Inspection on 13/10/09 for Victoria House Care Centre

This inspection was carried out on 13th October 2009.

CQC found this care home to be providing an Adequate service.

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 Centre 09/06/10

Victoria House Care Centre 25/11/08

Victoria House Care Centre 03/12/07

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Victoria House Care Centre Park Road North Middlesbrough TS1 3LD Lead Inspector Tanya Newton Key Unannounced Inspection 10:00 13th October & 16th November 2009 DS0000070099.V378037.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria House Care Centre Address Park Road North Middlesbrough TS1 3LD 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) 01642 242975 vh@keyhealthcare.co.uk Key Healthcare (Operations) Limited Care Home 68 Category(ies) of Dementia (58), Old age, not falling within any registration, with number other category (10), Physical disability (12) of places Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category - Code OP, maximum number of places 10 Dementia - Code DE, maximum number of places 58 Physical Disability - Code PD, maximum number of places 12 The maximum number of service users who can be accommodated is: 68 25th November 2008 2. Date of last inspection Brief Description of the Service: Victoria House Care Centre is a large converted Victorian property with a modern extension that has been in place for a number of years. The home is close to the centre of Middlesbrough and is opposite Albert Park. It is close to public transport and shops are nearby. Victoria House Care Centre offers spacious accommodation. There are lots of very pleasant communal areas located throughout the home. Some of the bedrooms have ensuite facilities, whilst others have wash-hand basins. There are a number of units within Victoria House Care Centre, a unit for younger adults with physical disabilities on the ground floor, a unit for older people with dementia, set across two floors and two units for older people with dementia who have nursing needs set across two floors. The cost of care at the time of the inspection visit ranged from £428.00 to £577.00 per week depending on the category of care. Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is a one star - adequate service. This means that the people who use this service experience adequate quality outcomes. This unannounced visit to Victoria House care Centre took place over two days on the 13th October and 16th November 2009. Prior to the visits being carried out the home completed an Annual Quality Assurance Assessment (AQAA). Two inspectors carried out the site visit on day one and on day two a pharmacist from the Care Quality Commission (CQC) was in attendance. The inspection of the home included a tour of the building, a look at a sample of documents and records, which the home is required to keep and discussions with people living and working at the home. Comments from which have been included throughout the body of the report. We also carried out a Short Observational Framework for Inspection (SOFI), which is a methodology we use to understand the quality of the experiences of people who use services who are unable to provide feedback due to their cognitive or communication impairments. SOFI helps us assess and understand whether people who use services are receiving good quality care that meets their individual needs. It allows us to get an insight into the general state of well-being of individuals and staff interaction with people who use the service during the observation. What the service does well: The home carries out an assessment on each person admitted to the home to ensure that they are able to meet their needs. There are good systems in place to monitor people’s health and people said that they were well cared for by staff. Each person living at the home has a care plan which details the ways in which their care needs should be met by staff working at the home. There is a comprehensive set of medication policies which provide clear guidance for staff handling medicines. There was a good record of anticoagulation therapy kept alongside the MAR chart of a person taking Warfarin which detailed next check date and a faxed copy of INR results and dosage regime. There are good arrangements to assess people’s social needs and a variety of activities on offer. Visiting arrangements are good. There are clear systems for managing complaints and protection. Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.2 Page 6 The home has policies and procedures in place to support staff and all staff receive a range of different training courses to support them in their roles. Feedback received, particularly from people on the physically disabled unit was positive and included, “It’s excellent here, I have the freedom to do what I want, when I want” and “I feel very positive about the move here, it’s been for the best”. What has improved since the last inspection? What they could do better: The care plans should be further developed to ensure that they include the fine detail in relation to how people’s needs are met. Further staff training is needed on the importance of medication administration and the accurate completion of MAR chart records. Management check of the medication processes and staff practice should be carried out to identify any improvements needed. Some areas of medication record keeping should be improved so that all medication in the home can be fully accounted for. The manager should continue to develop the environment with particular regard for the client groups accommodated. All staff should receive regular supervision; it is recommended that this be at least six sessions per year. Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.2 Page 7 A clinical management lead should be appointed to ensure that clinical practice is being monitored. A risk assessment on the hand sanitizer is needed so that all staff are clear of the action to take should it be ingested. Toiletries must be stored away safely in people’s bedrooms and should not be shared for communal use. The bed rail assessment needs to be reviewed and updated and should be based on the guidance from HSE. A risk assessment is required for the lift as it did not have a key pad code and was accessible to people on the dementia care units, both during the day and at night. Unless approval has been gained from the fire officer, then fire doors must not be wedged open. Again a risk assessment must be carried out regarding the layout of the building and staffing numbers in relation to the rooms which people occupy. The bolt locks on doors must be removed and a suitable alternative fitted where necessary. Consideration should also be given to the provision of equipment which is age appropriate, suitable and respects the dignity of the people accommodated. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 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 Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed before moving into the home and they are assured that their needs will be met. EVIDENCE: Six assessments were viewed. People who had been funded by the local authority had assessments which had been carried out by a care manager; these were then shared with the home. The manager then carries out a further assessment to determine whether or not the home is able to meet the person’s individual needs. Comments from people include, “I looked around before my wife moved in” and “I was able to visit the home first, I am very happy here”. The home does not admit people for intermediate care. Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health and personal care needs in the main are well met and recorded by the home. EVIDENCE: Care plans were looked at. Care plans set out the way in which people’s individual health and personal care needs will be met by staff working at the home. Care plans were reviewed regularly to reflect any changes in need. Care plans included risk assessments to minimize risks to people living in the home. Some areas of the care plan would benefit from further development as they did not contain enough detail or had not been completed fully. Some of the areas identified within the assessment had not been transferred onto the care plan. Some care plans were very general and need to reflect more accurately the needs and the abilities of the individual. Others were well written and contained very detailed information. Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 Page 11 People said that they were well cared for, comments included, “I can have a bath every morning” and “I am happy to be alive and have got my second chance at life”. There was clear evidence in care plans that people’s health needs were being closely monitored with input being sought from other professionals where this was required. This included district nurses for residential clients, GPs and dieticians. There was a good comprehensive set of medicine policies which if followed help staff work consistently and reduce the risk of medication errors. Medication storage varied between floors. There was a main ground floor storage room used to store excess medicines and controlled drugs. On the ground floor physical disability unit peoples’ medicines were mainly stored in individual locked cupboards in bedrooms. In other units medicines were stored in locked trolleys. The fridges in some units were not locked on the day of the visit. On the first floor the medicines were stored in a secured locked trolley with the door unlocked because access to a telephone was required, some thought could be given to relocating the telephone to allow the room to be locked. Controlled drugs were stored in a locked cupboard, which appeared to meet requirements, alongside other spare medicines. Consideration should be given to storing controlled drugs separately to restrict access. All stock balanced with records. The date of opening was not always added to eye drops, liquid and medicines with a limited use once open. In many cases there were several pots of opened creams and ointments in people’s bedrooms with no date of opening. This means that medication may be used beyond the expiry date recommended by the manufacturer and make them unsafe to administer. There were few gaps on the MAR charts but when an audit of medication was carried out, very few could be reconciled. The quantity of medication carried over from one medication cycle to another was not recorded on the new MAR chart. This means that it is difficult to have a complete record of medication within the home to check if medication is being administered correctly. Medication was available for administration on the trolley which was not written up on the MAR charts. Medication was available on the trolley both in boxes and also in the monitored dosage system. Some MAR charts were handwritten and although checked by a second person they were incorrect. To make sure that there is an accurate record the quantity supplied, the date of entry, the signature of the person making the entry and where possible a witness signature should be included. Care plans need to be updated to include risk assessments for medication especially for people on drugs like warfarin. People self administering creams, Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 Page 12 ointments and inhalers should also have a risk assessment included in their care plan. People spoken to during the inspection, said that they were treated with dignity and respect. Observations made during the inspection confirmed this. The manager should consider alternative types of monitors and door alarms as at present baby alarms and child safety gates are being used. The equipment being used at the home should be age appropriate. Sensory items displayed within the dementia care units should also be age appropriate, so that they are suitable for the people living there. The SOFI data showed some good interactions between staff and people living at the home which demonstrated respect for people’s privacy and dignity. Although we observed many positive interactions during the SOFI, we also noticed that the staff spent more time interacting with the people who could communicate. Staff must be mindful of this, to make sure that they develop additional ways of providing interactions with people who are less able to communicate their needs. Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have appropriate social, leisure and occupational opportunities and are encouraged to exercise choice in all aspects of their lives. Mealtimes are relaxed and there is a varied diet available. EVIDENCE: The home carries out a social assessment for each individual which includes information about their background history. This provides staff with detailed person centred information about each individual. The home has an activities co-ordinator who works 30 hours each week and will provide either a group activity or something on a one to one basis with people. Recent activities include; coffee mornings, hair and beauty sessions, baking, music, pat dogs, motivation class, outings, walks to the park, karaoke, painting, knitting, board games. The home has also opened a ‘sweet shop’ selling old fashioned sweets and a ‘bar’ where pub quizzes take place and people can meet up to socialise. The activities co-ordinator demonstrated a clear commitment to try a range of different types of activity in order that the needs of people living at the home can be met. She has also started to produce a colourful monthly newsletter. Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 Page 14 Comments from people included, “I go to church”, “I go into town with support from staff, if I ask to go one day, then they take me the next” and “The activities girl sings beautifully, she puts on lots of shows, there is enough going on to keep me occupied”. People said that visitors were always made welcome and that there were no set visiting times. Some people went out with relatives or friends for part of the day. Other people went out independently. People are supported and encouraged to make decisions and choices in all aspects of their daily lives. This included what time to get up and go to bed. What clothes people wanted to wear and how people spent their time. The home’s menus were looked at. There is a variety of food on offer which includes cereal and/or cooked items for breakfast. There is a 4 weekly menu with a choice of two main courses daily and people were observed being asked what they would like to eat. Alternatives are offered and special diets can be accommodated. Comments about the food include, “Some is good and some is not so good, I can go to the supermarket and buy my own food” and “my cholesterol has gone down, so the food is better for me” and “The food is good, I enjoyed my breakfast this morning”. Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Any concerns or complaints are managed well by the home with policies, procedures and training in place to support staff. EVIDENCE: The home has a complaints procedure. It requires minor updating to reflect the role of the local authority in investigating complaints and the move from registration and inspection to the Care Quality commission (CQC). People spoken to during the inspection said that they had no concerns or complaints but felt confident in raising any issues if they arose. Comments include, “I feel I could speak to Debbie the manager. She gets things done quickly” and “I could say if I had any problem, yes”. The home had received one complaint since the last inspection. Clear records of complaints are held and any action taken by the home in response is recorded. The home has policies and procedures in place to help protect people from abuse. Staff had received training in ‘safeguarding vulnerable adults’. Staff spoken too during the inspection said they knew what procedure needed to be followed if an allegation was made. They also confirmed that they would not hesitate to ‘whistle blow’ (tell someone) if they saw or heard anything inappropriate. The homes policy on abuse needs minor updating so that it links Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 Page 16 with the local authority policy on safeguarding. A copy of which is available in the home. Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment is being updated to make it more pleasant and accessible to those living there. It is clean and well maintained. EVIDENCE: Victoria house is a grade 2 listed building with many special features. Rooms are individually furnished and decorated and have been personalised by the occupants with support from their relatives and/or staff. The home has lots of communal areas where people can convene as a group or spend time alone or with their relatives/visitors. There are assisted bathrooms with specialised bathing equipment to support people who have difficulties with mobility. Many of the rooms have views over Albert Park. There is a large consecrated chapel on the ground floor which is available each day, with interdenomininational services often held at weekends. The home is in the Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 Page 18 process of updating its dementia units to make them more stimulating for the people living there. The home now has a unit for people with physical disabilities; the unit is large and spacious with specialist equipment to support people. One person commented, “I have a lovely big room”. Some people, particularly those who spend longer periods in bed, have child safety gates in place to stop other people from walking in and out of their room. The manager was advised that alternate arrangements should be considered to ensure people’s privacy and dignity. A number of doors had bolt locks in place, these need removing as they increase the risk of someone being locked in. The home has a new lift shaft and is waiting for a new door and interior to be fitted. The home has been undergoing a major programme of maintenance and work is still ongoing to improve the gardens, install a laundry area and to continue to improve the internal premises for its residents. Half of the existing staff team have recently completed training in infection control. The other half of the staff team are due to commence this training in the New Year. The home has hand sanitizer supplied throughout the home so that people can maintain good hand hygiene. A risk assessment must be completed so that all staff are clear of the action to take if someone ingests the sanitizer. Some of the bathrooms had communal toiletries in place. Toiletries must not be shared and must be stored safely in individual rooms to stop people going into communal bathrooms and ingesting them. Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are appropriately recruited, inducted and trained to meet the needs of the people they support. EVIDENCE: On the first day of the fieldwork visit there were 53 people accommodated. The home comprises of 4 separate units and each is staffed according to the numbers and needs of the people accommodated. There is one nurse on duty between the hours of 8am and 8pm, one between the hours of 9am and 5pm and one during the night. Staff recruitment files were looked at, of the three viewed, all contained an application form, two references, a CRB (police) check and an induction. This helps to protect people living at the home. Training plans were looked at. Mandatory training includes fire, first aid, infection control, manual handling, food hygiene and health and safety. In addition training is provided in dementia, medication and protection of vulnerable adults (POVA). Thirty seven of the forty four care staff also had an NVQ at level 2 or above. The manager said that there were also plans to provide training in Deprivation of Liberty (DOL) and the Mental Capacity Act Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 Page 20 (MCA). Dementia training is also planned for all care staff. It is also recommended that training be provided in epilepsy to ensure that the needs of all people accommodated can be met fully. Comments from staff included, “I like working here”, “There is enough staff on the PD unit, I can’t comment on other areas of the home” and “Staff are friendly”. Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a manager who although is not yet registered with CQC has demonstrated that the home is being run in the best interests of the people living there. EVIDENCE: Although the home has a manager, at present they are not registered with CQC. An application for registration has been submitted. The current manager is not a qualified nurse so a deputy manager/nurse lead position should be developed. The manager confirmed that this had been advertised. Comments about the manager were positive and included, “She is really nice”. Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 Page 22 The home has clear systems in place for seeking feedback and monitoring the quality of services being provided. The manager routinely invites comments and suggestions for improvement via a suggestion box, regular meetings, surveys and consultations. The provider carries out visits to the home as required under Regulation 26 of the care homes regulations. Supervisions and appraisals were not up to date, the manager confirmed on day 2 of the site visit that plans had been implemented to address this. Financial records were looked at. Each person has personal allowance records which detail any income and expenditure. Receipts are held for all transactions. Health and safety records were viewed. Regular checks are carried out to the premises and the home employs two handymen to carry out routine maintenance at the home. Health and safety records viewed were up to date. These included fire equipment checks, emergency lighting checks and kitchen safety records and records of gas and electrical safety. The risk assessment on the safe use of bed rails requires updating and should be based on the guidance from the Medicines and Healthcare Products Regulatory Agency (MHRA) DB2006 ‘Safe use of bed rails’. A risk assessment is required for the lift as it did not have a key pad code and was accessible to people on the dementia care units, both during the day and at night. Unless approval has been gained from the fire officer, then fire doors must not be wedged open. Again a risk assessment must be carried out regarding the layout of the building and staffing numbers in relation to the rooms which people occupy. Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X x X X x 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 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 OP9 Regulation 13(2) Requirement Medication must be given as prescribed and a record must be made at the time that it is given. This will make sure that people receive their medications correctly and the treatment of their medical condition is not affected. Medication must be stored securely and safely. A system must be in place to check expiry dates of medicines and add the date of opening when necessary. This makes sure medication is safe to administer. The risk assessment on the safe use of bed rails requires updating and should be based on the guidance from MHRA DB2006 ‘Safe use of bed rails’. Risk assessments are required for the lift and should include any concerns regarding the layout of the building and access by people living at the home. Timescale for action 31/01/10 2. OP9 13(2) 31/01/10 3. OP38 23(2) 31/01/10 4. OP38 23(2) 31/01/10 Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The work that has commenced on updating the care plans should continue. Care plans should be developed further to ensure that they contain the finer detail required for staff to appropriately meet people’s individual needs. Handwritten entries and changes to MAR charts should be accurately recorded and detailed. This makes sure that the correct information is recorded so a person receives their medication as prescribed. A system should be in place to record all medication received in to the home and medication carried over from the previous month. This helps to confirm medication is being given as prescribed and when checking stock levels. Alternate types of monitors, door alarms and sensory items should be considered to ensure that people’s privacy and dignity is maintained. The complaints procedure should be updated to reflect the move from CSCI to CQC. The adult protection procedure should be updated so that it links with the Local Authority procedure on safeguarding vulnerable adults. Bath and shower water temperatures should be checked and recorded weekly in line with the Health and Safety Executives recommendations ensuring more safety in these areas for people who use the service. Bolt locks to doors should be removed as they can be unsafe. An alternate type of lock should be considered. A risk assessment on what to do if the hand sanitizer is ingested should be provided and made available to all staff. Toiletries should be stored individually and not used for communal use or stored in communal areas. Staff should receive training in epilepsy, so that they can meet the needs of people living at the home. The system for managing resident’s personal allowances should be looked at in line with Regulation 20 Care Homes Regulation 2001. DS0000070099.V378037.R01.S.doc Version 5.3 Page 26 2. OP9 3. 4. 5. 6. OP10 OP16 OP18 OP19 7. OP26 8. 9. OP30 OP35 Victoria House Care Centre 10. OP36 All staff should receive formal supervision six times per year. Victoria House Care Centre DS0000070099.V378037.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission North Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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