Inspection on 15/06/06 for Victoria House

This inspection was carried out on 15th June 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Victoria House 07/08/08

Victoria House 08/08/07

Victoria House 13/12/05

Victoria House 14/06/05

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 Lancashire BB9 5RH Lead Inspector Mrs Pat White Key Unannounced Inspection 09:30 15th June 2006 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 DS0000063398.V287758.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 DS0000063398.V287758.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Victoria House Address 25 Victoria Avenue Brierfield Nelson Lancashire BB9 5RH 01282 697535 01524 845667 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) Delta Care Limited Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Victoria House DS0000063398.V287758.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 home is registered to provide personal care for up to 15 service users who fall into the category of Older People (OP) 13th December 2005 Date of last inspection Brief Description of the Service: Victoria House is an older type detached two-storey property, in a residential area on the outskirts of Brierfield. Delta Care Ltd owns the home and Mr Baki of the company was the Responsible Individual. 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. Access between the two floors is by two stair lifts. Various aids and adaptations were available; 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. There were pleasant gardens and views for residents to enjoy. Current fees for accommodation at the home are £320 to £350 per week, with additional charges for hairdressing, toiletries, magazines and papers. Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced “key” inspection, the purpose of which was to decide an overall assessment on the quality of the services provided by the home. This included checking important areas of life in the home that should be checked against the National Minimum Standards for Older People and checking the progress made on the matters that needed improving from the previous inspection. The inspection took about 9 hours and involved: talking to residents (eight were spoken with in some depth), touring the premises, observation of life in the home, looking at residents’ care records and other documents, discussion with members of staff and discussion with the manager, Mrs Margaret Thornton, and one of the owners Mr Adam Baki. Comment cards were sent to the home for residents and relatives to complete but none had been received at the time this report was written. What the service does well: The way residents were admitted to the home was good. The owner made sure that he met people in their own home or hospital so that he could find out about their needs and whether or not Victoria House was suitable place for them to live. These details were then written down so that staff knew what they needed. The written details of what staff needed to do to look after people was also of a good standard and provided useful information to staff. The home was successful in meeting the needs of the residents. There was a good atmosphere in the home and residents and staff appeared to get on well. Over a period of time there has also been consistent praise from residents about the care given by staff. At this inspection all residents spoken with praised every aspect of the home. Residents praised staff for their kindness and patience and comments such as “It’s a lovely home” and “I like living here and wouldn’t want to live anywhere else” were made. Residents have consistently praised the food served that is appetising and well cooked, with daily freshly baked cakes and puddings. The home provides pleasant, homely and comfortable accommodation with a high standard of décor and furnishings, which suits the residents’ tastes and needs. Residents complimented the environment, and comments such as “it is pleasant and comfortable” were made. Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The written information about the risks that residents face in their daily life, such as the risk of falling, and how these risks are managed, could be improved. This should include written information that supports the use of bedrails. The procedures and practices for the management and administration of medication must be improved with priority to ensure medication is given correctly and safely. The provision of easy chairs and a new bed in the bedrooms identified at the inspection could improve the comfort and choice of the residents. The unpleasant odours in some bedrooms must be eliminated to improve the comfort and dignity of the residents concerned. The way that staff are recruited to work in the home must be improved to help prevent unsuitable staff from working in the home. Staff must not commence work until the Criminal Record Bureau (CRB) checks and two written references from employers have been obtained. This must be addressed as a matter of priority and failure to do so may result in enforcement action being taken by the Commission. The way the residents’ finances were managed could be improved, for example through better record keeping of the money given to residents. Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 7 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 DS0000063398.V287758.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 DS0000063398.V287758.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): 3, 4 & 5. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence, including a site visit to this service. The home’s admission procedures, including 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. EVIDENCE: The viewing of residents’ records showed that the owner of the home had undertaken pre admission assessments with those residents recently admitted and he had confirmed in writing that the home could meet their needs. The in house assessment documentation included all the matters listed in standard 3.3 The inspection methods, including discussion with residents, showed that residents and relatives were able to visit the home prior to admission and that the person carrying out the assessment visited people in their home Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 10 environment to carry out the pre admission assessment. This assisted people to make a choice about whether or not they wanted to live at Victoria House. All residents spoken with 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. A recently admitted resident stated that he had settled, and liked living in the home. Staff were to undertake training to help them to understand the needs of the residents with dementia related needs. Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. The health and personal care needs of the residents were met. Most details of the residents health and personal care needs were written in the care plan in sufficient detail. However the risk assessments and risk management for residents at risk of falling and using bedrails could be improved. Medication management and procedures did not ensure the safe administration of medicines to residents. The residents’ rights to privacy and dignity were upheld. EVIDENCE: All the residents had care plans prepared from an assessment (see standard 3) and the information recorded on these plans was in general in sufficient detail for staff to understand what they had to do to look after people. The care plan documentation included all matters listed in standard 3.3, and there were comprehensive risk assessments on matters relating to mobility, moving and handling, the risk of falling and the use of bedrails. Although some aspects of assessing risks and risk management had improved since the previous inspection, risk assessments relating to falls had not been appropriately completed for all the residents whose records were viewed. For example there Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 12 was no risk assessment to support the use of bedrails for one resident. This is outstanding from the previous inspection. Residents were involved in the preparing of their care plan if possible, and care plans were being reviewed more frequently since the previous inspection. The inspection methods used showed that residents’ physical and psychological health was promoted and maintained, and that residents had access to all necessary health care professionals. The intervention and advice of the district nurses were sought for pressure area care and continence promotion. Information about diet and food preferences was recorded on the care plans, and residents’ weights were regularly monitored and recorded. There were some good practices with respect to the management and administration of medication and some previous legal requirements had been met. For example staff were undertaking relevant training, accurate records were being kept of all medication being received into, and leaving the home and the storage of medication had improved. However the policies and procedures seen in the home still did not include, drug errors, covert administration and non – prescribed medication. None of the residents were administering their own medication but at least one resident was thought to be capable of doing so. In addition there were a number of unsafe practices that must be improved to ensure the safe administration of medicines to all the residents: • Prescriptions were not being checked by the home prior to dispensing. • For one resident there was not a supply in the home of one medicine listed on the MAR and signed as being given. There was no explanation for this though it appeared another resident’s supply of the same medication was being used. • The administration of “homely remedies” was not recorded and the GP was not consulted about the individual use of these substances. • The criteria for the administration of PRN (“when required medication”) and variable dose medication was not defined and written down. • The dose administered for “variable dose medication” was not being recorded. For another resident whose medication was checked there were a number of errors. • Two bubble packs were damaged and some tablets had been lost. No action had been taken to remedy this. • The MAR sheet indicated that a tablet been given but it had not. • One medication on the MAR sheet did not have clear instructions for its administration • Another medication was not being given in the evening without the reason being recorded or explained on the MAR. In addition though medication was stored appropriately in a trolley, some creams were not stored securely in some bedrooms. Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 13 Residents’ rights to dignity, respect and privacy were understood by staff, and upheld. This was confirmed by some of the residents spoken with. One resident said that the staff were “very good and kind” and treated her appropriately. Members of staff were observed treating residents with kindness and respect. Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. 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 site visit to this service. There were varied leisure activities which suited the needs and preferences of the majority of residents. Residents had sufficient choices in their everyday lives and were enabled to maintain contact with their relatives and the community. The food served was appetising and wholesome and suited the needs and the preferences of the residents. EVIDENCE: The opportunity for activities had improved since the last inspection. There were a variety of activities to suit the interests and capabilities of most of the residents. Records, and the homes notice board showed activities such as cards, board games, arts and crafts, visiting musicians and trips out round the local beauty spots. Residents confirmed that there was “plenty going on” and that they enjoyed sitting in the gardens in the nice weather. There were opportunities for contact in the local community through trips out and visitors to the home, including local clergymen. The home had its own minibus for trips out. A Summer Fayre was being planned. The care plans recorded residents’ interests and religious preferences. Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 15 Visitors were made welcome at any reasonable time and this is stated in the home’s Statement of Purpose. Some residents were able to say that they felt they had sufficient choice in such matters as rising and retiring times, whether or not they could stay in their rooms, leisure activities and in the food served. Most residents had small items of furniture to personalise their rooms. Useful details of residents’ preferred routine were included in the care plans. The food served was nutritious and varied and was praised by the residents who were spoken with. It suited their expectations and preferences. There was an option of a cooked breakfast and the main (hot) meal was served at mid day with a snack meal at tea time. Drinks and biscuits were served at times throughout the day. Staff gave assistence to those who needed it and on the day of the inspection the midday appeared relaxed and unhurried. Resident’s wishes to eat tea watching the World Cup football match was accommodated. Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. 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 site visit to this service. The complaints procedure was accessible to most residents and visitors and residents stated that they knew who to speak to if they had any concerns. There were satisfactory policies and procedures to protect the residents from abuse and residents felt safe living in the home. EVIDENCE: The home had a simple complaints procedure, a copy of which was on the home’s notice board and was therefore available for residents and visitors. All residents spoken with stated that they had no complaints and several stated they would speak to a member of staff or Mr Baki if they were unhappy about any aspect of their care. There had been no recorded or reported complaints since the previous inspection. 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. Since the previous inspection procedures had been developed which support the protection of residents’ money and valuables. However there was no written guidance to staff on how to deal with aggression from residents. Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 17 There had been no recorded incidents, or allegations of abuse in recent years and residents stated that they felt safe living in the home. The member of staff spoken with had a good knowledge of the adult protection procedures. Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. The home was well maintained and furnished and provided pleasant, comfortable accommodation. However some residents did not have an easy chair in their bedroom. There was a satisfactory standard of cleanliness in most areas of the home, but some bedrooms had unpleasant odours. EVIDENCE: The home was well maintained and furnished and was bright and well decorated throughout. The outside of the home was safe and accessible for residents, including those in wheelchairs, some of whom enjoyed sitting outside on the day of the inspection. A recent fire inspection confirmed that the home met the fire regulations. Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 19 As a care home registered before the National Minimum Standards were implemented in April 2002, Victoria house had enough space, both private/ bedroom and communal space, to meet the needs of the residents. The home also had suitable bathing and shower facilities and WCs There was suitable equipment and adaptations in the home to assist those with mobility problems. Several residents had hoists for transfer and the bathrooms were suitably adapted. However some bedrooms did not have an easy chair for comfortable seating and at least one bed needed replacing. Though the home appeared clean in all areas, some bedrooms had an unpleasant odour. The communal toilets and bathrooms, including the staff toilet, still used bars of soap instead of the more hygienic liquid soap, and there were no paper towels in the staff toilet. Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. The numbers and skills of the staff met the needs of the residents. The staff training programme ensured that the staff team had the necessary knowledge and skills to understand the needs of the residents. However staff recruitment procedures were not sufficiently thorough to ensure that unsuitable staff did not work in the home. EVIDENCE: Rotas examined, and discussion with residents and staff, indicated that there were enough staff on duty to meet the needs of the residents. There was also a cleaner and a cook in the home at the time of the inspection. The information supplied on the pre inspection questionnaire, and information from the manager, confirmed that when the care staff complete the NVQ courses they were studying at the time of the inspection, the home will have achieved the target of 50 qualified staff. The staff recruitment procedures did not comply with the legislation and did not ensure that unsuitable staff would not work in the home. The records viewed of the most recently appointed member of staff, showed that she had commenced work prior to a Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) check being returned, and prior to the written Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 21 references being returned. In addition one reference was from a friend and not an employer. There was also no evidence in the home of this member of staff having completed any induction training. The lack of adequate preemployment checks potentially puts service users at risk and must be addressed with priority. This matter has been the subject of a legal requirement at previous inspections. The staff training programme had improved and was being developed to ensure that staff had the skills and knowledge to carry out their work. At a previous inspection it was confirmed that the home had an Induction training programme for new staff that was in accordance with Government guidelines. Staff had completed training in diabetes and “medication awareness”, and were about to undertake training in dementia. Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a site visit to this service. The home was managed by a new manager who was not yet qualified or registered with the Commission. Quality assurance policies and procedures were implemented which took into account the views of residents and relatives. Due to the absence of key records in the home it was not possible to assess overall whether or not residents money was safeguarded. The health and safety of both residents and staff were promoted. EVIDENCE: The manager at Victoria House had been in post for a few months and had spent a number of years as the deputy manager in the home. She had applied to the Commission for registration and was also waiting to commence the relevant NVQ course. She had completed NVQ level 3 and recently had Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 23 attended courses on medication management and diabetes. Mr Baki, one of the owners, was closely involved in the running of the home and supported both the manager and the care staff. Staff meetings and residents meetings were held to assist their respective involvement in the running of the home. A member of staff spoken with confirmed that staff meetings were held about every 2 months and that she frequently sees the manager and Mr Baki. Both were described as approachable and supportive. The home had a quality monitoring system, and a residents’ and relatives’ survey had been undertaken at the end of 2005. A report on this had been provided to the Commission. This report indicated overall satisfaction with the service but that residents would like more activities. This had been implemented. There were insufficient records kept in the home regarding individual resident’s finances and payment of fees. Therefore it was not possible to assess overall whether or not residents’ monies were managed safely and efficiently. However it was established that the pension of two residents was paid into the Delta Care company account for the purpose of deduction of fees. This is not good practice and should be reviewed by the owner. Also for one of these residents there was no record of the money given to her after the deduction of fees and no signatures to confirm that this money had been received. Appropriate records were kept of the cash given to the home by relatives for residents’ spending money, and the spending of this money. However the records for one resident did not balance with the money held. The home’s health and safety policies and procedures ensured that the home was a safe place to live and work. Equipment, gas and electrical appliances and installations in the home had been serviced appropriately and since the previous inspection the home’s water supply had been tested and found free from Legionella. A fire safety inspection had been recently undertaken which determined that the home’s fire precautions were satisfactory and staff had completed appropriate fire safety training. There was a rolling programme of moving and handling and sufficient staff were qualified in first aid. However not all staff involved in food preparation had completed food hygiene training. Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 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 2 2 X 3 3 X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X 2 2 Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 1. OP8 13(8)17 The use of bedrails must be 14/07/06 (1a) sch 3 supported by a risk assessment and kept under review. (Previous timescale of 31/01/06 not met) 2. OP9 13 (2) The medication policies and 21/07/06 procedures used by staff in the home must cover all areas of recording, storage, handling, administration and disposal of medication. These must include drug errors, covert administration and non prescribed medication (Previous timescales of March 2005 and 31/01/06 not met) 3. OP9 13 (2) All medication must be stored 07/07/06 securely including creams that are kept in bedrooms 4. OP9 13 (2) There must be a timely ordering 07/07/06 of medication so that supplies do not run out. 5. OP9 13 (2) Medication prescribed for one 07/07/06 resident must never be administered to any other resident. 6. OP9 13 (2) All secondary dispensing, 07/07/06 including “potting up” of medication by night staff for the day staff to administer, must cease. Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 26 7. OP9 13 (2) 8. OP9 13 (2) 9. OP9 13 (2) 10. 11. 12. OP9 OP9 OP9 13 (2) 13 (2) 13 (2) 13. OP9 13 (2) 14. OP9 13 (2) 15. OP9 13 (2) 16. OP24 16 (2)(c) Damaged bubble packs and/or lost tablets must be reported to the manager and the pharmacist immediately. The MAR sheets must have clear instructions for the administration of medicines, for example a written explanation of “administer as directed” Medication must not be omitted without clarification of the reason and the correct entry/code on the MAR sheet. Prescriptions must be seen and checked by the home prior to dispensing. All medication must be stored securely, including creams in residents’ bedrooms. Blood sugar testing must only be carried out by designated care staff who have been trained by the District Nurse and who then provides written evidence of competence. The residents’ GP must be consulted about the use of individual “homely remedies” and the administration of “homely remedies” must be recorded on the MAR sheet. (A recommendation at the previous inspection) The criteria for the administration of PRN and Variable Dose medication must be clearly recorded on or near the MAR sheet. For Variable Dose medication the actual dose given must be recorded, for example “1” or “2” (tablets) The registered person must ensure that all residents have adequate seating arrangements in their bedrooms, including easy chairs, and suitable beds. DS0000063398.V287758.R01.S.doc 07/07/06 07/07/06 07/07/06 14/07/06 07/07/06 14/07/06 07/07/06 14/07/06 07/07/06 21/07/06 Victoria House Version 5.1 Page 27 17. 18. OP26 OP29 16 (2)(k) 19(1)(3) 19. OP29 19, amended sch. 2 9 20 (1) 20. 21. OP31 OP35 22. OP37 17 (2) sch 3 & sch 4, 8&9 23. OP38 13(3) The home must be kept free from offensive odours The registered person must ensure that members of staff are recruited according to the Regulation, and must not commence work until CRB/POVA checks and two written references from previous employers have been obtained. The registered person must also ensure that details of the Induction training are kept in the home. (Previous timescale of 13/12/05 not met) The manager must complete the relevant qualifications as soon as possible. The registered person should not use the company bank account for the paying in of residents’ pensions. All the records specified in the Care Homes regulations must be kept in the home, including the records regarding residents’ fees and money given back to residents with an appropriate written acknowledgement. (Previous timescale of 13/12/05 not met) The registered person must ensure that staff have appropriate food hygiene training. 14/07/06 07/07/06 07/07/06 31/12/06 14/07/06 07/07/06 31/10/06 Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard OP9 OP9 OP9 OP9 OP18 OP19 Good Practice Recommendations The manager should review with some residents whether or not it would be appropriate for them to administer their own medication. The medication trolley should be secured when not in use. The opening date should be written on bottles of eye drops. The registered person should ensure that homely remedies are not administered without the authorisation of the GP. Written guidance for staff on how to deal with aggression from residents should be developed. 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 liquid soap is used in the communal toilets, including the staff toilet and that paper towels are used in this toilet. It is recommended that the practice of paying residents’ pensions into the home’s company account ceases. 7. 8. OP26 OP35 Victoria House DS0000063398.V287758.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park 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 DS0000063398.V287758.R01.S.doc Version 5.1 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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