CARE HOMES FOR OLDER PEOPLE
Victoria House Low Grange Crescent Belle Isle Leeds West Yorkshire LS10 3EG Lead Inspector
Ann Stoner Unannounced Inspection 9:20am 2 February 2006
nd 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 DS0000001519.V260026.R01.S.doc Version 5.0 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 DS0000001519.V260026.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Victoria House Address Low Grange Crescent Belle Isle Leeds West Yorkshire LS10 3EG 0113 270 8529 (0113) 2765090 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) Mrs Mary Margaret Lavelle Mrs Mary Margaret Lavelle Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 26th April 2005. Brief Description of the Service: Victoria House provides residential care, without nursing, for 36 older people of both sexes. It is set in its own grounds, situated centrally in Belle Isle, a suburb of Leeds. There are three floors, two of which are used by residents. An activity/games room will shortly be available on the lower ground floor. There is a lift between the ground and first floor, with plans being considered to extend this to the lower ground floor. There is a large reception area with a bar, three lounges, three dining areas, and a small library/visitors room. Local amenities, such as shops and a post office are in close proximity and the home is on a bus route with buses running regularly into the centre of Leeds. Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was unannounced and took place on the 26th April 2005. There have been no further visits until this unannounced inspection. The purpose of this inspection was to monitor progress in meeting the requirements and recommendations made at the last inspection and to look at the standard of care for people living in the home. This inspection was carried out by one inspector between 9.00am – 5.15pm. The people who live in the home prefer the term resident therefore this will be used throughout this report. During the inspection, I looked at records, I saw staff carrying out their work and spoke with residents, staff, and visitors. Feedback at the end of the inspection was given to the manager and her deputy. Comment cards/questionnaires are left for residents, visitors and other professionals at each inspection. These provide an opportunity for people to share their views of the home with the Commission for Social Care Inspection. Comments received in this way are shared with the provider without revealing the identity of those completing them. Since the last inspection none have been returned. What the service does well: What has improved since the last inspection?
The extension to the home is now complete. This has provided an additional lounge, bedrooms, toilets, bathrooms and shower room, a medical room and larger office space. Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 6 The home carries out a pre-admission assessment to make sure that it can meet the needs of the person before any decision about admission is reached. Screening is provided in shared bedrooms, which gives privacy to residents in these rooms. Additional domestic staff have been employed, which means that care staff have more time to spend with residents. Recruitment procedures have improved to make sure that staff are suitable to work with residents. Measures are in place to identify those residents who may be at risk of falling or poor nutrition. What they could do better:
The home must try to improve records by developing and improving the information recorded in care plans, so that staff have detailed information about how care is to be given. The home must make some changes to the way that it records, stores and disposes of medication, so that medication is safe and mistakes are prevented. There are several infection control issues that must be addressed. These include providing liquid soap and paper towels throughout the home, not storing toiletries in bathrooms and providing a clinical waste bin in the laundry. It would be good practice for the home to seek advice from the infection control nurse. A review of bedding and bedroom furnishings must be carried out. Stained pillows must be replaced, a headboard must be fitted to all divan beds, and valances should be fitted. The home must have a registered manager who is qualified to manage the home. Staff rotas must show the job role of workers and the person in charge of each shift. A training and development plan must be introduced so that training updates are not overlooked. Staff must carry out proper moving and handling techniques so that residents are not put at risk. In order to review care and standards in the home a quality assurance audit must be developed. Some improvements to records should be made. These include an analysis of accident records so that any trends or pattern can be identified. Two signatures should be obtained when financial transactions are carried out on behalf of a resident.
Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 7 A number of requirements and recommendations have been made to address these issues. These can be found at the end of this report. 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 DS0000001519.V260026.R01.S.doc Version 5.0 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 DS0000001519.V260026.R01.S.doc Version 5.0 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 & 5. Residents do not move into the home until their needs have been assessed. Residents and/or their relatives can visit the home before deciding about admission. EVIDENCE: The care records of three residents were sampled, and in all cases there was an assessment of need carried out by a social worker, followed by the home’s pre-admission assessment. Care plans confirmed that residents visit the home before admission. During this inspection one person, who was unsure about the home, was spending the day getting to know the residents. Visitors described their unannounced visit to the home, which was out of normal office hours. They said staff were exceptionally helpful in providing information when showing them around. Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Care plans have improved, but some are more detailed than others, which means that some residents’ needs may be overlooked. Residents’ health care needs are met and overall their privacy and dignity is respected. Medication is not stored properly and some practices increase the risk of error. EVIDENCE: Three care plans were sampled and whilst there has been an improvement, the level of information provided was inconsistent. One care plan had clearly identified needs and aims, but failed to show the precise action that staff should take to make sure the resident’s needs were met. Other plans for bathing and oral hygiene were more detailed. A care worker described how she assists one person to move, but this information was not in the resident’s care plan. Social care plans did not address the needs and interests of each individual resident. There were no care plans for residents who were at risk of falling or who had fallen. Moving and handling care plans did not include the methods to be used, the number of staff required and the aids that must be used for each transfer. Two care plans did not have a photograph of the
Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 11 resident. Terms in daily records such as ‘had a brill tea’ should be avoided and replaced with factual accounts without using jargon or abbreviations. Care plans showed that GPs, chiropodists, opticians, dentists and community nursing staff visit when necessary. Visitors were pleased with the way that the home arranged health care visits. Recording on medication administration records (MAR) was inconsistent. Some handwritten entries had been checked and countersigned by a second person, whilst others had not. On some, there was no record of the amount of medication received and the person receiving the medication had not signed the MAR. Medication is stored in a locked medical room, but once inside this room, the keys to the various medicine cupboards are all in the locks. This allows unauthorised access to these cupboards. Staff who administer medication have completed training, but one person was still unsure about the use of homely remedies. Unused medication that should have been returned to the pharmacy was in a cupboard. Staff explained how they respect the privacy and dignity of residents, but then said that male residents are not assisted to shave at the same time as being assisted to wash and dress. Instead they are taken to a bathroom at some point during the morning. This does not respect the dignity of the resident. Two visitors praised staff for the way that they protected the dignity of a resident who had fallen in view of residents and visitors. Requirements have been made to address these issues. Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 12 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): 13, 14 & 15. Residents are able to make choices, they have a well balanced diet and visitors are welcome. EVIDENCE: Residents spoke about the choices they have, which included times for going to bed and getting up in the morning. Some said that staff spend time with them outside of the home. One person described, how with support from staff, he is able to go to the local club for a drink, another described how staff accompany her to the local shops. Two visitors said they were concerned about the lack of stimulation and activities, but they felt that this would be rectified when the activity room is put into use. Residents spoke highly about the meals, and said that they had a choice of menu. The lunchtime meal was a choice of roast chicken or sausage with potatoes and vegetables. This was followed by a choice of puddings. The cook said two vegetables are served at lunchtime, one of which is fresh, the other frozen. Visitors said the food always looks delicious. One resident said that his daughter had visited one morning and had been invited to stay and have breakfast with him. Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 13 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 Complaints are investigated and staff are aware of the signs of abuse. EVIDENCE: The manager said that the complaints procedure is being updated, and when completed all residents will be given a copy. Residents and relatives said that they would have no hesitation in making a complaint. A care worker described the different types of abuse and explained what she would do if she suspected a colleague or a manager of abusing a resident. Senior staff have attended training on abuse, but have been unable to access any training on the use of the Multi-Agency Adult Protection procedures. Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 14 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, 24 & 26. The premises are well maintained, but bedding and bedroom furnishings must be reviewed to make sure that all bedrooms are of the same standard. Some practices increase the risk of the spread of infection. EVIDENCE: The home is spacious and the completion of a recent extension has provided additional lounge, bedroom, toilet and bathing areas. Two rooms on the lower ground floor will soon be ready for use, one as a staff training room the other as an activity/games room for residents. Some dispensed soap containers were empty and where paper towels were provided they were stored on window ledges, thereby creating the opportunity for cross infection. Toiletries were seen in bathrooms, again creating the risk of cross infection. There was no clinical waste bin in the laundry. The infection control nurse should be contacted for advice. Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 15 Not all divan beds had valances fitted, two beds did not have a headboard, in one room the pillows were badly stained, and there was only lockable space for one person in a shared room. Requirements and recommendations have been made to address these issues. Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 16 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 & 30. Staffing levels meet the needs of residents. Staff are supported through induction, National Vocational Qualifications (NVQ) and ongoing training. EVIDENCE: Staffing levels have increased to reflect the numbers and needs of residents. Residents and visitors confirmed that there are always sufficient numbers of staff on duty, but the duty rota does not show the job roles of each person, the total number of hours worked, and the senior person in charge of the shift. A requirement has been made to address this. A new member of staff confirmed that she completed a TOPSS (Training Organisation for Personal Social Services) induction, and other staff spoke of a commitment to NVQ. The manager said that 57 of the care team have completed an NVQ, one person is currently being assessed and a further two staff are waiting to be registered. An external training provider is delivering a training programme on ‘dementia care’ in the home. Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 17 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. Changes to the management team are planned so that the registered manager is qualified to manage the home. Residents’ finances are safeguarded. Quality assurance systems are in place but these should be developed further so that an effective improvement plan can be produced. The health & safety of residents is compromised by some practices. EVIDENCE: The registered manager has many years of experience but does not have an NVQ (National Vocational Qualification) in Care or Management. There are plans to promote the deputy manager, who does have these qualifications, to the post of manager. There is no quality audit of services and standards within the home, other than the distribution of annual questionnaires to relatives, other professionals and
Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 18 residents. The distribution of this questionnaire is now overdue. The home does not analyse feedback or use comments in a structured way to improve services within the home. The financial records of three residents were sampled. These were found to be in order, but two signatures are not always recorded when money is withdrawn. Similarly, where money is handed over for safekeeping a signature is not always obtained from both the person handing over the money and the person receiving the money. Where an accident is not witnessed, staff do not always record when the person was last seen and by whom. There was some confusion about the recording of accidents, and an analysis is not carried out to identify any patterns or trends. Fire alarms are tested at a different point each week, but the records do not indicate which point has been tested. The deputy manager is the designated ‘fire marshal’ for the home and carries out fire training and fire records. There is no structured plan to show when mandatory staff training updates are required. Although staff have received moving and handling training, one care worker was seen using an under arm lift, which places the resident at risk of injury. A number of requirements and recommendations have been made to address these issues. Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 19 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 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 20 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 OP7 Regulation 15 Requirement Timescale for action 30/04/06 2. 3. *RQN OP9 Schedule 3 13 (2) Care plans must set out in detail all of the actions required to ensure that all aspects of the health, personal and social care needs of the residents are met. A photograph of each resident 28/02/06 must be kept on file in the home. 28/02/06 All handwritten Medication Administration Records (MAR) must be signed by the person making the record and must be checked and countersigned by a second person. The amount of medication received must be specified. This is unmet from 10.4.05. Medication cupboards must be kept locked. The keys must be in the personal possession of, and be the personal responsibility of, the designated person in charge of the shift. Unused medication must be returned to the pharmacy. All staff who administer medication must know how to Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 21 use and record homely remedies. 4. OP12 16 (2) (n) Facilities for recreation and leisure must be provided, taking into account the ability, capacity and individual needs of the residents. This is carried forward from the last inspection. Liquid soap and paper towels must be provided in all areas where clinical waste is handled. This includes bedrooms, bathrooms, and toilets. This is unmet from 30.9.04 and 10.4.05. Toiletries must not be stored in bathrooms. A clinical waste bin must be provided in the laundry room. Lockable space must be provided for each resident in his or her bedroom. Bedding in the home must be reviewed. Stained pillows must be replaced and headboards must be fitted to all divan beds. Staff rotas must show the job roles of workers and the person in charge of the shift. The registered manager must have the qualifications necessary for managing the home. An effective quality audit system must be introduced to make sure that systems and services are reviewed and improved. A safe system of moving and handling residents must be followed at all times. A training and development plan must be developed to identify when mandatory training updates are required. 31/03/06 5. OP26 13 (3) 28/02/06 6. 7. 8 9 OP26 OP26 OP24 OP24 13 (3) 13 (3) 16 16 28/02/06 28/02/06 31/03/06 31/03/06 10 11 12 OP27 OP31 OP33 18 9 24 28/02/06 30/06/06 30/06/06 13 14 OP38 OP38 13 (5) 18 03/02/06 30/04/06 Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 22 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. Refer to Standard OP7 OP26 OP24 OP35 Good Practice Recommendations Abbreviations and jargon should not be used in daily records. The infection control nurse should be contacted for advice. Valances should be fitted to all divan beds. Two signatures should be obtained when financial transactions are made on behalf of residents. Where money is handed over for safekeeping, a signature should be obtained from the person handing over the money and the person receiving the money. Where staff do not witness an accident, a record should be kept of when the person was last seen and by whom. An analysis should be kept of all accidents so that any patterns or trends can be identified. Records of fire alarm tests should show which fire point has been tested. 5. OP38 6 OP38 Victoria House DS0000001519.V260026.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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