Inspection on 22/08/06 for Victoria House

This inspection was carried out on 22nd August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 17/07/08

Victoria House 24/07/07

Victoria House 02/02/06

Victoria House 26/04/05

Victoria House 03/08/04

Victoria House 13/04/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Victoria House Low Grange Crescent Belle Isle Leeds West Yorkshire LS10 3EG Lead Inspector Ann Stoner Key Unannounced Inspection 22nd August 2006 9:00 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.V306625.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 DS0000001519.V306625.R01.S.doc Version 5.2 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.V306625.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2nd February 2006 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. The main living accommodation, which consists of a large reception area with a bar, three lounges, three dining areas and a small library/visiting room, is on the ground and first floor. An activity/games room has recently been opened on the lower ground floor. There is a passenger lift between the ground and first floor, with plans being considered to extend this to the lower ground floor. There are 33 bedrooms, 30 single and 3 double rooms, all of which have en-suite facilities. 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. Outdoor seating is provided at the front of the home and landscaping is taking place. On the 30th August 2006 the administrator confirmed that the fees were £422.40p per week. Copies of previous inspection reports are available in the reception area of the home. Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This unannounced key inspection took place between 9.00am – 1.00pm on the 22nd August and 8.45am – 5.00pm on the 30th August 2006. The purpose of the visit was to monitor standards of care in the home and to look at progress in meeting the requirements and recommendations made at the last visit. The manager completed a pre-inspection questionnaire and the administrator provided additional information. The information provided has been used in the preparation of this report. The people who live in the home prefer the term ‘resident’ and this will be used throughout this report. Before the inspection I sent out survey cards to residents, relatives and health care professionals and had a telephone conversation with one relative. I received four completed survey cards from relatives, six from health care professionals and eight from residents. Comments from the survey cards and telephone conversation can be found throughout this report. During the inspection I spoke to residents, visitors and staff on duty, I looked at records and made a tour of the building. The registered provider (owner) has stepped down as the registered manager and promoted her deputy to the manager’s post. This person is in the process of applying to the Commission for Social Care Inspection for registration. Feedback at the end of this inspection was given to the manager and the administrator. I would like to extend my thanks to everyone who contributed to the inspection and for the hospitality during the visit. Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The management in the home has been re-organised and the registered provider’s son is now employed in the home as an administrator. Both he and the manager are working together to improve care practices and record keeping. Together on a monthly basis they do a joint tour of the home to identify any shortfalls in the environment and the manager has started an audit of care practices in the home against the National Minimum Standards for Older People. The home now has a web site and the administrator is transferring many paper records onto a computerised programme. Staff training records have been transferred and it is now easy to see exactly what training each member of staff has done. There has been a big improvement to the outside of the home. Landscaping is taking place to the side and rear of the home and attractive outdoor seating, tubs and baskets with colourful bedding plants and a paved area with table and chairs have been provided. The home has purchased new documentation for care planning, which if used properly should improve care record keeping. Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 7 Improvements have been made to the way that the home records medication and the keys to the medication room are kept with the person in charge of the shift. Staff rotas have been amended to show the job roles of people and the person in charge of the shift. What they could do better: During the feedback session the administrator and the manager were aware of some of the shortfalls and showed a commitment to addressing these quickly. They listened carefully to feedback and were eager to improve the home’s overall quality rating. To achieve this, improvements must be sustained and the following must be addressed. To make sure that staff have precise and up to date information on what care to give and how to give it, a care plan must be in place for all aspects of the resident’s health, personal and social care needs. All care records must have a current photograph of the resident. Reviews of care plans must show how the care plan is still meeting people’s needs. To prevent backdating records staff should not leave gaps in daily records. To make sure people who use bed rails are safe, a risk assessment must be carried out before the bed rails are put into use and regular safety checks must be made. The home must follow safe practices when dealing with medication. All unused medication prescribed for residents must be returned to the pharmacy. Some minor amendments are needed to the homely remedy policy to make sure that staff have enough information on when they can give this medication and how much they can give over a 24-hour period. For safe storage of medication the medication room temperature must not exceed 25oc. Food/fluid charts must be in place for all residents who are at risk of poor nutrition. This will provide staff, GPs, district nurses and others with a clear record of the amount of food and fluid the resident is taking. Senior staff should be shown how to adjust pressure mattresses so that they are able to do this if the manager is not in the home. The home must provide stimulating activities for people so that they are not left sitting with nothing to do. To make sure that the needs of all residents are met staff must have training on cultural awareness. Infection control must be managed properly to stop the spread of infection and all care staff must complete food hygiene training. To prevent injury to staff and residents a safe system of moving and handling people must be followed at all times. Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 8 Staff should wear name badges with their job title, so that people know whom they are speaking to. A daily menu should be displayed so that residents know before the actual meal what is being served. Residents should choose their meal not more than 24 hours in advance. Serving tongs should be used by staff when offering biscuits or cakes. The home must make some changes to the way that it recruits staff to make sure that the right people are employed. The frequency of staff meetings and the method of keeping a record of the meeting needs amending so that everyone is kept informed of what is happening. The manager should analyse accidents to identify any patterns or trends. Requirements and recommendations to address these issues 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.V306625.R01.S.doc Version 5.2 Page 9 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.V306625.R01.S.doc Version 5.2 Page 10 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): 1, 2, 3, 4 & 5. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Prospective residents have the opportunity to visit the home, stay for a meal and speak to other residents before making any decisions about admission. The home carries out a pre-admission assessment to make sure that it can meet the person’s needs. EVIDENCE: There is plenty of written information about the home for people to read. Copies of the statement of purpose and service user guide were seen in lounges and bedrooms and copies of previous inspection reports are on display in the reception area. There were assessment details in all of the care records sampled, and staff said that they had enough information about the care needs of people before they were admitted. The home has started to use new care documentation and the assessment format is comprehensive and includes staff making a check of the person’s room before admission. There is also an assessment of the relative’s view about admission, along with any issues they think the home Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 11 should be made aware of. If used properly the assessment information has the potential to form the basis of a good care plan. For this to happen the home should make sure that all relevant assessments are completed before admission and because of the large number of available assessments; any that do not apply to the resident should be removed. Information from these assessments must be used when developing the care plan. It was clear that prospective residents are given the opportunity to visit the home as many times as they like. One person visited three times before deciding to move in. Another resident told me that she visited the home, stayed for a meal and spoke to other residents. She said that she liked it very much and didn’t look anywhere else because she had decided that this was the place for her. In two care records sampled there was no statement of terms and conditions. The administrator said that these were signed and completed in other people’s records, but in the two sampled the Local Authority had still to provide information about payment of fees. Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 12 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 visit to the service. Residents’ health care needs are met, and the new paper work for care planning has the potential to provide good care records if used properly. However, care plans are not in place for all aspects of people’s care, so there is the opportunity for needs to be overlooked. Medication practices have improved, but the home does not always follow safe guidelines and return unused medication to the pharmacy. EVIDENCE: A number of care records were sampled; some were in the new format others were in the old style care records. Two people’s records in the new format were seen. In one person’s records the information from the assessment had not been transferred to a care plan, for example the assessment stated that her skin condition was poor but there was no care plan in place on how to manage this. From the daily records it was clear that district nurses were visiting and had given instructions for her leg to be elevated, but there was no care plan for this. Another resident had no care plan for cultural and spiritual needs despite the fact that he was a Muslim, and no care plans were in place Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 13 for night time/sleep, bedtime routines and activities and social interests. In both cases there was no photograph of the resident. The manager said that staff were still learning how to use the new paper work. The new documentation has the potential to provide good care records, particularly the section where residents can write in or contribute to the care plan on a daily, weekly or monthly basis. However, if the new system is to be effective information from assessments must form the basis of the care plan and all aspects of the person’s care needs must have a care plan in place. Other records using the old style format had similar omissions. One person had suffered a fall shortly after admission, but there was no care plan for the prevention of falls, he had short-term memory loss but there was no plan for managing this. He had no care plan for managing his depression and anxiety and assessment information said that although his wife had died 10 years ago, he thought this was a recent event and often became upset. Once more there was no plan for staff on how to deal with this. The daily records for another resident showed that he had aggressive outbursts, but again there was no plan on how to deal with this. Care plans are reviewed monthly, but these reviews are not robust and do not show what factors have been taken in consideration. For example in most cases the record state ‘reviewed no change.’ There were gaps in daily records allowing the opportunity for retrospective entries to be made. In all of the care records sampled there was evidence of health needs being met, by dental appointments, chiropody, community psychiatric nurse visits, optical prescriptions and visits from GPs and district nurses. 5 survey cards have been returned from GPs, one indicated that there is not always a senior member of staff to confer with, but the staffing rotas did not confirm this. It is recommended that staff have badges identifying their name and job role. Another GP was impressed not only by the care given to residents but also by the knowledge of staff about resident’s health care needs. One relative said that she was not always kept informed of any changes in her mother’s condition but during the feedback session the manager said that she had already addressed this with staff. During the inspection a visitor said that he is always kept informed about any changes in his relative’s condition. Another relative surveyed said that carers go out of their way to make sure health care needs are met. As a result of a fall district nurses had assessed one resident as being in need of a hospital type bed with bed rails fitted. The manager was unaware that the home must also carry out a risk assessment for the use of bed rails. Information about the safe use of bed rails was left with the home. Appropriate equipment is provided for those residents at risk of developing pressure sores. One person had a pressure mattress on her bed; the manager Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 14 said that each month she checks the pressure of the mattress, and adjusts it where necessary, against the person’s weight. It is recommended that all senior staff are shown how to do this and that a record is kept when the checks are made. One resident has a low weight and is at risk nutritionally. The manager said that the dietician, GP and CPNs were all involved. Whilst appropriate action was being taken there was no food/fluid chart in place. Medication records were sampled and found to be in order, and the manager said that the keys to the medication cupboards are kept separate from other keys in the building. The medication room was hot and there was no way of monitoring the temperature. The homely remedy policy needs amending slightly so that staff are aware of when they can administer a homely remedy and the maximum dose they can give in a 24-hour period. The home must make sure that any unused medication that has been prescribed for a resident is returned to the pharmacy and is not put into stock as a homely remedy. Through observation on the two days of the inspection, and by speaking to residents and staff it is clear that the privacy and dignity of residents is respected. Requirements and recommendations have been made to address these issues. Victoria House DS0000001519.V306625.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 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 adequate. This judgement has been made using available evidence including a visit to the service. The lack of activities based around individual choice and ability means that residents are left with nothing much to do. Visitors are made welcome and information is available for people who may need to use advocacy services. The lack of cultural awareness means that some people’s needs may be overlooked. Residents can choose what to eat but the length of time between choosing the meal and it being served is unacceptable. Residents often do not know what is being served until it appears at the table. EVIDENCE: Staff and residents spoke about the choices that are available to people such as times for going to bed and getting up in the morning. One visitor described the home as ‘great’ and said that whatever his relative wants she gets. Information about advocacy is on display in the reception area, and the manager said that an advocate from Age Concern was due to visit a resident later in the week. Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 16 Staff were providing one person with a Halal diet, and whilst this is good practice, generally there was a lack of understanding about the religious and cultural needs of residents, and why this was important. Since the last inspection the home has opened an activity/games room on the lower ground floor, but access to this is difficult without going outside of the home or using a steep staircase. During the inspection a snooker table was being delivered for this room. Most residents said that there was little to do. One person said, “It is good here because everyone see to you. The only thing missing is there is nothing to do.” One returned survey card from a resident said “Activities have been discussed at a residents’ meeting but that was as far as it got.” It was clear that staff and relatives were also unhappy about the lack of activities, and it had been an agenda item at a relatives’ meeting. One member of staff said, “People just sit here day in and day out.” Both the administrator and the manager acknowledged the lack of activities and explained how they have tried to rectify this without any success. Whilst problems with recruiting an activity organiser are accepted, this is an area that must be addressed without further delay. Visitors over the two inspection days and in returned survey cards said that they are always made welcome. One person visiting his relative was offered refreshments, and one person surveyed described the hospitality offered when both she and her husband were offered free overnight accommodation, with meals, when visiting a relative who had just returned to the home following surgery. Residents were complimentary about the meals. The lunchtime meal of roast chicken or mince and Yorkshire pudding with swede, broccoli and mashed potato, followed by sponge and custard or milk pudding looked appetising. One resident said, “You can choose meals to a certain extent,” and staff said that residents are asked to choose their meal but this choice can often be made as long as two months before the meal is served. The home should adopt a system where the meal is chosen not more than 24 hours in advance and a daily menu, which can be easily seen by residents should be displayed in different parts of the home. Residents were offered plenty of fluids, but the home must make sure that when drinks are served this is done on an individual basis rather than in an institutional way, where all the cups are filled with the same amount of milk and the same strength of tea/coffee. Residents helped themselves to biscuits from a Tupperware box. Whilst this encourages choice it also increases the risk of cross contamination and serving tongs or another similar system should be introduced. Two residents eat their meals after everyone else has finished and have moved away from the dining table. The manager explained the reason behind this and had involved the relatives of the two people involved. Whilst this situation Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 17 is not ideal the home has tried to explore alternative eating arrangements without any success. The reasons for this action are difficult and the manager is aware that the residents must not suffer any discrimination or be isolated. This situation must be kept under constant review. Requirements and recommendations have been made to address these issues. Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 18 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 visit to the service. Residents and relatives feel listened to and know how to make a complaint. Staff are clear about what constitutes abuse and how and where to report any suspicions or allegations of abuse. EVIDENCE: Information about how to complain is in every bedroom, and it is also in the statement of purpose and service user guide available in lounges. Four out of five relatives who returned survey cards said that they knew how to complain, one person said, “The owners, senior staff and assistants are always ready to listen to any small problems.” A resident said, “Staff listen to you, I would definitely complain if I needed to.” Care workers said that they would pass any complaint on to a senior member of staff. The manager said that minor complaints have not been recorded but that this would be rectified. All staff were familiar with the different types of abuse and were clear that they would report any suspicions or allegations of abuse to the manager and/or social services and the Commission for Social Care Inspection. Victoria House DS0000001519.V306625.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The environment meets the needs of the residents, but because infection control is not well managed staff and residents are placed at risk. EVIDENCE: Attractive seating areas, tubs and containers with colourful bedding plants and the start of landscaping to the front and rear of the home has made a big difference. The manager said residents have made the most of the good weather by sitting outside. Inside the home was fresh, clean and tidy and there were no offensive odours. During a telephone conversation with a relative the home was described as, “One of the better ones, that was always clean.” Bedrooms were personalised with adaptations such as raised toilet seats and handrails provided where necessary. As can be seen later in this report the home has a mobile hoist but this is not always used as it should be in communal areas. Some divan beds did not have a valance but the administrator and the manager were aware of Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 20 this. They said that they now complete a monthly tour of the building making a note of health & safety issues along with things that need replacing. They produced a record noting the room numbers where valances were needed along with other minor repairs and areas that needed decorating. This is good practice. Experienced staff have completed a distance-learning package on infection control but new staff were not sure about how to stop the spread of infection in the home. They were also putting themselves and other people at risk by not wearing protective gloves and aprons when coming into contact with bodily fluids, working in the laundry or cleaning toilets. The manager said that the home uses a system of double wrapping used and soiled incontinent products, but this does not always happen in practice because some pads in a clinical waste bin had not been double wrapped. There are not always supplies of gloves, bags, and aprons in all areas where clinical waste is handled. Staff said that when changing an incontinent pad in a bedroom they often had to go to a bathroom or toilet for gloves and had to carry the soiled incontinent pad along a corridor. The home has replaced clinical waste bins to the type that are controlled by a foot pedal but there is still no means of disposing of clinical waste in the laundry. There was no liquid soap or disposable towels in the laundry and it was clear that proper hand washing in this area does not take place, as it should. An item of soiled clothing was soaking in the hand washbasin. The administrator and manager showed a willingness to improve the way that infection control is managed. Requirements and recommendations have been made to address these issues. Victoria House DS0000001519.V306625.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 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 visit to the service. The staffing levels and the amount of training on offer meets the needs and numbers of residents, but recruitment practices are unsafe and do not always guarantee that people are suitable to work with older people. EVIDENCE: One member of staff thought that there was not always enough staff on duty and this was a view echoed by a relative on a survey card. However, the staff rota shows sufficient staff on duty, but the home should look at deployment of staff to make sure that staff do not take breaks together and perform tasks in pairs unnecessarily, which results in residents being left unattended. The recruitment records of three people were sampled. One person’s records showed that the home had only received one written reference and there was no evidence of her start date, no interview record, her employment record consisted of her last two jobs and there was no evidence that gaps in employment had been explored. The second person’s records showed no evidence of his start date, no list of full employment history and no evidence that gaps in employment had been explored. The third person’s records showed similar gaps in employment, no evidence that these gaps had been explored and one written reference was not returned until two weeks after the person had started work at the home. The manager confirmed that CRB/POVA Criminal Record Bureau/Protection of Vulnerable Adults checks had taken place before each person started work, but this could not be verified because they Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 22 had been destroyed. The administrator and manager knew that these records were unacceptable and said that they were the next set of records that were being reviewed and updated. The home supplied information about training before this inspection visit and a computerised record of staff induction, mandatory and other training was seen. Staff spoke about the level of training on offer, which included medication training, infection control, moving and handling and dementia care. They said that as a result of the dementia training they now understand how difficult it is for people with dementia to communicate and as a result they are more patient and try to make time to listen carefully. One person said that she now uses body language and gestures when trying to convey a message to people with dementia. Requirements and recommendations have been made to address these issues. Victoria House DS0000001519.V306625.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 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 visit to the service. There have been some management improvements particularly around quality assurance and with the introduction computerised records, but health and safety issues relating to moving and handling residents put staff and residents at risk of injury. EVIDENCE: The registered provider has stepped down from the registered manager’s post and has promoted her deputy manager to the post of manager. This person is in the process of applying to the CSCI for registration, and has the necessary qualifications for this post with an NVQ (National Vocational Qualification) level 4 in Care and the Registered Manager’s Award. She has a new job description and working alongside the administrator is trying to improve and update standards and practices in the home. Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 24 Senior staff said they had a weekly meeting with the manager and administrator, but the manager said that this is an informal meeting with no minutes taken. The manager said that she has delegated responsibility for staff meetings to the deputy manager and a senior carer and these happen about twice a year. One carer didn’t think that the views of care staff were taken seriously and that appropriate action was always taken following staff meetings. It is recommended that senior staff meetings be formalised and link into full staff meetings at intervals of no longer than 2 months with the manager chairing the meeting. A record should be kept on the minutes of what action, if any, is being taken, who has responsibility for taking action, and the timescale for any action. The manager has started to audit practices in the home against the Care Homes for Older People National Minimum Standards. Her system needs adapting but could, along with quality assurance surveys and feedback and inclusion of staff, residents and relatives from meetings, form the basis of a good quality assurance system. The home is appointee for one person and records of all transactions for this person were seen. The administrator is transferring all paper records onto a computerised system that will be easier to audit. The manager said that residents were discouraged from bringing valuables into the home, but on the rare occasions that this happened a receipt was always given and valuables were stored safely. The administrator and manager said that money for one resident is never used to fund someone else who has a negative balance. A number of accident records were seen. In all cases where an accident was not witnessed there was no record of when the person was last seen and by whom. In some cases there was no review of the accident or follow up, particularly where in one case where a pressure bandage was applied and in another where a 999 call was made. The manager does not analyse all accidents on a monthly basis to identify any trends or patterns. Over the 2 days of this inspection staff were seen on several occasions moving and handling people incorrectly. Three residents who were unable to weight bear were manually transferred by two members using an under arm lift. This could cause injury to both the resident and the care workers. The hoist was not used at all in communal areas. Staff said that they are completing a moving and handling course by a distance learning pack but a tutor is coming into the home to give a practical session. During the feedback the manager said that she felt she was infringing the rights of people by using the hoist in communal areas because many residents are uncomfortable, do not like the hoist and it is undignified. People must be moved safely and the home must obtain professional advice on how to move and handle people who cannot always weight bear from a qualified occupational therapist. Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 25 The manager said she thought food hygiene training was unnecessary for staff because they do not prepare food. She did agree to rectify this. The returned pre-inspection questionnaire showed that servicing of equipment takes place as required and a selection of service certificates were seen, along with the records of fire alarm tests which show a different actuation point is tested each time. The manager said that first aid training is taking place in the home for all staff on the 7th & 8th September. Requirements and recommendations have been made to address these issues. Victoria House DS0000001519.V306625.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 3 2 3 3 3 N/A 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 1 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X 3 X 1 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 3 X X 2 Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 27 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15, 17 Requirement 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. This is outstanding from an inspection on 2.2.06. Care records must contain a photograph of the resident. This is outstanding from an inspection on 2.2.06. Reviews of care plans must be robust and show that the care plan is still effective. 2. OP8 13 The home must carry out a risk assessment for the use of bed rails whenever they are being considered for use. A system of safety checks on bed rails in use must be put into place with a record kept of the date of the check and how the check has been carried out. Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 28 Timescale for action 30/11/06 30/09/06 3. OP9 13 (2) Unused medication must be . returned to the pharmacy and must not be put into use as stock for homely remedies. This is outstanding from an inspection on 2.2.06. The homely remedy policy needs amending to show when the medication can be used, the maximum dose in a 24-hour period, and time limit for using homely remedies. The temperature of rooms used for storing medication must not exceed 25o c. 31/08/06 4. 5. OP8 OP12 12 16 (2) (n) A food/fluid chart must be in place for all residents who are in a high nutritional risk category. Facilities for recreation and leisure must be provided, taking into account the ability, capacity and individual needs of the residents. This is outstanding from 25.4.05 and 2.6.06. Staff must have some training on culture and diversity. Liquid soap and paper towels must be provided in the laundry room. This is unmet from 30.9.04, 10.4.05 and 2.2.06. A clinical waste bin must be provided in the laundry. This is unmet from 2.2.06. Soiled clothing must not be left to soak in the hand washbasin in the laundry. 30/09/06 31/10/06 6. 7. OP12 OP26 12, 18 13 (3) 31/12/06 30/09/06 Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 29 8. OP26 13 All staff must wear disposable protective aprons and gloves when cleaning toilets, dealing with laundry and coming into contact with bodily fluids. Soiled and used incontinent products must be double wrapped. Sufficient supplies of aprons, gloves, and disposal bags must be provided in all areas where clinical waste is handled. This must include bedrooms. All staff must be made aware of correct hand washing procedures and these must be followed at all times. 31/08/06 9. OP29 19 All staff application forms must include a full employment history. Any gaps in employment must be explored and a record of this kept. The home must receive two written references before an offer of employment is made. A CRB/POVA disclosure check must be returned before an offer of employment is made. This must be retained in the home until the next inspection. 31/08/06 10. 11. OP38 OP38 13, 18 13 (5) All care staff must complete food hygiene training. A safe system of moving and handling residents must be followed at all times. Advice must be obtained from an OT on how to move and handle people who cannot always 30/12/06 30/09/06 Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 30 weight bear. This is outstanding from an inspection on 2.2.06. 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. Refer to Standard OP7 OP8 Good Practice Recommendations There should be no gaps in daily records. All senior staff should know how to use and adjust pressure mattresses. A record should be kept of checks on the pressure settings of pressure mattresses. Staff should wear name badges identifying their name and job role. The home should adopt a system where residents choose their meals not more than 24 hours in advance. A daily menu, which can easily be seen by residents, should be displayed in different parts of the home. Drinks should be prepared and offered on an individual basis, taking into account personal choice. Tongs, or a similar safe system should be used when offering residents biscuits and other snacks. Valances should be fitted to all divan beds. The manager should monitor deployment of staff when they are completing tasks and taking breaks, to make sure that there is a member of staff available at all times in all of the communal areas. Recruitment interviews should be conducted by a minimum of two people. A record of the interview should be kept and signed and dated by both people conducting the interview. Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 31 3. 4. OP8 OP15 5. 6. OP24 OP27 7. OP29 8. OP31 Senior staff meeting should be formalised with minutes taken of the meeting. Senior staff meetings should link into full staff meetings at intervals of no longer than 8 weeks. The manager should chair these meetings. A record should be kept on the minutes of what action, if any, is to be taken, who has responsibility for the action and the timescale for any action. 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. This is outstanding from an inspection on 2.2.06. 9. OP38 Victoria House DS0000001519.V306625.R01.S.doc Version 5.2 Page 32 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 © 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 DS0000001519.V306625.R01.S.doc Version 5.2 Page 33 - 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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