Inspection on 08/08/07 for Victoria House

This inspection was carried out on 8th August 2007.

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 07/08/08

Victoria House 15/06/06

Victoria House 13/12/05

Victoria House 14/06/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Victoria House 25 Victoria Avenue Brierfield Nelson Lancashire BB9 5RH Lead Inspector Mrs Pat White Key Unannounced Inspection 10:00 8th August 2007 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 DS0000063398.V341105.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 DS0000063398.V341105.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria House Address 25 Victoria Avenue Brierfield Nelson Lancashire BB9 5RH 01282 697535 01282 697535 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) Delta Care Limited Margaret Thornton Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 15 service uses in the category of OP (Old age, not falling within any other category). 15th June 2006 Date of last inspection Brief Description of the Service: Victoria House is an older type detached two-storey property, in a residential area on the outskirts of Brierfield. Delta Care Ltd owns the home and Mr Baki of the company was the Responsible Individual. The home is registered to provide accommodation and care for 15 older people over the age of 65 yrs of age. Accommodation consists of single and double bedrooms on the first floor, two lounges and a separate dining room on the ground floor. Access between the two floors is by two stair lifts. Various aids and adaptations were available to assist people with restricted mobility. There were two bathrooms providing assisted bathing facilities, including a shower. There were no en suite facilities, but commodes were provided in each bedroom and there were sufficient communal toilets. There were pleasant gardens and views for residents to enjoy. Current fees for accommodation at the home are £320 to £350 per week, with additional charges for hairdressing, toiletries, magazines and papers. The home had a Statement of Purpose and a Service User Guide providing information about the care provided, the qualifications and experience of the owner and staff and the services residents can expect if they choose to live at the home. Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection site visit was carried out on the 8th August 2007. The site visit was part of an inspection to determine an overall assessment on the quality of the services provided by the home. This included checking important areas of life in the home that should be checked against the National Minimum Standards for Older People, and checking the progress made on the matters that needed improving from the previous key inspection. The inspection included: talking to residents, touring the premises, observation of life in the home, looking at residents’ care records and other documents, discussion with the registered manager and deputy manager, both on duty in the home at the time of the visit. In addition an Annual Quality Assurance Assessment (AQAA) was completed for the Commission and information from this is included in the report. Six residents spoke about their views on the home. Survey questionnaires from the Commission were sent to the home for residents and relatives to complete. Questionnaires were also sent to general practitioners (GPs) and social workers. Seven residents and 4 relatives returned these questionnaires. A district nurse was also spoken with and gave some views about the home. Some of the views of these people are included in the report. What the service does well: The owner and manager made sure that they met people in their own home or hospital before they moved into the home so that they could find out about their needs and whether or not Victoria House was a suitable place for them to live. These details were written down so that staff knew what they needed. Residents and relatives felt that the home was successful in meeting the needs of the residents. There was a good atmosphere in the home and residents and staff appeared to have a good rapport. Over a period of time there has also been consistent praise from residents about the care given by staff. At this inspection all residents spoken with praised every aspect of the home. Residents praised staff for their kindness and patience and comments such as “It’s a lovely home” and “I like living here and wouldn’t want to live anywhere else” were made. Residents have consistently praised the food served cooked. Comments such as “I always enjoy my food” and “the food is very good” were made. Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 6 The home provides pleasant, homely and comfortable accommodation with a high standard of décor and furnishings, which suits the residents’ tastes and needs. Residents complimented the environment, and comments such as “it is pleasant and comfortable” were made. The home was clean and fresh for the residents’ comfort. The home had ways to find out the views of residents and relatives about the service. Residents and relatives meetings were held every few months and they were asked to complete survey satisfaction questionnaires. What has improved since the last inspection? What they could do better: The written information about the risks that residents face in their daily life, such as the risk of falling, and how these risks are managed, could be improved. Some residents would also benefit from nutrition assessments to make sure that residents have the right diet. Other written information about the care people need and how that should be provided needs to be improved. On the records looked at there should be more details about continence, nutrition, falls management, teeth and oral care and leisure interests and hobbies, to help staff understand these care needs. This information must be updated as residents’ needs and the care given to them changes. Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 7 The procedures and practices for the management and administration of medication could be further improved, so that for example residents receive the right dose of painkillers and the right application of skin creams. Staff should understand the correct procedures to follow in the event of an allegation or incident of abuse, and have training in this matter, in order to ensure that residents are protected. The way that staff are recruited to work in the home could be further improved so that references from employers and genuine character references are obtained. This will ensure more unbiased and credible information is received about the applicant. Residents’ finances could be managed even more safely by ceasing the practice of staff borrowing money from one resident to use for another resident. Some safety aspects of the home must be improved for the benefit of the residents and the staff, such as the electrical wiring needs to be tested and the pegging open of fire doors needs to be reviewed with the fire service to make sure that people are safe in the event of a fire. To further enhance safety staff should undertake fire safety training. Staff should undertake up dated moving and handling and first aid training to make sure people are moved safely, and that staff knew what to do in a health emergency. 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. The summary of this inspection report can be made available in other formats on request. Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 & 5. Standard 6 not applicable Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s admission procedures helped to determine whether or not the home could meet people’s needs and helped staff understand them. Residents and relatives had sufficient written information about the home. EVIDENCE: The viewing of residents’ records showed that the owner and the manager of the home had undertaken pre admission assessments with those residents recently admitted. Social work assessments had also been obtained for those residents admitted through care management arrangements. The in house assessment documentation included all the matters listed in standard 3.3. However not all the assessments were completed in sufficient detail in all relevant matters. One assessment viewed did not include a risk assessment on falls, though the person was known to be at risk from falling, or sufficient information about diet and nutrition. Also relevant and useful information from the social work assessment had not been transferred to the home’s assessment and care plan. Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 10 The inspection methods, including discussion with residents, showed that residents and relatives were able to visit the home prior to admission and that the person carrying out the assessment visited people in their home environment to carry out the pre admission assessment. This assisted people to make a choice about whether or not they wanted to live at Victoria House. All the residents and relatives who completed the questionnaires stated that they had enough information to help them make a decision about moving into Victoria House. The Annual Quality Assurance Assessment (AQAA) stated the home had a comprehensive service user guide that is given to each resident and that after the pre admission assessment the owner confirms in writing that the home can meet the person’s needs. All residents spoken with indicated that their needs were met. Residents stated that they were happy living in the home, that they were well cared for and that staff treated them well. Two out of 4 relatives who completed the questionnaires said that their relative’s needs were “always” met, 2 said “usually”. Four relatives said that they felt the service met the diverse needs of people living in the home. However staff had not yet completed training to help them to understand the needs of people with dementia. Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 11 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. 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 this service. Residents had care plans that helped staff to provide personal care for residents. However the care plans did not have sufficient details on all matters of health, personal and social care and how to reduce or eliminate the risks that had been identified. Residents’ health care needs were monitored and addressed but some procedures and practices, including some relating to medication and nutrition, should be improved to further safeguard residents’ health. Residents felt staff treated them properly and with respect. EVIDENCE: All the residents had care plans prepared from an assessment (see standard 3). However not all plans had sufficient detail in all matters relating to health, personal and social care to inform staff of what they had to do to look after people and to help them understand people’s individual preferences. One care plan viewed did not contain sufficient information about falls and mobility, continence, oral care, foot care, nutrition and personal and social history. Residents were involved in the preparing of their care plan if possible, and care plans were reviewed at satisfactory intervals. However for one resident, Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 12 though there was evidence of reviews of care needed, the person’s care needs had changed considerably and the written care plan needed updating in all areas. Some care plans included risk assessments on matters relating to mobility, moving and handling and the use of bedrails. However not all residents had a risk assessment for falls (see above), nutrition or pressure areas, even though these were relevant. There was no evidence that the risk assessments had been reviewed. The inspection methods used showed that in general residents’ physical and psychological health was promoted and maintained, and that most residents had access to all necessary health care professionals (see below). The intervention and advice of the district nurses were sought for pressure area care and continence promotion, and some of this information was recorded on the care plan (see above). Some information about diet and food preferences was recorded on the care plans, and residents’ weights were regularly monitored and recorded. However as stated above this was not in sufficient detail for all residents and some residents could not be weighed on the home’s scales. There was evidence that this was important for at least one resident who had not been weighed for some time and whose weight needed to be monitored. At the time of the site visit this resident had not received the necessary intervention from the required specialists, including a dietician. However this was subsequently addressed after the site visit. The district nurse spoken to in the home at the time of the site visit felt that the staff looked after the residents’ health care needs, and that staff always carried out the district nurse’s instructions and communicated well. A number of medication procedures and practices had been improved since the previous inspection and a number of legal requirements had been met. This included administration of medication more correctly, the home checking the prescriptions for errors prior to dispensing, consultation with the GPs on the use of homely remedies and the ceasing of secondary dispensing by the night staff. The medication trolley had been moved from the dining room and was now secured in a less obtrusive place. The temperature of the medication trolley was regularly monitored. All staff who administered medication had appropriate training. However some written procedures were still outstanding, and these were - ordering medication, drug errors, verbal changes and a procedure for self - medication. The Medication Administration Records (MARS) viewed and the medicines checked showed the following. Records kept of medication received into the home and returned to the pharmacist were accurate. Since the previous inspection useful information about when to give “when required” (PRN) medication had been written on the MARs of some residents. However this information was not written down for all residents, and for one resident whose Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 13 records were viewed there was evidence that written information about PRN medication was necessary. Also one of the medicines was being given as PRN but this was not stated on the MAR instructions and there was no supporting evidence from the GP. It was not clear whether or not one resident had completed a course of cream application because there was insufficient information on the MAR, and the instructions on the medication information leaflet had not been used. Also the pain killers of another resident were not being given according to the instructions on the MAR as the manager thought the instructions were incorrect. This had not been checked with the GP. There was no staff “signature list” for the signing of the MARs and there was evidence that this was necessary in order to establish who had signed the sheets. Not all verbal dose changes and written additions/alterations to the MARs were dated or had a witness signature. Since the previous inspection only designated (senior) staff carry out blood sugar tests when needed, but there was still no supporting evidence from the district nurse to indicate that these people were competent. Residents’ rights to dignity, respect and privacy were understood by staff, and upheld. This was confirmed by some of the residents spoken with. One resident said that the staff were “very good and kind” and treated her appropriately. Members of staff were observed treating residents with kindness and respect. Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were varied leisure activities which suited the needs and preferences of the majority of residents. Residents had sufficient choices in their everyday lives and were enabled to maintain contact with their relatives and the community. The food served was appetising and wholesome and suited the needs and the preferences of the residents. EVIDENCE: There was a variety of activities to suit the interests and capabilities of most of the residents. However the care plans did not record residents’ interests or personal history in sufficient detail. Discussions with residents and staff and the homes notice board showed activities such as cards, board games, arts and crafts, visiting musicians and trips out round the local beauty spots. Residents confirmed that there were outings, and that they enjoyed sitting in the gardens in the nice weather. There were opportunities for contacts in the local community through trips out and visitors to the home, including local clergymen. The home had its own minibus for trips out and one resident spoken with felt there should be more of these trips. Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 15 Visitors were made welcome at any reasonable time and this is stated in the home’s Statement of Purpose. Two relatives who completed the questionnaires stated that the home “always” helped the residents to keep in touch and always kept them informed of important matters. Two said “usually”. Some residents were able to say that they felt they had sufficient choice in such matters as rising and retiring times, whether or not they could stay in their rooms, leisure activities and in the food served. Most residents had small items of furniture to personalise their rooms. All seven residents said that they could do what they liked each day. Three out of 4 relatives stated on the questionnaires that the home helps people to live the life they choose The food served was nutritious and varied and was praised by the residents who were spoken with. It suited their expectations and preferences. There was not a choice of main cooked meal, served at mid - day, but alternatives were given to residents who request it. Also there was an option of a cooked breakfast. Drinks and biscuits were served at times throughout the day but one resident said more drinks should be offered, paricularly in the afternoon so that residents did not have to ask. Staff gave assistence to those who needed it and on the day of the inspection the midday meal appeared relaxed and unhurried. Residents spoken with all spoke positively about the food. One said, “I always enjoy my meals”. Another said the food was good. Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 16 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. 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 this service. The complaints procedure was accessible to most residents and visitors and residents stated that they knew who to speak to if they had any concerns. There were satisfactory policies and procedures to protect the residents from abuse but staff were not sure how to implement them. EVIDENCE: The home had a simple complaints procedure, a copy of which was on the home’s notice board and was therefore available for residents and visitors. All residents spoken with stated that they had no complaints but would speak to a member of staff if they were unhappy about any aspect of their care. There had been no recorded or reported complaints since the previous inspection. All the 7 residents who completed the questionnaires said they knew who to speak to if they were not happy and knew how to make a complaint. Two out of 4 relatives said they knew how to make a complaint and were satisfied with the response when they had expressed concerns. The home had policies and procedures to follow in the event of an allegation or suspicion of abuse and the AQAA stated that there was now a policy and guidance on staff dealing with aggression from residents. However the procedures did not state that the CSCI must be informed of any allegations or incidents of abuse and the staff were not clear about what should be done, neither had they undertaken any training in “Safeguarding adults”. Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well maintained and furnished and provided residents with pleasant, clean and comfortable accommodation. EVIDENCE: The home was well maintained and furnished, and was bright and well decorated throughout. Since the previous inspection, all the old sash windows had been replaced by safer plastic, double - glazed units. However some fire doors were being pegged open and this could put residents and staff at risk in the event of a fire. Also some fire doors did not have an appropriate sign. The outside of the home was safe and accessible for residents, including those in wheelchairs, some of whom enjoyed sitting outside on the day of the inspection. The communal areas consisted of two lounges and a dining room and there were new easy chairs since the previous inspection. However one of the Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 18 lounge carpets was badly stained and needed replacing. There was suitable equipment and adaptations in the home to assist those with mobility problems. Several residents had hoists for transfer and the bathrooms were suitably adapted. Since the previous inspection residents had been provided with easy chairs in their bedroom and some had new beds. There was also new bedding and curtains. At the time of the site visit all areas of the home viewed were clean and fresh and six residents said that the home is “always” fresh and clean and one said “usually”. Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 19 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. 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 this service. The numbers and skills of the staff met the needs of the residents. The staff training programme needed further development in accordance with Government guidance to ensure that the staff team had the necessary knowledge to understand the needs of the residents. Staff recruitment procedures were sufficiently thorough to ensure that unsuitable staff did not work in the home. EVIDENCE: At the time of the site visit, in the morning, the home was short of one member of staff due to short notice absence. The manager and deputy manager were working in the home and both undertaking care duties in order to ensure the residents received the care needed. There had been recent difficulties with staff leaving and staff recruitment but there was no evidence that overall the needs of the residents were not being met. Residents spoken with stated that staff were available when needed, and that they did not have to wait an unacceptable time for attention. Relatives who completed the questionnaires stated that they felt staff had the right experience and skills. One said that, “staff are always at hand watching everything”. Another said that, “staff are caring and considerate”. Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 20 The AQAA stated that 6/13 staff were qualified to at least NVQ level 2, that is 46 . Others were studying for these qualifications. Other training included stoma care, food hygiene and diabetes. However not all staff had undertaken up to date moving and handling training or first aid training or dementia training. Staff recruitment procedures had improved since the previous inspection making it less likely that unsuitable staff would be employed in the home. The records viewed of the most recently appointed staff showed that they had not commenced work until the appropriate checks had been made, including the Criminal Records Bureau and Protection of Vulnerable Adults checks. However for one person whose records were viewed there was no reference from a previous employer, only colleagues, and there was no unbiased character reference. Also the other member of staff whose records were viewed had not undertaken suitable induction training in accordance with Government guidance. Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 21 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. 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 this service. The home was managed by a new manager who was studying for the relevant management qualification. Quality assurance policies and procedures were implemented which took into account the views of residents and relatives. Not all practices promoted the health and safety of the residents and staff. EVIDENCE: The manager at Victoria House had been in post for about a year and was registered with the Commission. She was experienced and studying for the relevant NVQ management course. She had completed NVQ level 3 and attended courses on medication management and diabetes. An experienced and qualified deputy manager had recently been appointed. Mr Baki, one of the owners, was closely involved in the running of the home and supported Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 22 both the manager and the care staff. Staff meetings and residents meetings were held to assist their respective involvement in the running of the home. The home had a quality monitoring system, and a residents’ and relatives’ survey had been recently undertaken. There was also a “suggestion box” in the home. Residents meetings were held every 3 or 4 months with relatives being invited and their views were given about such matters as trips out and the food served. There were insufficient records kept in the home regarding individual resident’s finances and payment of fees. Therefore it was not possible to assess this aspect of the residents’ finances. However some aspects had improved since the previous inspection as residents had opened post office accounts for the paying in of the pensions. Appropriate records were kept of the cash given to the home by relatives for residents’ spending money, and the spending of this money. However records showed that a member of staff had used money belonging to one resident to pay a small bill of another resident. Some aspects of the home’s health and safety procedures needed improving. Fire drills were only held once a year and some fire doors were routinely pegged open, potentially putting residents and staff at risk. Also staff had not undertaken fire safety training. Testing of the electrical wiring was outstanding and there was no current test certificate for the stair lift. The gas installations and portable electrical appliances had been recently tested Since the previous inspection staff had undertaken food hygiene training, but not updated training in moving and handling or first aid, and had not undertaken infection control training. Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 23 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 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 3 x 3 3 3 x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 13 (4)(b)(c) Requirement A written risk assessment must be undertaken regarding the risk of falls for all residents, which clearly states the management strategies for reducing the risk. Care plans must be revised and updated as necessary, including the one identified at the time of the site visit. The registered person must ensure that all residents have access to all medical attention needed unless there is appropriate supporting evidence to show that this is not in the residents’ best interests and including the views of the residents themselves if possible. The medication policies and procedures used by staff in the home must cover all areas of recording, storage, handling, administration and disposal of medication. These must include ordering drug errors, verbal changes and self - medication (Previous timescale of 31/01/06 and 21/07/06 not met) DS0000063398.V341105.R01.S.doc Timescale for action 31/08/07 2. OP7 15(2)(c) 14/09/07 3. OP8 12 (1)(a) & (2) 31/08/07 4. OP9 13 (2) 14/09/07 Victoria House Version 5.2 Page 25 5. OP9 13 (2) 6. OP9 13 (2) 7. OP27 18 (1)(a) 8. OP38 13(4) (a)(c) 23(4)(c)v, & (e) 9. OP38 10. OP38 13 (4)&(5) Medication should always be administered according to the instructions on the Medication Administration Records (MARs) unless there is supporting evidence that these have been changed or were originally wrong. This includes medication being given as “when required”. The criteria for the administration of “When Required” and Variable Dose medication must be clearly recorded on or near the MAR sheet. The registered person must ensure there are enough care staff on duty at all times to meet the needs of the residents and enable the manager to fulfil her managerial duties. The registered person must ensure that the electrical wiring in the home is tested and that the stair lift is serviced. The home’s fire precautions must be reviewed with the fire service including the practice of pegging open fire doors and the frequency of fire drills. The registered person must ensure that staff have updated moving and handling and first aid training to help ensure the safety of residents and staff are safe. 31/08/07 31/08/07 30/09/07 07/09/07 07/09/07 30/09/07 Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 26 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 OP3 OP7 Good Practice Recommendations The homes assessment should include all relevant written information about health, personal and social care to assist staff understand the care needed. The care plans must contain sufficient information on all matters related to health, personal and social care, including nutrition, continence, oral and foot care and personal social history. Relevant risk assessments on nutrition and pressure areas should underpin this care. Risk assessments in place for bedrails should be reviewed to determine whether or not they are still required. Suitable weighing scales for those residents unable to weight bear should be purchased. There should be written information and instructions about when residents need to be given “when required” medication. This should include information from the GP or medicine leaflet and should include the sign and indicators when this is needed. There should be written confirmation from the district nurses that the designated staff who carry out blood sugar testing have been suitably trained and are competent. There should be sufficient written information/instructions on or with the MARs to determine whether or not short courses of medication had been completed or not. Information from the medicines’ leaflets should be used. All verbal dose changes and hand written additions/alterations to the MARs should be signed, dated and have a witness signature. There should be a staff signature list for the completing of MARs so that which member of staff administering medication can be identified during an audit. Details of people’s former hobbies and interests and personal history should be recorded in the care plans so that staff can assist residents to continue fulfilling activities. The registered person should ensure that all staff understand the procedures to follow in the event of an allegation or incident of abuse and that these procedures are underpinned by training in this matter. DS0000063398.V341105.R01.S.doc Version 5.2 Page 27 3. 4. 5. OP8 OP8 OP9 6. 7. OP9 OP9 8. 9. 10. OP9 OP9 OP12 11. OP18 Victoria House 12 13. 14. 15. 16. OP29 OP30 OP30 OP35 OP38 References from previous employers should always be obtained wherever possible and from college tutors and authentic unbiased character referees. The registered person should ensure that staff undertake appropriate training in looking after people with dementia. New members of staff without National Vocational Qualifications should undertake an Induction training in accordance with the Skills for Care guidance. The money of one resident must not be used to pay for other residents’ goods or services. Staff should undertake training in fire safety and infection control. Victoria House DS0000063398.V341105.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000063398.V341105.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!