Inspection on 06/06/06 for Victoria House Care Home

This inspection was carried out on 6th June 2006.

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 Care Home 14/08/08

Victoria House Care Home 15/08/07

Victoria House Care Home 25/01/06

Victoria House Care Home 01/07/05

Victoria House Care Home 17/02/05

Victoria House Care Home 28/04/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Victoria House 71-73 Victoria Road Polegate East Sussex BN26 6BX Lead Inspector Gwyneth Bryant Unannounced Inspection 08:00 6th June 2006 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 DS0000021277.V289294.R01.S.doc Version 5.1 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 DS0000021277.V289294.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Victoria House Address 71-73 Victoria Road Polegate East Sussex BN26 6BX 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) 01323 487178 01323 487178 Supreme Care UK Limited Mrs Esther Redmond Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty (20). That service users must be older people aged sixty-five (65) years or over on admission. 25th January 2006 Date of last inspection Brief Description of the Service: Victoria House is registered to provide care and accommodation for up to twenty older people. The home is a three-storey detached property situated in a residential area of Polegate. It is located in close proximity to local amenities including bus and rail links. Service users accommodation consists of twenty single rooms, eleven of which have en-suite facilities. All bedrooms have at least a wash hand basin. The home has a range of communal areas including a large lounge and dining area. There are two communal bathrooms, both of which are assisted, and four communal toilets. There are toilet riser seats and handrails fitted as required. The external grounds offer an attractive garden and patio area. Car parking is available at the front of the property. The home has a passenger lift and a series of ramps that enable service users to access all parts of the home; however there are some internal steps so service users on the upper floors need to be mobile. The service provides prospective service users and their families with a copy of the Statement of Purpose and Service Users Guide when the pre-admission assessment takes place. Copies of inspections reports are made available on request. Fees charged as from 1 April 2006 range from £324 to £485. Additional charges are made for hairdressing, chiropody and newspapers. Intermediate care is not provided. The home does not currently have an email or website address. Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by two inspections for the first 4 hours and the following 2.5 hours by one inspector. There were twenty service users in residence on the days of which six were spoken with. The purpose of the inspection was to check compliance with the requirements made during the last inspection and that the issues discussed during a meeting with the providers had been addressed. The Manager, a one member of care staff and the cook were spoken with. A range of documentation was accessed and viewed including service users care plans, personnel files and medication records. A tour of the premises was carried out. Ten service users surveys were returned and comments were generally positive with service users stating that the care is good and that they would be happy to raise any concerns with the manager. The Registered Providers make monthly visits and the subsequent reports were used as part of the inspection process. No comments were received from any social or healthcare staff regarding the care provided at Victoria House. What the service does well: What has improved since the last inspection? Since the last inspection the manager has made significant progress in addressing the requirements following the last inspection and facilitating the improvements made. The home’s Statement of Purpose and Service Users Guide has been reviewed and contains the required information and all care plans now include a photograph of the service user. A suitably qualified person has made an assessment of the premises to ensure there are sufficient aids and adaptations provided to meet the needs of all service users. Heating systems have been repaired as required and service users bedrooms now include the required furniture. Suitable weighing equipment has been purchased and the ground floor bathroom is now available for use by service users. Staff training has been provided in a number of key areas including infection control, manual handling, health and safety, First Aid, adult protection and fire safety. Recruitment practices now meet the requirements. Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 Page 6 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 House DS0000021277.V289294.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 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 the following standard(s): 1, 3 and 4. Standard 6 is not applicable Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users and their representatives are provided with sufficient information of the services provided on request prior to moving into the home. Pre-admission assessments need to be more robust to ensure that only service users within the home’s registration category are admitted. EVIDENCE: There is an up-to-date Statement of Purpose and Service Users Guide and a new brochure is due to be printed in the near future. The manager has devised a checklist to ensure prospective service users and their relatives are provided with the information they need to make an informed decision as to whether or not Victoria House is suitable for them. A sample of pre-admission documents were viewed and while it is evident that the manager identifies care needs, two service users recently admitted appear to be out of the homes’ registration category. The home has been required to ensure these two service users are re-assessed without delay. Pre-admission documents are used effectively to create a detailed care plan for each service user. Intermediate care is not provided. Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The content of the care planning system is consistent and provides staff with most of the information they need to satisfactorily meet service users’ needs however they would be better protected if risk assessments included the management of the risk in relation to individual disabilities. Service users are protected by satisfactory systems for the recording and storing of medication. EVIDENCE: Four care plans were viewed and it was clear that a great deal of work has been done to ensure these documents are used as a tool to identify service user’s care needs. Each care plan now includes a photograph of the service users to facilitate identification. In viewing care plans and talking to service users it is clear that the dependency of some service users in terms of their physical and mental health needs is such that they may be out of the home’s registration category. There was evidence to demonstrate that where service users have a particular condition the manager obtains relevant information to ensure staff are aware of any additional care needs. Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 Page 10 Risk assessments have improved but also need to be expanded to include any increased risk in respect of service users individual disabilities and in particular for manual handling. Some care plans showed that service users had been involved in reviews and two service users were aware that they had a care plan. However, other service users said they did not know they had a plan of care and this needs to be addressed to ensure service users agree the content of the plan. Arrangements are in place to cater for those who need assistance from dentists, opticians and chiropodists. New weighing scales have been purchased and service users are weighed regularly and action taken in the event of weight loss or gain. Medication administration records were viewed and found to be accurate, up to date and complete. Staff were seen to dispense medication in line with the home’s policies and procedures. However, prescribed creams were found in rooms that were not for use by the occupant. This was discussed with the manager who explained that staff are not checking the name of the service user on the label before dispensing the cream and that she will be addressing the matter. The staff were observed to treat the service users with respect and maintain their privacy and respect, this was supported by service users comments ‘the staff here are all very kind’, ‘everybody is very helpful’ and ‘I am satisfied with all their help’. Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14, and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for the in-house leisure and social activities need to be based on service users preferences to provide opportunity for mental and physical stimulation and promote independence and choice. Service users benefit from well-balanced, varied and nutritious meals. EVIDENCE: The home has a weekly programme of activities, including cards, board games, music and exercise during weekday afternoons only. Service users spoken with said they very much enjoyed the activities, but especially the entertainers from outside such as the musician and exercises. The pre-inspection information provided by the home states that service users go out to church, shops, cinema and bingo. However, in discussion with the manager it was found that only two service users accesses the wider community in this way. One service user also told the inspectors that they missed going to church. The manager confirmed that she herself would provide assistance to enable other service users to access the wider community. The daily life of service users could be improved by increasing the number of activity sessions provided and linking this to meeting individual preferences, which satisfies services users social, cultural, religious, and recreational interests. Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 Page 12 The home has an ‘open house’ policy for visitors and service users spoken with confirmed their relatives are made welcome. Service users care plans included their individual preferences and the manager ensures they are given the opportunity to exercise control over their daily lives. Since the last inspection lunchtime menus now include an alternative for both the meat and the vegetarian option. All service users spoken with were very complimentary about the food and specific comments included ‘I enjoy my meals’, ‘good choice and varied menu’ and ‘plenty of variety and nutritious’. The cook is knowledgeable about service users individual and special dietary needs. Fresh fruit and vegetables were available and the cook said she uses them whenever possible. All dishes, including cakes are made on the premises. Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All complaints should be investigated in line with the home’s policies and procedures to ensue that complainants are confident that their complaints are taken seriously and acted upon. Staff training ensures that service users are protected from abuse. EVIDENCE: There have been no complaints to the home since the last inspection. Appropriate policies and procedures are in place. The complaints book was viewed and while complaints are recorded, the records did not include outcomes and action taken to ensure a clear audit trail is created as part of the investigation process. One service user confirmed that ‘the manager is the person to whom I go to, to complain’. The home has policies and procedures on adult protection and all staff have been trained in adult protection including the types of abuse, what action should be taken if staff have any concerns and of whistle blowing. Staff training records confirmed they had received this training and staff spoken with were aware of the correct procedures. Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ benefit from an environment which provides choice of space and privacy, however, a number of maintenance issues impact on both safety and comfort including, the provision of suitable aids and adaptations to create a pleasing, safe and comfortable environment for service users to live in. EVIDENCE: A tour of the premises was carried out and service users bedrooms were tastefully decorated and many have taken the opportunity to personalise their rooms with pictures and ornaments. Since the last inspection bedside tables and lamps have been purchased and made available to all service users who require them. Generally rooms are well decorated and furnished. Service users spoken with said that they were happy with the décor in their rooms and one said that she was able to choose the colour scheme for her room. It was noted that ceiling lights in some en-suite facilities and in corridors did not have lampshades and the light in the corridor leading to the dining room did not work. These shortfalls detract from the generally attractiveness of the home. Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 Page 15 The home has a hoist located on the top floor, however it is too heavy and bulky to move into the lift. Therefore a more suitable lifting device needs to be provided given the increased dependency levels of some service users. New weighing scales have been provided enabling staff to accurately weigh service users. A suitably qualified person had made an assessment of the premises and work is in progress to address all the recommendations in respect of providing grab rails and ensuring all areas are easily accessible to service users. Service users are unable to control the heating in their own rooms and this must be rectified to ensure service users personal accommodation is at a temperature they choose. The hot water delivery temperature in service users’ bedrooms was erratic with some being as low as 34.2o C and others up to 58oC. Water needs to be delivered at temperatures that are comfortable for service users but not so hot as to place them at risk. Not all communal toilet facilities had wash hand basins fitted and this needs to be addressed to reduce the risk of infection. Throughout the inspection the laundry door was left open, this is a fire door and should be kept closed. Staff training records showed that all staff have received training in infection control and were observed to be following infection control procedures. Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The deployment and number of staff at key times is insufficient to meet service users care needs and staff would benefit from training relating to meeting the specific needs of service users to ensure that they have the skills and competencies to fulfil their roles. Recruitment practices are robust and provide the necessary safeguards to protect service users. EVIDENCE: Staff rotas were viewed and found that a total of 223 care hours per week are provided by care staff. In addition to providing care, staff are also required to serve meals, make breakfast and drinks and provide activities for service users. The Residential Forum staffing tool recommends a minimum of 462.58 care hours be provided for 20 service users taking into consideration their dependency levels and the layout of the home. Cooks and domestic staff are also employed. It was disappointing to note that the manager remains on the staff rota for the afternoon shift in place of a senior carer. Care plans showed that due to confusion and disabilities some service users dependency levels are such that there are insufficient staff to meet their needs. In addition, all staff would benefit from training in meeting the needs of those service users who have become confused or have other healthcare needs. Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 Page 17 A concern has been raised with the CSCI in respect of the provision of just one night waking staff. The informant was concerned that one carer could not meet the needs of twenty service users, as some need assistance during the night. There was no evidence that the care needs of service users are not being met at night and the manager is available in an emergency. Service users spoken with all mentioned the kindness of staff and that they were caring. However they added that staff were often very busy and one said ‘although she would like a bath more often she doesn’t like to ask as it would make more work for staff’. Consequently, in order to meet service users needs and in view of the increase in the dependency levels, staffing levels need to be reviewed and where necessary increased to ensure the needs of all service users are fully met both during the day and night hours. On inspection of staff recruitment files it was apparent that the required level of documentation is now in place for the staff that had been recently recruited. All staff have provided employment histories, two references, proof of qualifications, identification and Protection of Vulnerable Adult and Criminal Records Bureau checks had been carried out. These robust recruitment systems ensure the protection of service users. Currently two staff have achieved National Vocational Qualification (NVQ) level 2 in Care and the manager said she hopes to enrol 4 to 5 other staff on this course in September 2006. A written plan demonstrating how 50 of staff will achieve this qualification needs to be devised and implemented. Discussion with the manager found that she is not privy to staff training budgets so is unable to make firm plans for staff training. The provider confirmed that staff are expected to pay 50 of NVQ training costs. The home has induction and foundation training programmes that meet the Care Skills Sector specifications and there was evidence that staff received both parts of the training. However, all staff would benefit from training in meeting the needs of those service users who have become confused or have other healthcare needs. Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 Page 18 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, and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager provides good leadership and clear direction to staff, thus service users benefit from a well-supported staff team. Formal quality assurance and quality monitoring systems need to be created and implemented to enable the Provider to objectively evaluate the service and ensure it is run is service users best interests. Not all aspects of service users health, safety and welfare are safeguarded. EVIDENCE: The manager has both a care and management qualification that meets the required standard. In addition she has many years experience in the care industry and is knowledgeable about the client group. She has an open management style and it was observed that both staff and service users are comfortable approaching her with any concerns. Service users spoken with said that would be happy to raise any concerns either with her or their key Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 Page 19 worker. Staff spoken with also confirmed she is approachable and that supervision sessions are a good opportunity to discuss all aspect of their work. As mentioned under Standard 27 the manager still provides ‘hands on’ care during the afternoons and while this enables her to work with staff it does impinge upon her management time. The manager has been gathering evidence as part of the quality assurance process including introducing a questionnaire to receive feedback from professional visitors to the home. This process needs to be further developed to enable the Provider to objectively evaluate the service and ensure it is run in service users best interests. The manager has plans to carry out a service users meeting and to hold a staff meeting the week following the inspection. She agreed that these need to held more regularly to ensure service users comments are recorded. The registered provider is an appointee for one service user. The manager maintains satisfactory records for this service user and these records showed that the personal allowance is held in the home and is collected and signed for by relatives every few months. The provider has been asked to clarify the arrangements for the payment of this personal allowance, as it was noted that there can be delays and it is not always received every four weeks. Documents relating to safe working practices and health and safety were available and found to be satisfactory as were accident records. There were records showing the regular testing of call bells, emergency lighting and fire alarms and that fire equipment and systems are regularly serviced. Two service users bedroom doors were wedged open with furniture. In the event of fire this practice puts service users at risk. Suitable closing devices need to be fitted if service users require their bedroom doors to be left open. In addition a number of fire doors did not close properly which also poses a risk to both staff and service users in the event of fire. One service users has a portable radiator in her room and this presents a risk of fire as it was observed that clothing had been placed on top of it. As identified under Standard 25 service users need to be able to control the heating in their own rooms, thus the need for additional heating will not be necessary. Staff training records showed all staff have been trained in fire safety, manual handling, first aid, health and safety and infection control. The manager is aware of fire safety, however the home needs to develop a clear policy to ensure service users accommodated on the top floor are fully ambulant as they would need to be able to use the narrow stairs in the event of fire. Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 Page 20 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 X 3 2 X 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 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 1 X X 2 X 3 2 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 2 3 X 1 Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP4 Regulation 12(1)(ab) 14 (1)(d) Requirement Timescale for action 08/09/06 2. OP7 13(4bc) All service users potentially out of the home’s registration category must be reassessed. All future admissions must be within the home’s registration category. (timescale of 16/02/06 not met). Risk assessments must be 08/09/06 expanded in relation to service users individual disabilities. Detailed manual handling risk assessments need to be carried out for all service users as required. Evidence needs to be provided to demonstrate service users or their representatives are involved in care plan reviews. That prescribed creams be used only for the person intended. That the activities programme be increased to meet the individual preferences of service users and satisfies their social, cultural, religious, and recreational interests. That arrangements are put in place to enable service users to worship at the establishment of DS0000021277.V289294.R01.S.doc 3 OP7 13 (5) 08/09/06 4 OP7 15(1)(2) (a-d) 13 (2) 16 (2) (m) (n) 08/09/06 5. 6. OP9 OP12 06/06/06 08/09/06 7. OP13 12 (4b)16 (2)(m) 08/09/06 Victoria House Version 5.1 Page 22 8. 9. OP16 OP19 22(8) 23(1a) (2b) 10. OP22 16(1)(2c) 23(2n) their choice. That complaint records include outcomes and actions taken. That all parts of the home are properly maintained and all repairs undertaken as necessary. (timescale of 131/03/06 not met). That the recommendations made by the suitably qualified person be addressed to ensure the needs of all service users are met. 08/09/06 08/09/06 08/09/06 11. 12. OP25 OP25 13(4)(a-c) That hot water delivered in service users bedrooms is at a temperature near 430C. 23(1)(2p) That heating can be controlled in service users bedrooms. (timescale of 31/03/06 not met). 16(2j)13( 3) That wash hand basins be fitted to all communal toilet facilities that require them. (timescale of 1/10/05 and 31/03/06 not met) 06/07/06 08/09/06 13. OP26 08/09/06 14. OP27 18 (1) (a) Staffing levels need to be 08/09/06 increased to ensure service users needs are met. (timescale of 1/10/05 and 09/02/06 not met) 08/09/06 15. OP28 18(1)(a-c) That a plan is developed to (i) ensure 50 of staff achieve NVQ level 2. (timescale of 31/03/06 not met). 18 (1c) (i) (ii) 9(1)(2bi) 12(1b) That staff are trained to meet the needs of those service users who have become confused. That the Managers’ management hours be increased to enable her to fulfil her management duties. (timescale of 1/10/05 and 31/03/06 not met). That formal quality monitoring and quality assurance systems DS0000021277.V289294.R01.S.doc 16. 17. OP30 OP31 27/10/06 08/09/06 18. OP33 24(1ab) (2)(3) 27/10/06 Victoria House Version 5.1 Page 23 be created and implemented. (timescale of 1/10/05 and 31/03/06 not met) 19. OP38 23 (4ac) (i)(v) That the use of wedging open doors with furniture ceases and appropriate door closing devices provided. (timescale of 1/07/05 and 28/02/06 not met) That a hoist be purchased to enable staff to safely lift service users. (timescale of 31/03/06 not met). That fire doors close properly. 06/06/06 20. OP38 13 (5) 08/09/06 21. OP38 23 (4a)(c)(i) 06/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Victoria House DS0000021277.V289294.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 DS0000021277.V289294.R01.S.doc Version 5.1 Page 25 - 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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