualifications, undertake an induction programme in accordance with the Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 19 “Skills for Care” specifications. Courses in dementia, diabetes, food hygiene and health and safety were planned. Staff records showed that, despite previous requirements, the home’s recruitment policies and procedures were still not in accordance with the Care Home’s Regulations, and therefore did not support the protection of residents from the appointment of unsuitable staff. Since August 2004 five members of staff had commenced work prior to the receipt of CRB/POVA checks, and these checks were still outstanding. Applications had been made for CRB and POVA checks, but not for “POVA first”, despite this being the subject of an “Immediate Requirement Notice” at the last inspection. A further “Immediate Requirement Notice” was issued to obtain “POVA first” for the five identified members of staff. The registered person must address this matter with urgency and notify the CSCI of the action taken to comply with this Requirement by the 14 July. Failure to do so will result in the Commission taking enforcement action. It is also recommended that the home develop a system for recording all the stages in the CRB/POVA check applications, the problems encountered and the outcomes. Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36 & 38 The new owner and manager were competent and fit to run the home. They were beginning to demonstrate leadership, and ideas for change for the benefit of the home, the residents and staff. Residents’ monies were managed appropriately and safeguarded. The health and safety of the residents and staff was promoted but further improvements need to be made. EVIDENCE: The manager, Mrs George, expected to gain NVQ level 4 in “Care” and the Registered Managers’ Award before the end of 2005. At the time of the inspection she was undergoing registration with the CSCI. She had numerous years’ experience of looking after elderly people and demonstrated the necessary skills and commitment to the job. Delta Care purchased Victoria House in February 2005 and Mr Baki the “responsible individual” was closely involved in the day to day running of the home, and supportive to the manager, staff and residents. The changes in the Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 21 management team had lead to a change in approach within the home that should benefit both residents and staff. Residents spoken with stated that their lives had not been adversely disrupted by the changes in the home. Staff meetings were being held for the first time in the home’s history. The management team should ensure that the planned service quality monitoring exercise is undertaken, and publish the results to all interested parties, including the CSCI. Residents’ finances were organised appropriately and records showed that residents’ monies in the home were managed safely. Members of staff were supervised informally on a day- to- day basis and appeared confident and supported in their work. However it is recommended that the registered person ensure that staff receive one to one supervision in accordance with standard 36. A policy for annual appraisals had been developed. The health and safety of the residents and staff was promoted in the home, and examples of good practice were: all staff had undertaken recent moving and handling training, there was a person competent in first aid on every shift and accidents in the home were appropriately recorded. However the registered person must ensure that all members of staff attend fire drills at appropriate intervals, that the home’s water supply does not pose a threat of the Legionella and that the home’s gas appliances and central heating system are checked annually. The CSCI must be notified of when this has been carried out. In addition the registered person must ensure that residents are not at risk from windows that open wide, and must demonstrate whether or not window restrictors are necessary through risk assessments based on the vulnerability of individual residents and the nature of individual windows. This is outstanding from the previous inspection and must be addressed as a matter of urgency. Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 3 2 x 3 2 x 2 Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 23 no Are there any outstanding requirements from the last inspection? 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 3 Regulation 14(1) (b) Requirement The registered person must ensure that a copy of all social work assessments are obtained by the home prior to admission and that the said assessment for the identified resident is obtained retrospectively (Previous timescale of 31 March 2005 not met) The reasons for the use of bed rails must be discussed with residents, representatives and relevant professionals, and the outcome of the discussion documented on file. The use of bedrails must be subject to a risk assessment and kept under review. The manager must ensure that the care plans detail all relevant aspects of health / medical, personal and social care needs of the residents. The medication policies and procedures must be developed to cover all areas of recording, storage, handling, administration and disposal of medication. (Previous timescale of March 2005 not met) Accurate records must be kept of Timescale for action Immediate from the date of the inspection 2. 8 13(8) & 17 (1)(a), schedule 3,3(p). 31 July 2005 3. 8 15 (1) 31 July 2005 4. 9 13 (2) 31 July 2005 5. 9 13 (2) Immediate Page 24 Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 6. 9 13 (2) 7. 9 13 (2) 8. 9 13 (2) all medication received into and leaving the home and administerd to residents. (Previous timescale of January 2005 not met) The criteria for the administration of PRN and variable dose medication must be clearly defined and recorded. (Previous timescale of March 2005 not met) Prescriptions must be checked by the home prior to dispensing. (Previous timescale of January 2005 not met) Staff must not sign for medication that has not been given. The registered person must ensure that the MAR sheets contain accurate information and instructions about the medication prescribed. Any changes in doses made by a medical practitioner must be clearly recorded and witnessed on the MAR sheets The temperature of the medication storage areas must be monitored regularly. There must be a recognised means of identification of residents Eye drops must be supplied separately for each to prevent cross infection. from the time of the inspection. 14 July 2005 14 July 2005 Immediate from the time of the inspection. Immediate from the time of the inspection. Immediate from the time of the inspection. 14 July 2005 31 July 2005 9. 9 13 (2) 10. 9 13 (2) 11. 12. 13. 9 9 9 13 (2) 13 (2) 13 (2) 14. 15. 9 19 13 (2) 13 (4)(a) & (c) 16. 29 19(1)(b) Immediate from the time of the inspection. All staff administering medication 31 August must have appropriate outside 2005. training from a qualified body The registered person must 14 July ensure that broken sash 2005 windows are made safe and that the propping over of these windows ceases. The registered person must Immediate Version 1.30 Page 25 Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc & 13 (6) 17. 29 19 (1)(b) & 13 (6) 18. 33 24 (2) 19. 38 23 (4)(e) 20. 25 13(3) & (4)(a)&(c) 21. 38 13 (4)(c) 22. 38 13 (4)(a) & (c) ensure that POVA first applications are made for the identified members of staff and notify the CSCI of the action taken by the date specified in the report. The registered person must ensure that recruitment procedures are in accordance with the (Amended) Regulations and that memebers of staff do not commence work until CRB/POVA checks have been obtained. (Previous timescale of January 2005 not met) The registered person must supply to the Commission a report of the quality monitoring review and must make this information available to the residents and relatives. The registered person must ensure that the fire service is consulted on the frequency of fire drills and ensure that all staff attend at approprate intervals. The registered person must ensure that the homes water supply does not pose a threat of the spread of Legionella. (Previous timescale of March 2005 not met) The homes gas appliances, boilers and central heating system must be service regularly and a certificate obtained. A copy of this must be sent to the CSCI. The registered person must ensure that residents are not at risk from windows that open wide, and must demonstrate whether or not window restrictors are necessary through risk assessments based on the vulnerability of individual residents and the nature of individual windows. (Previous Immediate 31 August 2005 31 July 2005. 31 August 2005 31 July 2005 31 July 2005 Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 26 timescale of 4 February 2005 not met) 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 18 18 19 Good Practice Recommendations The homes adult protection policies and procedures should include guidance to staff on dealing with aggression from residents. The registered person should ensure there are policies and procedures to support the safeguarding of residents money and valuables according to standard 18.6 The registered person should undertake regular audits of the premises to ensure rapid identification of, and action on, parts of the premises which need repairs and renewals It is recommended that the registered person establishes a system for recording and tracking all the stages in the CRB/POVA applications, the problems encountered and the outcomes. The registered person should ensure that the homes induction programme is in accordance with the Skills for Care specifications. It is recommended that staff receive formal one to one supervision according to standard 36 4. 29 5. 6. 30 36 Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Unit 4, Petre Road Clayton Business Park Clayton-le-Moors, Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Victoria House F57 F07 S63398 Victoria Hs V223060 140605 Stage 4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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