Inspection on 16/06/08 for Victoria House

This inspection was carried out on 16th June 2008.

CSCI found this care home to be providing an Poor service.

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 10/12/08

Victoria House 21/02/07

Victoria House 22/11/05

Victoria House 12/07/05

Victoria House 03/11/04

Victoria House 14/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Victoria House 22 Nelson Place Ryde Isle Of Wight PO33 2ET Lead Inspector Anita Tengnah Unannounced Inspection 11:00a 16thJune 2008 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 DS0000012550.V365620.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria House Address 22 Nelson Place Ryde Isle Of Wight PO33 2ET 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) 01983 614515 01983 613370 Venetian Healthcare Ltd Mrs Judith Garvey Care Home 22 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (22), of places Physical disability (1), Physical disability over 65 years of age (5) Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for up to 22 persons in the old age category including: 5 persons over the age of 65 years with a physical disability; 1 person over the age of 65 years with dementia. Date of last inspection 21st February 2007 Brief Description of the Service: Victoria House is a well-appointed care home, which occupies a fine elevated site in Ryde. It boasts sea views from all the rooms at the front of the building. Whilst the home has a number of double rooms they are presently used as singles. The home has a passenger lift that provides access for residents to all levels of the building. The home offers a varied programme of social and recreational activities including music and art activities. For those that like animals the home has a cat and a parakeet. The home has its own transport and outings are arranged to the theatre and other places of interest on the Island. There are extra charges for items such as chiropody, hairdressing, toiletries, which are not included in the fee. The current fees range from £380-£474 per week Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience Poor quality outcomes An unannounced visit to the service was undertaken as part of the inspection on the 16th June 2008. The process included a tour of the service where a number of the bedrooms, communal areas, kitchen, and bathrooms were viewed. As part of case tracking staff, residents and a visiting professional’s views were sought, care records were looked at and practices observed. We sent out the Annual Quality Assurance Assessment (AQAA) to the service. A reminder letter was also sent, as the AQAA was not returned to us. Information gained from the AQAA was also used and included in this report, as was information gathered by the commission since the last inspection to contribute in assessing judgements in this report. We also sent out service users’ surveys to people using the service and staff. We gave feedback to the person representing the organisation at the time of the visit. We have received 9 completed residents’ surveys and 7 from the staff we surveyed. Comments we have received will be reflected in the body of the report as appropriate. The home has a registered manager who has day-to—day management responsibility fro the service. What the service does well: The residents are provided with a clean, homely and well-maintained environment that they say meets their needs and is to their satisfaction. There is evidence that the residents are encouraged to bring into the home items of personal belongings and all the bedrooms seen were highly personalised. The meals at the home looked well presented and offer the residents choices. The garden is well maintained and offers the residents pleasant surroundings that they say they enjoyed. The staff and the residents have developed good relationships with each other. Care was provided in a respectful manner. Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The preadmission assessment is inadequate and must be further developed. The service must ensure that prospective residents needs are fully assessed prior to providing care. The records and care plans do not contain sufficient details of how the resident’s needs would be met and there is a lack of reviews of care plans and assessments. The medications management at the service do not protect the people and puts them at risk. Staff were not adhering to the safe procedures for dealing with medicines including controlled medication. Medication including creams and ointments must only be used for the named person. Any identified risk such as falls and nutritional risks must be followed by a care plan to demonstrate how these risks will be managed and inform staff practices. There is inadequate checks completed prior to staff being employed and this does not protect people using the service. The home must complete a training needs analysis and plan training for the coming year to ensure that staff have all the necessary mandatory and additional training to meet peoples’ needs. There is no evidence of an audit process to demonstrate how the home was meeting their commitment as per the statement of purpose. There is a lack of clear management process at the service. Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 7 There is a failure on the part of management in reporting to the Commission all incidents that are detrimental to the welfare of people accommodated at the service. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 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 DS0000012550.V365620.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is a lack of evidence to demonstrate that all the residents are assessed prior to moving into the home and that the home can meet their needs. The service does not provide intermediate care. EVIDENCE: The last visit in February 07 required that the registered person must complete a pre- admission assessment and a record of the assessment must be maintained at the service. This is to ensure that the home only admits people whose assessed needs can be met. The care plans of three residents were looked at as part of this visit. We found that there was a pre- admission assessment for one of the new residents who Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 10 had been admitted. This related to a resident who was admitted for respite care and a social services assessment was completed. The assessment included sight, hearing, mobility and religion. The pre-admission assessments were not available for the other two residents. Both of these residents had complex needs and were supported by external healthcare workers. The manager had confirmed in writing to us that an assessment for one of the residents admitted for palliative care had been completed, prior to admission and the home was able to meet his needs. However the assessment’s record could not be located at the time of the visit. There was no evidence that the residents/ relatives or carers were involved in the pre assessment process to ensure that all the care needs are identified. This was discussed with the staff at the time of the visit. The registered person must supply the residents with written confirmation that following assessment the home is suitable to meet their health and personal care needs. Staff reported that prospective people are offered the choice of visiting the home. The 6 residents’ comments we have received except for one indicated that they had adequate information prior to moving into the service. The manager confirmed that some residents are admitted for short- term respite care. The service did not provide intermediate care. Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is a lack of clear guidance in care plans and inadequate assessments to promote and protect people’s welfare and safety. The access to external healthcare provision is satisfactory. The medication management is poor and puts people at risk. The privacy and dignity of people using the service is protected and people are treated with respect. EVIDENCE: Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 12 The last inspection report required that information contained in residents’ care plans must include specific details as to what care/assistance should be provided to meet their assessed needs. We looked at three records of people receiving care at the home. Care plans were formulated and there was basic information about the needs of people. Of the three records seen one of them contained a risk assessment for moving and handling. However the information was not clear, as it did not tell the staff how the risks were to be managed in practice. Two of the residents had been identified as difficulty with mobility and may get breathless when walking. No other information was available of how this would be managed. Information available to staff for moving and handling stated help of one carer. Another record stated transfer with one carer when tired. It did not state how the person was to be moved, or any specific equipment to be used. Records seen did not contain any information about the pressure risks assessments. There was inadequate information and assessments such as nutritional risk, fall risk assessments to ensure that care is provided in a consistent manner. We noted that one of the residents record showed that they required support with personal care and the care plan stated staff to assist with morning wash and shave. Care plans contained details of care given such as washed and dressed. Other record seen contained little information about what support was required and given. Daily records of care for a twenty- four hour period stated coffee am, or inhaler given and no further entries for the day and night. As discussed the care plans must be further developed and include details of support that people need in order to meet their assessed needs and ensure consistency of care. The previous requirement has not been met. The residents’ preferences regarding their activities of daily living should form part of their care planning. The manager reported that three of the residents were got up and dressed by the night staff. There was no evidence that this was of their own choices. The record of one person seen indicated that they had lost weight and care records stated weekly weight to be monitored. The weight record could not be found at the time of the visit. The manager reported that this person had gained some weight since admission to the home. There was no nutritional assessment completed and staff reported that this person was experiencing difficulty in swallowing. A swallowing assessment was not available and staff stated that a soft diet had been introduced. As discussed care plan must be developed and details of nutritional needs/ type of diet including supplements must be clearly recorded in the care plans. Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 13 The residents were registered with the local surgery and staff reported that they were supported. Records of GP visits were recorded in the records seen, other records included referral to the respiratory nurse for one of the residents. It was evident that access to external health care support was sought and well managed. This included regular contact with the McMillan nurses for advice and support. A visiting professional commented that the staff maintained regular contact with them if they were worried and needed support. The last report required the registered person to ensure that medication must not be pre dispensed in advance and must be administered from the pharmacist’s container at the prescribed time. We observed the lunchtime medication being administered. The staff dispensed the medication at the time of administering them. We noted that there were a number of medication pots labelled with the residents’ names, however the manager assured us that they were no longer secondary dispensing medication. A sample of the Medication Administration Record (MAR) sheets were looked at and this indicated that a record of medication administered was maintained and there were no gaps in these records. The manager stated that only staff who had completed medication training were responsible for the residents’ medication. We noted that one of the residents was receiving controlled medication. Records of the MAR sheet and the amount prescribed on the bottle did not correlate with the amount given. Records showed that the resident had received the wrong amount of this controlled drug. This was brought to the attention of the manager who reported that the amount to be administered had been changed. There was no record of this at the service and an immediate requirement notice was left. The manager must ensure that prescribed medication is administered as per the prescription to ensure the safety of people at all times. Any changes to dosage made must be written on the MAR chart. If a handwritten entry is made it must be signed and then verified; there must be the signatures of two staff members, verifying that the dosage is correct. Guidance is available from the Royal Pharmaceutical Guidelines. Another resident record showed that they were receiving oxygen. There was no prescription for this at the service. Care record seen for this person and in additional comments stated, “may get breathless, oxygen in room.” There was no guidance to the volume/ litres of oxygen to be administered; no record of when oxygen was maintained was available. One instruction indicated that the resident may have oxygen for no more that two hours in a twenty–four hour period, which is confusing. We noted that prescribed medication were not maintained safely at the time of the visit. This included a number of prescribed ointments/ creams that were Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 14 left in a cupboard on the ground floor. This was brought to the attention of the manager and an immediate requirement was made as the key remained in the door. We found that a cream prescribed for one resident had been given and was being used by another resident. This was discussed with the manager, as prescribed medication including creams/ ointments must only be used for the named person. The surveys received and people spoken with said that they were treated with respect and their privacy was respected. All the residents looked well groomed and dressed appropriately. One resident commented, “I can choose what I wear”. It was evident that the staff and the residents and developed good relationship and attended to them in a coring and respectful manner. Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a varied activity programme that people say met their needs. The visiting policy supports people to maintain contacts with their relatives. The meals at the home were good and choices were offered. EVIDENCE: There is a monthly activity programme in place and the residents spoken with were aware of these. Activities included arts and crafts, exercise to music, musical entertainment, sing-along sessions and reminiscence. The service also has its own transport and the staff stated that some of the residents went out to the sea front and enjoyed ice creams. A visiting activity person was attending the service on the day of the visit and a number of the residents took part in clay modelling. The home was also celebrating a resident’s birthday where sherry was served and another resident was enjoying a glass of beer at lunchtime. Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 16 Comments from the residents included: “Usually activities available but I prefer to read and listen to the radio.” “Staff are very caring, helpful and friendly”. “Nothing is too much trouble”. Residents spoken with say that the staff respected their autonomy and choices. One resident was observed sewing the hem of a skirt. Another resident was supported to continue with his hobby of painting. Example of his work was displayed in his room. Another resident had his keyboard brought in from home. We observed the lunchtime meal that offered choices and the meal provided was varied and nicely presented. Meals looked appetising and balanced, soft diets were served individually. Meals were taken in the communal dining room that overlooked the well- maintained garden to the side. Staff were available to offer support with meals as required. We noted that meals were not rushed and two residents had their meals in their rooms as they chose. Comments from our surveys and people we spoke to included: “usually offered an alternative choice. Lightly cooked evening meals and cakes are available” “The food is good. Can’t grumble” “I like the food. It’s all right”. Two comments to do you like the meals at the service were “sometimes “. “Depends on who is cooking.” Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a complaint procedure in place and people are able to raise their concerns. There is a procedure for raising alert, however training for staff in safeguarding need to be developed in order to inform their practices. EVIDENCE: The home has a complaint policy and procedure that staff and the service users spoken with said that they were able to raise any concerns with the staff. As part of this visit we looked at the complaint log as maintained at the home. This showed that there had been two concerns raised including a safeguarding alert since the last visit. The complaint has been resolved. Social services investigated the safeguarding alert and recommendations were made for the manager to implement. These included that the home should ensure they are able to meet the needs of self-funding clients. Victoria House needs to be aware of implementing palliative/continuing care and linking with clients GP. As a result of the concerns regarding the care and the safety of the residents identified at the time of this visit, a safeguarding referral has been made to Isle of Wight Social Services department. Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 18 Information we have received indicated that the staff were aware of what constituted abuse and they say that they would approach the manager. We were unable to assess what training staff had been completed in safeguarding, as these records were not available. The AQAA told us that staff had been provided with the Whistle blowing procedure. Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides the service users with a homely, clean and well-maintained accommodation that meets their needs. The infection control procedures at the home are satisfactory. EVIDENCE: A tour of the premises was undertaken as part of the visit and a number of bedrooms, communal areas, bathrooms, and kitchen were viewed. It was evident that the home has an ongoing programme of refurbishment. Information from the AQAA told us that there had an extensive programme of improvements including the installation of a new kitchen ,laundry ,wet room and sluice and home furnishings. The home was warm, bright, clean and homely. Furnishing was of very good standard and appropriate to the needs of the service users. The residents are Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 20 provided with ample communal areas where a variety of activities are undertaken. Most of the bedrooms seen have views of the garden and panoramic sea views for some of the bedrooms. These bedrooms were highly personalised with pictures, televisions, small item of furniture and family photos. It was evident that the residents are encouraged to bring in items of personal belongings on admission. Equipment and information on infection control was available to the staff. Practices observed during the visit indicated that staff were aware of the procedure and aprons were used as appropriate. Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staffing numbers are adequate to meet the present needs of the service users. The home has inadequate system in place to ensure that staff have the skills to deliver care safely. The recruitment process is poor. All checks are not undertaken prior to employment to ensure the safety of the service users. There is a lack of evidence/training programme in place to ensure that staff are supported in their work. EVIDENCE: The home has a duty roster for the carers and ancillary workers. The manager reported that there are 4 carers on the morning shift, a senior care and 3 carers on the afternoon shift and night duty has two awake carers. The home also employs 2 staff for the domestic work, 2 part time cooks, a part time handy man and an administration staff. Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 22 The manager was preparing lunch on the day of the visit, as there was no cook. Staff and the residents we spoke to stated that there was adequate staff to meet their needs. It was evident from interaction observed that the staff and the residents had developed good relationships. A resident spoken with said that they all got on well. Another said that they were treated with respect. The last inspection report required the provider to ensure that staff must only commence work after two written references have been obtained, a CRB has been applied for and POVA first check completed. The AQQA stated that pre employment checks had been completed for staff. A sample of two staff records was looked at as part of this visit. One of the record contained references and records of checks completed. However the other record did not contain any references. An immediate requirement was made at the time of the visit. The manager must ensure that all checks including references are in place prior to employment in order to safeguard people living at the home. Information from the AQAA showed that of the 15 permanent staff, 10 have completed national Vocational Qualification NVQ 2 or above and 2 were working towards this qualification. We were unable to evidence any induction for the staff who had been recently employed at the service. There were inadequate training records available at the service to assess what training was available and how the staff were supported to maintain their skills. The AQAA did not provide any information of the number current permanent care and catering staff who had completed training in safe food handling. Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a registered manager who is responsible for the service. There is a lack of internal auditing process to demonstrate how the home was meeting its commitment as the statement of purpose. There is a system in place for servicing of equipments. However practices do not always ensure that the residents are protected including safe storage of substances that are detrimental to health. EVIDENCE: Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 24 There is a registered manager who has been at the service for a number of years. Staff reported that they have a good team work and supported each other. The medication, health and safety and recruitment must be addressed by the home’s management. This is to ensure that care is provided in a safe way and do not put the residents at risks. The manager reported that a quality assurance to seek the views of the residents was due to commence on a three monthly basis, this has not as yet been completed. It was reported that the Responsible Individual undertook monthly audit as regulation 26 visits. There were no records of these available at the service and the manager stated that she did not receive copies of these visits. The provider must ensure that information relating to the Regulation 26 visits are shared with the manager and copies of these reports must be available as required at the home. The manager confirmed that the service do not deal with any of the residents personal allowances. Some of the residents dealt with their own moneys or their relatives dealt with these. We also noted that the home did not keep us informed of all incidents that must be reported to us as Regulation 37. The manager stated that she thought hat there has been problems with the fax machine. The registered person must ensure that reports of all incidents that affect the welfare of people accommodated are reported to the commission as required. Information from the AQAA showed that there is a programme in place for the servicing of equipment. The home’s appliances are checked and serviced by qualified persons and the fire logbook showed that the fire safety equipment was last tested in February 008 and emergency lighting, as appliances were done in March 08. The last report required the provider to ensure that fire drills/fire safety instructions are carried out twice yearly. The manager reported that fire drill was carried out once last year in May 07. The home used DVD for fire training which was planned for this week. A copy of the training as completed by staff showed that training in health and safety including moving and handling dated back to 2003-2005. This would indicate that there is inadequate training and update in health and safety for the safety of people using the service. We noted that a cupboard containing substances that were identified as COSHH was not maintained securely. An immediate requirement was made at the time of the visit. Other practices that put the residents at risks have been mentioned in the different section of the report and included poor management and storage of medication. There is a lack of appropriate checks for staff prior to employment to ensure the residents are safeguarded. Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 25 Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 26 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 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 X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X 2 1 Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 27 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. 1 Standard OP3 Regulation 14 Requirements The home must be able to demonstrate that an assessment of needs have been carried out by a suitably qualified person. Assessments carried out by the home must be recorded. This is to ensure that the home only accommodates those whose needs it can meet. This is repeated requirement from 21/04/07 that has not been met. Information contained in 15/08/08 residents’ care plans must include specific detail as to what care/assistance should be provided to meet their assessed needs. These must include details such as nutritional needs and pressure care assessments and management. This is repeated requirement from 31/03/06, 21/04/07 that has not been met. The registered person must ensure that arrangements in DS0000012550.V365620.R01.S.doc Timescale for action 15/08/08 2. OP7 15 (1) 3. OP9 17 (1) 25/06/08 Page 28 Victoria House Version 5.2 place for the safe handling, administration, storage and management of all medication in the care home. Prescribed medication must only be administered to the named person. The home must handle and administer medication in accordance with the guidance of the Royal Pharmaceutical Society. This is a requirement from the 21/04/07 that has not been met. Immediate requirement notice issued. The registered person must ensure that clear guidance and prescription for the administration of medication are in place for the resident receiving oxygen therapy. The registered person must ensure that all necessary checks are in place for staff prior to employment. This is a repeated requirement from 22/02/07 that has not been met. Immediate requirement notice issued. 6. OP33 24 The home must have a system of quality assurance that involves an audit and annual development plan and which incorporates the views of residents and others who are involved in the home. Records of Regulation 26 visits must be maintained at the DS0000012550.V365620.R01.S.doc 4 OP9 13(2) 15/08/08 5 OP29 19 25/06/08 15/08/08 Victoria House Version 5.2 Page 29 service. This is a repeated requirement of 21/05/07 that has not been met. 7 OP30 18(1) 13(4) The registered person must ensure that there is a training and development programme in place to include induction as skills for care guidance and records of these must be maintained. The registered person must ensure that all staff complete mandatory training in health and safety including moving and handling and fire procedures. This is to ensure that the residents are not put at risks. This is a repeated requirement for fire safety from 21/05/07 that remains outstanding. 9 OP38 13(4) All substances that are hazardous to health must be stored safely and these were not on the day of the visit and put people using the service at risk. Immediate requirement notice issued. 25/06/08 15/08/08 8. OP38 23 (4) 15/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Victoria House DS0000012550.V365620.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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