Inspection on 26/04/05 for Victoria House

This inspection was carried out on 26th April 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 17/07/08

Victoria House 24/07/07

Victoria House 22/08/06

Victoria House 02/02/06

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 LS10 3EG Lead Inspector Ann Stoner Unannounced 26th April 2005 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 House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Victoria House Address Low Grange Crescent Belle Isle Leeds LS10 3EG 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) 0113 2708529 0113 2765090 Mrs Mary Margaret Lavelle Mrs Mary Margaret Lavelle Care Home Only 25 Category(ies) of Old Age (25) registration, with number of places Victoria House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3rd August 2004. Brief Description of the Service: Victoria House provides residential care, without nursing, for 25 older people of both sexes. It is set in two acres of grounds, situated centrally in the Belle Isle community of Leeds. Accommodation is provided on two floors with the provision of a lift to aid access. There is a large reception area with a bar, two lounges, each leading to a dining area, and a small library/visitors room. Plans have been submitted for an extension at the side of the building. 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 J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, regulated care homes have a minimum of two inspections a year; these may be announced or unannounced visits. The last inspection was announced and took place on the 3rd August 2004 and an unannounced monitoring visit to assess the progress made with care planning and assessment took place on the 14th December 2004. There have been no further visits until this unannounced inspection. The people who live in the home use the term resident; therefore this is the term that will be used throughout this report. During this inspection, the care records of three residents were examined in detail, some areas of the home were seen, such as bedrooms, lounges, dining areas, toilets and bathrooms, care staff were observed carrying out their work, and discussions were held during the day with the registered manager and her deputy, senior and other care workers, 18 service users and two visitors. This inspection started at 11.00am and ended at 7.30pm. What the service does well: What has improved since the last inspection? What they could do better: The most serious concerns from this inspection were around medication and the fact that a member of staff was employed without a proper police check. Victoria House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 Page 6 The medication records that the home is required to keep were poor, and staff were unclear about the proper procedures to follow. The home must put these areas right immediately to ensure residents are not put at risk. People coming to look round should be offered written information about the home, so that they can decide whether or not the home and its facilities is right for them. Before a resident is admitted, the home must carry out a proper assessment to make sure that staff are able to give the care needed. Progress already made with care plans must continue and proper procedures must be in place to make sure that people who have fallen before coming into the home have this risk reduced. It is unacceptable for residents to share a bedroom without having screens or curtains for privacy. The home must look at ways of making sure that residents are not bored. To ensure proper hygiene procedures staff must make sure they use liquid soap, rather than bars of soap when washing their hands. Because there are not enough cleaners at the home care staff have to spend some time doing cleaning tasks. As a minimum another cleaner must be employed. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Victoria House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 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 House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 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) 1,2,3,4 & 5 Prospective residents and their carers/relatives are able to decide if the home is appropriate to their needs from the detailed information provided, and the opportunity to visit. The home could not demonstrate that it could meet the assessed needs of prospective residents, thus providing the opportunity for unmet needs. EVIDENCE: The care records of three residents who have recently been admitted to the home were examined and although there was a social work assessment in all of the files, the home’s assessment was completed in only two of these. The information that was recorded did not state all of the person’s needs, such as personal hygiene needs and was not in enough detail for an effective care plan to be developed or to demonstrate that the home was in a position to meet the assessed need. Signed terms and conditions were seen in all of the care plans, but the room number was not always identified. Two out of the three residents were able to confirm that they had visited the home before admission. One person said that she looked at other homes before visiting Victoria House, and that her priority was not the building, but Victoria House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 Page 9 her feelings about staff. She said, “I immediately felt that this was the place for me, and it has been the right decision.” She was aware that her admission was based on a trial period of 6 weeks, and said that she would be involved in a meeting within the next two weeks to confirm her stay. Neither of the residents or visitors, when asked, could remember being offered any written information about the home. Victoria House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 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 standard(s) 7,8,9 & 10 Staff are provided with the level of detail required to carry out care tasks, as a result of their being a big improvement in the information recorded within care plans. There is still further work need on this. The lack of nutritional screening and falls risk assessments could result in needs being overlooked. Lack of access to a medication policy, unclear procedures, poor recording and unsafe practices, results in residents being placed at risk. The absence of screening in shared rooms, does not guarantee the privacy and dignity of residents. EVIDENCE: The level of detail recorded within care plans has improved and a senior care worker explained how these are being developed further to include all areas of need. Daily recording has also improved. From the three care plans sampled there were good instructions for staff to follow, such as precise details on how a resident was able to care for herself and the remaining help she needed from staff, exactly how staff should support another resident when walking, and Victoria House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 Page 11 exact details of how and why drinks needed to be given in a particular cup. This resident confirmed that the instructions in her care plan were carried out in practice, and staff were seen giving her a drink in her special cup. All of the care plans were signed, but two of the three residents were unaware of the existence of the care plan, as were two visitors. Reviews are taking place, and further work is being carried out to evidence the extent of the review and explain the need for a change to the care plan. There was little evidence seen within the care plans of social and leisure activities being provided according to past and current interests and information recorded within daily records is not always transferred to the care plan. There was no nutritional screening seen in any of the care plans sampled. It was recorded on the pre-admission assessment information that one resident had a recent weight loss of 3 stone, and another person had a poor appetite, was quite thin, and after admission, due to a pressure sore, was prescribed a food supplement. No nutritional risk assessments were in place. The records of all three residents indicated that they had suffered falls at home; the main reason for admission for two of the residents was recorded as being the risk of falls, but there were no falls risk assessments in place identifying measures taken to reduce the risk of further falls. Medication was an area of serious concern. From the daily records it was evident that one resident was being given Paracetamol for pain on a regular basis, both during the day and at night, but there was no record of this on her MAR (Medication Administration Record). Staff said that a hospital discharge letter confirmed the use of this medication, but no evidence of this could be found. The home’s system of handwriting the MAR on admission without being checked by a second system creates the potential for error, which on this occasion was the case. From discussion with staff it was clear that some were unaware of the homely remedy policy and those that were aware of the policy were not following the correct procedures. In some cases residents were being given medication that was not prescribed for them. Although the home has a policy on medication, this could not be located. The home has three shared rooms. One resident in a shared room described dressing, undressing and using a commode in view of another person. The home has only one portable screen for both floors, and whilst staff said that residents in shared rooms use the en-suite facilities for washing, dressing, and undressing, this is obviously not the case for those residents with poor mobility. Victoria House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 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 standard(s) 12 Social activities for residents are limited, thus creating the opportunity for boredom. EVIDENCE: Staff said that although group activities are provided such as bingo, a balloon game and quizzes, there is no structured activity programme and they do not have specialised knowledge about activities for people with sight and hearing loss or those with some degree of memory loss. Staff said that if activities are provided it is between 2 pm and 4 pm. Throughout the inspection there was little stimulation offered other than TV and music. The position of the television in one lounge creates a problem, as it is wall mounted in a corner, which places some residents, sitting along a wall, at a disadvantage. Some residents said that they could not see the TV without physically moving, others said that they could see it but couldn’t hear it and others said it was frustrating as it was on all the time. Residents have the opportunity of watching TV in their room, but some said that they preferred company in the lounge. Most of the residents said that they were bored; one said it was “very boring after tea,” another said, “there isn’t a lot going on, a lot of people just sleep”. Victoria House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 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) These outcomes were not looked at on this visit. EVIDENCE: Victoria House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 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) 26 The lack of proper facilities for hand washing creates the risk of spread of infection. EVIDENCE: Service users were pleased with the laundry facility in the home; one resident said that her clothes were, ‘beautifully laundered’. From discussions with staff it was evident that they are aware of the correct procedures to prevent the spread of infection, such as wearing protective clothing, and many are now starting an infection control course. Liquid soap was provided in the laundry area and staff toilet, but was not available in all other toilet and bedroom areas. Victoria House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 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) 29 Residents are placed at risk as recruitment policies and procedures have not been consistently followed. Staffing levels are inadequate as care staff have to do cleaning tasks. EVIDENCE: Examination of personnel records for two members of staff recently appointed to the home identified that the home is not using the new documentation introduced at the end of last year. As a result, a full employment history was not recorded on the application form, there was no evidence of any gaps in employment being explored, there was no record of an interview being held, and one of the two references obtained for one person was from a family member. The registered manager was unaware of the optional POVA First facility and had failed to request a CRB (Criminal Record Bureau) disclosure for one person. The home employs one person Monday to Friday to undertake domestic duties. When this person is on holiday, or absent due to sickness and at weekends care staff have to carry out these duties. Victoria House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 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 outcomes were not looked at on this visit. EVIDENCE: Victoria House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 2 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x 2 STAFFING Standard No Score 27 x 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x Victoria House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 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 (1) (2) (a) Requirement Timescale for action 31.5.05. 2. 7 15 (2) (b) Wherever possible service users and/or their representatives must be involved in the development, and consulted about the care plan. The care plan must be made available to them. There must be a thorough review 31.5.05. of the care plan, documenting all the aspects taken into account as part of the review. Wherever possible, residents and/or (with the residents permission) their relative or representative must be involved in the review process. A falls risk assessment must be completed for all residents identified as being at risk of falling. In order to make safe arrangements for recording, all handwritten entries on Medication Administration Records must but be checked and countersigned by a second person. In order to ensure safe administration of medication, the 3. 8 13 (4) 31.5.05. 4. 9 13 (2) Immediate as advised. Victoria House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 Page 19 policy relating to medication must be readily available to staff at all times. The home must obtain a book for the recording of homely remedies. All staff must follow the correct procedures when administering homely remedies. Service users must only be given medication that has been prescribed for them unless the homely remedy policy is being followed. A record must be made on either the Medication Administration Record or in the homely remedy book whenever medication is administered. Screening must be provided in all shared rooms. Facilities for recreation and leisure must be provided, taking into account the ability, capacity and individual needs of the residents. Liquid soap and paper towels must be provided in all areas where clinical waste is handled. This includes bedrooms, bathrooms, and toilets. The previous timescale of 30.9.04 is unmet. Domestic cover must be provided 7 days a week. The previous timescale of 30.9.04 is unmet. Staff must not be employed until the home is in receipt of either a POVA First (Protection of Vulnerable Adults), or a successful CRB (Criminal Record Bureau) check. 5. 6. 10 12 16 (2) 16 (2) (n) 31.5.05. 31.5.05. 7. 26 13 (3) 31.5.05. 8. 27 18 (1) 30.6.05. 9. 29 19 (1) (b) Schedule 2 Immediate as advised. Victoria House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 Page 20 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. Refer to Standard 1 2 3 Good Practice Recommendations The home should make more use of the statement of purpose and the service user guide during the admission process. The statement of terms and conditions should specify the room number that the resident will occupy. The home should carry out an assessment of need on all prospective service users. This assessment should identify the following: All of the persons care needs at the time of the assessment Justification of how the home is able to meet the persons needs 4. 5. 8 29 The outcome of the assessment. Nutritional screening should take place on admission. This is outstanding from the previous report. A full employment history should be obtained on the application form. A record on the recruitment and selection interview, giving evidence of how any gaps in employment have been explored should be kept within the staff file. The interview should be conducted by a minimum of two people, both of whom should sign the interview record. Written references from family members should not be accepted. Victoria House J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 Page 21 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 J52 J03 S1519 Victoria House V221138 260405 Stage 4.doc Version 1.20 Page 22 - 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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