Inspection on 23/06/05 for Victoria House

This inspection was carried out on 23rd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 03/03/09

Victoria House 13/12/07

Victoria House 10/08/07

Victoria House 11/10/06

Victoria House 24/11/05

Victoria House 11/11/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Victoria Road 77 Victoria Road Rushden Northants NN10 0SA Lead Inspector Linda Preen Unannounced Thursday, 23rd June 2005 at 10:00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Victoria Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 77 Victoria Road Address 77 Victoria Road Rushden Northants NN10 0SA 01933 417 950 01933 417 951 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Shaw Healthcare (de Montfort) Ltd Mrs Susan Anne Attley Care Home 45 Category(ies) of DE (E) Dementia - over 65 (8) registration, with number PD (E) Physical Disability - over 65 (6) of places OP Old Age (45) Victoria Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: All re-development work detailed in the refurbishment plan submitted to the Commission on 25.04.04 must be completed by March 2009. The home may continue to accommodate 2 named service users who fall within the registration category MD(E) No one falling within the category of DE(E) may be admitted into the home where there are 8 service users who fall within the category of DE(E) already accommodated within the home No one falling within the category of PD(E) may be admitted into the home where there are 6 service users who fall within the category of PD(E) already accommodated within the home Date of last inspection 11/11/04 Brief Description of the Service: 77 Victoria Road is a residential care home currently owned by Shaw Healthcare. The home provides care for up to 45 Service Users over the age of 65 years. Within the home’s total of 45 Service User up to 8 older people with dementia and up to 6 people with physical disabilities can be provided with personal care. The Home is situated within walking distance of Rushden town centre, has extensive gardens and all facilities are located on the ground floor. Service Users have easy access to local facilities and amenities. All bedrooms are single occupancy rooms with easily accessible communal areas. The home is made up of several smaller units, each with their own lounge, dining area and kitchenette as well as a central larger lounge and bar area. Victoria Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two hours were spent prior to the inspection reviewing previous requirements and recommendations, comments from residents and relatives and collating information provided by the service. The inspection took place over a period of three and a half hours as part of the statutory inspection programme. Two residents were chosen in order that their experience in the home could be monitored. This included looking at their records, talking to them and also to the staff concerning the care received. In addition to this staff rotas and staff records were seen. 21 comment cards had been received from residents, 21 comment cards from relatives and information was available from a questionnaire completed by the providers of the service. Resident comment cards confirmed that staff treated them well and that they felt well cared for. Nine commented on the suitability of activities, and two commented that it was cold in Walnut lounge. It was not possible to assess this on this occasion as it was a very hot day and all areas of the home were very warm. None of these residents expressed a wish to speak to the inspector. Relatives comment cards all recorded satisfaction with the care provided, but twelve commented on the perceived shortage of staff on occasion, and seven stated that they were unaware of the complaints procedure. The complaints procedure was seen to be clearly displayed on notice boards throughout the home. One relative commented on the lack of attention to personal hygiene. Staffing levels were monitored and no shortfall was observed. Residents seen were all well groomed and appeared well cared for. Several of the ladies were having their hair done at the time of the inspection. Requirements and recommendations made at the previous inspection were monitored. What the service does well: All of the residents and relatives spoken to complimented staff on the care and attention provided. Such comments as “ It’s very nice here”, Staff are lovely” and “Food is excellent” were made by those spoken to. There was a very pleasant relaxed atmosphere in the home, with good relationships observed between residents and staff. Victoria Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: 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 Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Victoria Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 and 4 Residents are assured that their needs may be met in the home, prior to admission. EVIDENCE: Residents case tracked had copies of Terms and Condition of residence on file and comprehensive pre- admission assessments were completed, which demonstrated that the resident and their family had been consulted. Victoria Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10 Care planning records did not give sufficient guidance to staff on how to meet resident’s needs, but staff treated residents with dignity and respect. EVIDENCE: Some work has been done to improve care planning since the last inspection, but care plans are still not in sufficient detail to enable staff to provide care. For example: one resident had been identified in the daily record as having challenging behaviour, but there was no care plan in place to guide staff as to how to deal with this. Another resident had a care plan for promotion of continence, which did not record that incontinence pads were worn. This was recorded elsewhere in her file on her NHS assessment. Risk assessments were in place, but action was not always prescribed to reduce identified risks. For example: A resident was identified as being at high risk of developing pressure ulcers but there was no evidence of pressure relieving measures having been put in place. This resident was observed to be sitting in a wheelchair without a pressure relieving cushion. A requirement concerning care plans was made at the last inspection and remains outstanding. Victoria Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 Page 10 Staff were observed to be treating residents with dignity and respect. Those residents spoken to complimented staff on the care provided. Victoria Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Social activities and meals are both well managed and provide daily interest and variation for people living in the home. EVIDENCE: A new activities co-ordinator has been employed in the home since the last inspection. Weekly activities were advertised on the notice boards in the lounge areas and included such things as Bingo, card games, sherry afternoons and sing-a-longs. The activities co-ordinator keeps records of activities provided and of resident participation. Each resident has a record of their hobbies and interests in their individual files. Those residents spoken to confirmed that they enjoyed the activities, particularly the prize Bingo. One gentleman stated that he preferred to watch his own television. Advice was given concerning suitable activities for those residents with dementia. Residents were observed to be freely accessing all areas of the home, and one new resident stated that she had already made friends with the other residents. Visitors are able to come at any time and several were visiting during the inspection. One family had brought a small dog to visit and another family had a baby, which was appreciated by all. Relatives spoken to confirmed that the standard of care was very good and complimented the carers. Victoria Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 Page 12 Records of individual choices concerning rising and retiring and food preference were seen in the files checked. Menus provided as part of the pre-inspection questionnaire, demonstrate that a varied nutritious choice of food is on offer. Residents eat in small family groups in their individual units. Some of the residents had been involved in making their own placemats to make the tables attractive. Menus were on display on each table to remind residents of the daily choice. Residents spoken to were complimentary about the food and made such comments, as “food is excellent”. One gentleman said he was trying to loose weight but the food was too good. Victoria Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 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 standard(s) 16 Residents and their relatives may be assured that complaints will be taken seriously and acted upon. EVIDENCE: A complaints procedure was on display in the main entrance lounge of the home. The Commission has received no complaints for Social Care Inspection since the last inspection. The company have demonstrated their commitment to dealing with complaints in a satisfactory manner on other occasions. Victoria Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 23, 24, 25 and 26 Residents live in a safe, comfortable environment, which meets both individual and collective needs. EVIDENCE: A limited tour of the environment demonstrated that the home was clean and maintained to satisfactory standards. Bathrooms remain very institutional in appearance and are very unwelcoming. Light, airy communal rooms are available throughout the home and pleasant gardens are available in good weather. Resident’s rooms showed evidence of personalisation with small items of furniture, pictures and ornaments on display. All areas of the home were very warm owing to the hot sunny day. Walnut Lounge was comfortably warm and it was not possible to substantiate the complaint that this room was cold. The home is advised to monitor the temperature in this room and adjust as appropriate. Victoria Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Residents are cared for by sufficient numbers of well trained staff. EVIDENCE: Duty rotas demonstrate that there are sufficient staff on duty to meet resident needs. The use of agency staff is no longer necessary following a successful recruitment drive in Eastern Europe. The company have a commitment to training and have a training manager employed. A training matrix is available to monitor statutory training and updates. One staff member spoken to stated that she had enjoyed a recent mental health training day. Evidence was available that staff had attended training in the care of those residents with dementia. One of the Slovakian staff stated that she had undergone a weeks induction course on arrival and that a translator had been available to ensure that instruction was fully understood. Fourteen staff currently hold a National Vocational Qualification in care, with a further three working towards this. This commitment to training ensures that resident’s needs may be met by a competent team of staff. Two staff files were seen. These demonstrated that the information required in Schedule 2 of the Regulations was available with the exception of a photograph in one case. Advice was given concerning this omission. Victoria Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed on this occasion. EVIDENCE: Victoria Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x x x x Victoria Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 Page 18 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 7 Regulation 15 Requirement The Registered Persons must ensure that sufficient detail is recorded in the care plans that directs and instructs staff in the appropriate care provision required.( Previous timeframe of 30/9/04 and 1/1/05 not met ) The Registered Manager must include into the care plan and risk assessment details of the action required to meet health care needs( Previous timescale of 30/9/4 and 1/1/05 not met.) Timescale for action 1/9/05 2. 8 13 1/9/05 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. Refer to Standard Good Practice Recommendations Victoria Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection 1st Floor, Newland House Campbell Square Northampton NN1 3EB 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 Road C51 C08 S60005 77 Victoria Road V233105 230605 Stage 4.doc Version 1.30 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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