Inspection on 25/11/08 for Victoria House Care Centre

This inspection was carried out on 25th November 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Victoria House Care Centre 09/06/10

Victoria House Care Centre 13/10/09

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 27/03/2009.

CARE HOMES FOR OLDER PEOPLE Victoria House Care Centre Park Road North Middlesbrough TS1 3LD Lead Inspector Stephen Ellis Unannounced Inspection 25th November 2008 09:30 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 DS0000070099.V374079.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. DS0000070099.V374079.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) of places DS0000070099.V374079.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: Caer 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 The maximum number of service users who can be accommodated is: 68 3rd December 2007 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 both communal and bedrooms. 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 older people, set across two floors; two units for older people with dementia set across three different areas and a unit for older people with dementia who have nursing needs. The cost of care at the time of the inspection visit ranged from £355 to £545 per week depending on the category of care. DS0000070099.V374079.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 2 stars. This means the people who use this service experience good quality outcomes. This unannounced fieldwork visit to Victoria House took place over 2 days (12 hours in total) on 25th and 26th November 2008 as part of the statutory inspection of the service. Information received prior to the fieldwork visit was used in preparation and during the visit. This included the home’s Annual Quality Assurance Assessment (AQAA) that it completed on 28th August 2008. The last key inspection of Victoria House took place on 3rd December 2007. The visit to the home included a tour of the building, an examination of a sample of the documents and records that the home is required to keep, and various discussions with people who use the service, relatives and staff. Comments were received during the visit and from surveys that we carried out before the visit. In total, there were comments received from 19 people who use the service, 6 relatives, one visiting health care professional and 11 staff, including the manager. What the service does well: The service achieves good outcomes for people who use the service in all key areas covered by the National Minimum Standards, with the exception of environmental outcomes, where an excellent standard has been achieved. The home has been awarded the maximum five stars rating for food hygiene by the local environmental health authority. Typical comments received from people who use the service and/or their relatives included: “I received enough information about this home before I moved in so I could decide if it was the right place for me.” “The welcome was warm and the staff were sympathetic to our plight.” “Staff always listen and act on what I say.” “I always receive the medical support I need.” “I am very satisfied with everything.” “Staff inform me about matters – I do not need to chase.” “I am happy here.” “The staff are good to me and the food is also good.” “I know how to make a complaint and the staff are helpful in responding to any concerns.” “The home is always fresh and clean.” “His room is excellent; it is warm and comfortable.” “Staff are usually available when I need them.” “The staff are very helpful.” DS0000070099.V374079.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000070099.V374079.R01.S.doc Version 5.2 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 DS0000070099.V374079.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. People who use the service experience good quality outcomes in this area. People, who are thinking about using the service, and their representatives, have the information needed to choose a home that will meet their needs. They have their needs assessed and a contract which tells them much about the service they will receive. Intermediate care is not provided. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Comments received from people who use the service, relatives and staff confirmed that full assessments of needs were carried out prior to admission to the home. Most people felt there was enough information from which to make a choice about being admitted, although many had shared this responsibility with others such as relatives and/or social workers. The home supplies comprehensive statements of purpose, service user’s guides and contracts/terms and conditions of residence. These are informative documents and copies are available in Reception and in a variety of formats, including DS0000070099.V374079.R01.S.doc Version 5.2 Page 9 large print. The home keeps these documents under review (last reviewed and amended 12th November 2008). The home’s reception area is close to the manager’s office on the ground floor and a variety of useful information is available, including the service user’s guide, brochures, monthly newsletters, residents’ charter of rights, the home’s philosophy of care, complaints procedure, statement of purpose and previous inspection reports. There is also a large board with staff photographs and job titles to aid identification. A welcome pack is provided in each bedroom and includes useful written information about the home, plus small gifts of towel, toiletries etc. Typical comments included: “I received enough information about this home before I moved in so I could decide if it was the right place for me.” “The welcome was warm and the staff were sympathetic to our plight.” The plans of care of ten people who use the service were examined and revealed comprehensive, detailed assessments of need being carried out prior to admission, with regular evaluations and reviews of care needs and care plans at appropriate intervals following admission. These assessments showed that the home only admitted people whose needs were known and could be appropriately met by the service. The manager or deputy visits the prospective service user and completes a written assessment of needs. This assessment plus other information supplied by Social Workers or Care Managers, helps determine whether the home’s admission criteria are met and whether the service is right for the individual. Trial visits and short stays are encouraged, so that people can make informed choices about the suitability of the service. DS0000070099.V374079.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. The health and personal care received by people who use the service, is based on their individual needs. The principles of respect, dignity and privacy are put into practice. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: People who use the service and/or their relatives felt that the health and social care needs of people who use the service were well known by the staff team and were usually well met. An examination of 10 care plans confirmed that health and social care assessments and treatments/interventions were being carried out, with good input from the home’s nursing and care staff, local doctors, hospital specialists, dentists, opticians, falls team, speech and language therapist, tissue viability nurse, community liaison nurse, occupational therapist, physiotherapist, chiropodist and social workers. People who use the service and/or their relatives said that they felt supported by the staff team and the local health and social care services that worked in DS0000070099.V374079.R01.S.doc Version 5.2 Page 11 partnership with Victoria House. For example, the community nurse or doctor would see them whenever required and they were usually satisfied with the quality of service they received. They felt they were treated with respect and sensitivity. Families are involved in the care planning process and relatives’ signatures were often found in plans of care, indicating consultation and agreement, as representatives of the people who use the service. Relatives are also involved in biographical life histories, which management have recently introduced, so that staff can get to know the whole person better. Typical comments included: “Staff always listen and act on what I say.” “I always receive the medical support I need.” “I am very satisfied with everything.” “Staff inform me about matters – I do not need to chase.” There have been occasions over the past year when relatives and other representatives of people who use the service have not always been satisfied with the standard of care provided. However, the home’s management have taken such concerns and complaints seriously and have tried hard to rectify problems and prevent their recurrence, often in collaboration with external agencies, such as Local Authority Commissioning and Safeguarding teams, plus Primary Care Trusts. The home has demonstrated a willingness to learn from the experiences of people who use the service and their representatives and to work with external agencies where appropriate to put things right and improve its performance. Care plans and risk assessments from across the home were found to be detailed and comprehensive about the health and social care needs of people who use the service, providing clear guidance to staff. They were subject to regular review and evaluation, involving people who use the service, relatives and external health and social care professionals where appropriate. There were many examples of good provision and practice. These included each person who uses the service having a named nurse or key worker; special, adjustable beds and pressure relieving mattresses and chairs in many instances; alcohol gel available throughout the building (hand hygiene); tactile pictures and objects for people to touch and manipulate; pictures, posters, enlarged newspaper cuttings and artwork relevant to key episodes in people’s lives; doll therapy; memory boxes to stimulate recall and reminiscence; old fashioned ornaments and objects such as a traditional sewing machine, record player and candlesticks; orientation boards, detailing date, day, weather etc.; clocks at the right time; aprons draped over handrails with interesting objects in pockets, such as sponges and louvers; assortments of ladies’ hats and bonnets strategically placed on walls; good quality furnishings, fittings and décor; personalised rooms; plus regular audits of care plans and medicine records. Staff training, such as National Vocational Qualifications (NVQ) level 2 or above, includes the important issues of privacy and dignity and a high DS0000070099.V374079.R01.S.doc Version 5.2 Page 12 percentage of permanent care staff (over 70 ) have achieved NVQ in care. The home’s induction programme also addresses these issues systematically. There are good arrangements for the safe administration of medicines, including robust policies and procedures. All staff members responsible for the administration of medicine have completed Safe Handling of Medicines courses or equivalent. There is good support from a dedicated Pharmacist who supplies medication in Monitored Dosage form (in blister packs with the medication clearly identified for the individual resident). There are good storage systems, with designated senior staff checking all medication when it is received into the home. Medication is kept securely in lockable cabinets and trolleys. People who use the service may attend to their own medication, but in practice most prefer to delegate this responsibility to staff. Unwanted medicines are either returned promptly to the Pharmacist or collected by licensed waste disposal agency. The home is careful not to stockpile large quantities. The manager or senior staff members carry out regular medicine audits, sampling individual records and stocks. It is good that a photograph of the service user is kept next to their Medicine Administration Record, along with their name, date of birth and room number, to aid identification. Management intend to introduce periodic competency assessments and this is recommended as reinforcing good practice and helping to minimise the risk of errors in the administration of medicines. DS0000070099.V374079.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. People who use the service are able to choose their lifestyle, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet people’s expectations. People receive a healthy, varied diet according to their assessed requirement and choice. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Most people who were asked said they enjoyed living at Victoria House and described the staff as being caring and helpful. They liked the atmosphere in the home, describing it as being friendly and supportive. They liked the small groups in the various lounge and dining areas across the home. They were free to use any of the facilities within their particular unit, including any lounge or dining area, or their own bedroom. All appeared satisfied with the arrangements for daily life in the home. A small shop is available within the home, supplying drinks and snacks plus other items of interest to people who use the service. DS0000070099.V374079.R01.S.doc Version 5.2 Page 14 Comments received from people who use the service and/or their relatives, plus staff, confirmed that people were supported to exercise choice in their daily lives, such as what clothes they wore and how they spent their time, including when they got up and went to bed. There were different events and activities that they could take part in if they wished, including seasonal events such as Harvest Festival, Halloween Party and Bonfire Night; nail care, board games, crafts (including Christmas decorations, fashion pictures, glass and plate painting), visiting pat dogs, quizzes, raffles, chair exercises plus fortnightly physical motivation sessions, videos and DVDs, reminiscence and memory boxes, some shopping trips, clothes parties, monthly newsletters, tactile pictures and objects to be manipulated, doll therapy, music, television and radio. A hairdresser visits weekly and is very popular. The home has an activities organizer who has devised a varied programme of social and recreational activities. A full time activities coordinator is desirable in a home of this size and complexity: the current post holder is full time but on sick leave and her work is being covered by a part time member of staff. Typical comments from people who use the service included: “I am happy here.” “The staff are good to me and the food is also good.” People who use the service and their relatives are invited to quarterly meetings, at which matters of interest and suggestions are discussed. The minutes of these meeting are recorded. People who use the service and their representatives are encouraged to make comments or suggestions for improvements at any time and there is a suggestions/comments box available as well. People confirmed that they could pursue individual interests such as reading and television, and their religious needs were also addressed (for example, interdenominational services are held at the home each Saturday in the chapel and arrangements can be made for Holy Communion if desired). People said that visitors were always made welcome and there were no set visiting times. Some people went out with relatives or friends for part of the day. Many people spoken with said the catering was good. They felt there was a good choice and the Cook understood their preferences. Nutritional assessments take place routinely and the home provides a wide range of meals based on healthy eating and appetising menus for older people. Special diets are provided, including liquidised meals. People mainly dined together in the various dining areas. They could, however, eat their meals elsewhere (such as their bedrooms) and at different times if required. Décor and furnishing in dining areas was attractive, creating a relaxed and welcoming environment. Tables were supplied with linen tablecloths and napkins. Staff members will assist people with their meals wherever needed. Records are kept of meals served. A good choice of menu is provided. Birthdays are always celebrated with a cake and a special tea, and are mentioned in the home’s monthly DS0000070099.V374079.R01.S.doc Version 5.2 Page 15 newsletter. The home has been awarded the maximum five stars rating for food hygiene by the local environmental health authority. DS0000070099.V374079.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 and 18. People who use the service experience good quality outcomes in this area. Residents have access to a robust, effective complaints procedure and are protected from abuse. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Many people who use the service and/or their relatives said that they were confident about approaching staff and management about any concerns or complaints they might have. They described the staff and management as being very approachable, helpful and friendly. A written complaints procedure is provided in the statement of purpose, service user’s guide and in the reception area. The home invites comments, compliments and suggestions, plus complaints, which it records along with any necessary action taken to investigate and address issues. Typical comments included: “I know how to make a complaint and the staff are helpful in responding to any concerns.” The home actively seeks feedback from people who use the service and their representatives about the quality of its service, including inviting written comments and suggestions, quarterly meetings of people who use the service and relatives, frequent reviews of people’s progress and face-to-face discussions with staff and management. DS0000070099.V374079.R01.S.doc Version 5.2 Page 17 Staff and management are aware of the need to safeguard adults from abuse or neglect and most have undergone robust training in these issues. Staff members confirmed they are aware of the home’s ‘whistle blowing’ policy, which requires staff to speak out about any suspected abuse or neglect. All staff members undergo enhanced Criminal Records Bureau (CRB) checks and Protection of Vulnerable Adults (POVA) checks, as required by law. Also, two references are obtained in respect of each new employee, with special attention given to the last employment. This is to ensure that unsuitable people are not employed to care for vulnerable adults. Staff confirmed that new staff members go through comprehensive induction and foundation training, so that they have the right knowledge and skills to do their jobs competently. Records examined in four staff files supported these conclusions. DS0000070099.V374079.R01.S.doc Version 5.2 Page 18 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, 21, 22, 23 and 26. People who use the service experience excellent quality outcomes in this area. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: All staff members have undergone training in health and safety, fire safety, moving and handling, first aid, food hygiene and infection control. Bathrooms and toilets were supplied with liquid soap and paper towels in wall mounted containers, to help prevent cross infection. All people who use the service have their own personal towels and flannels, which they keep in their rooms. DS0000070099.V374079.R01.S.doc Version 5.2 Page 19 Alcohol gel is supplied throughout the home so that people can maintain good hand hygiene. A Health and Safety Committee meets monthly and there are regular audits completed to ensure that the premises and operating procedures are safe and promote the welfare of all people who use the service. The home was clean and well presented in all the areas inspected. The kitchen has recently received a maximum 5 stars award for hygiene from the local environmental health authority. Towels and bed linen are sent out to an external laundry. The home is planning to develop its own, on-site laundry facilities next year so that they can manage all laundry in-house. People who use the service and/or their relatives said they were pleased with the premises, finding them comfortable and homely, as well as clean and practical. Typical comments included: “The home is always fresh and clean.” “His room is excellent; it is warm and comfortable.” The home is well maintained, with much evidence of repairs, checks and servicing being carried out promptly and according to schedule. The home is planning to replace its passenger lift next year. Victoria House is a grade 2 listed building with many special features. These include exceptionally spacious, lockable single bedrooms on three floors, that have been personalised by the occupant with support from relatives and staff, attractively decorated, well furnished and equipped with aids and adaptations, such as wash hand basins, call points and adjustable beds; very good location opposite Albert Park with fine views from many of the rooms; numerous communal rooms and areas of very good size that provide opportunities for individual and group activities, personal choice and freedom of association; numerous toilets, bathrooms and shower rooms throughout the building, plus 7 bedrooms with en suite facilities; a large, consecrated chapel on the ground floor that is available each day, with interdenominational services often held at weekends; a private and secure garden, plus dedicated car parking space to the front. Over the past year, an extensive refurbishment has taken place, with new furniture, decoration and floor covering supplied throughout most parts of the building. A light and airy atmosphere is evident across the home, with many appropriate pictures, tactile objects, sensory boards and ornaments on display, creating an environment that is safe, gently stimulating and person centred. DS0000070099.V374079.R01.S.doc Version 5.2 Page 20 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 and 30. People who use the service experience good quality outcomes in this area. Staff in the home are trained, skilled and in sufficient numbers to fulfil the aims of the home and meet the changing needs of people who use the service. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: On the day of the fieldwork visit, there were 52 people who use the service being accommodated: 14 people in the second floor, dementia care unit (18 beds non-nursing) with 2 to 3 members of care staff typically during the day (8 am to 8 pm) including a senior carer; 18 people in the first floor dementia care unit with nursing needs (21 beds nursing) with one registered nurse and 4 care staff during the day, plus an additional member of care staff between 9 am and 1 pm; 5 people in the ground floor older persons’ unit (10 beds nonnursing) with one senior carer during the day; and 15 people in the Lodge unit (dementia care with nursing needs) on the first floor (10 beds nursing) and ground floor (7 beds nursing), with one registered nurse (usually mental health trained) and 2 to 3 care staff (sometimes 4 care staff, depending on assessed needs) during the day. DS0000070099.V374079.R01.S.doc Version 5.2 Page 21 In addition, there is a full time manager whose hours are not included in the care hours provided, a full time administrator, two maintenance officers, plus catering and domestic staff in sufficient numbers to support the smooth running of the home. A full time activities coordinator is employed, although the post holder is currently on sick leave and a part time activities coordinator (20 hours) is covering her duties. At night, there is typically at least one registered nurse and 6 care staff deployed across the home. Typical comments received from people who use the service and/or their relatives included: “Staff are always available when I need them.” “The staff are very helpful.” A visiting health care professional observed that a “lack of RMNs (Registered Mental Nurses) can impact care delivery and advice.” The home’s management has been taking action to try to ensure that the right skill mix is always available to support all people who use the service. This requires a combination of skills, including competencies and qualifications in mental nursing, general nursing and specialist social care. The visiting health care professional added that the care service does well by “looking for areas for development, seeking advice from others and welcoming feedback.” In each bedroom there is written information detailing the personal key worker and named nurse, where appropriate, for the individual person who uses the service. This is regarded as good practice, but it would be even better if laminated photographs of the staff concerned could be displayed in the rooms alongside the written information. Full staff induction, training and development programmes are in operation, including moving and handling, first aid, safe handling of medicines, safeguarding adults, fire safety, dementia care, managing challenging behaviour, health and safety, food safety, plus National Vocational Qualifications. Staff comments and records examined confirmed extensive programmes of induction and foundation training. Over 70 of permanent care staff members have achieved National Vocational Qualifications (NVQ) at level 2 or above, and the remaining care staff members are working towards NVQ, which is commendable. The home has introduced a mentoring scheme whereby new staff members are assigned to named mentors to help induct and support them. Thorough pre-employment checks are carried out on all staff, including enhanced checks with the Criminal Record Bureau (CRB) and Protection of Vulnerable Adult (POVA) register, plus the taking up of two references, as evidenced in personnel files. DS0000070099.V374079.R01.S.doc Version 5.2 Page 22 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, 36 and 38. People who use the service experience good quality outcomes in this area. The management and administration of the home is based on openness and respect, with effective quality assurance systems developed by an experienced registered manager. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The new registered manager is suitably qualified and experienced in senior roles within health and social care settings. People who use the service and/or relatives and staff described the home’s management as being approachable, responsive and responsible. The registered manager is a registered nurse who has completed dementia care training at Teesside University and is currently DS0000070099.V374079.R01.S.doc Version 5.2 Page 23 working towards the Registered Manager’s Award (RMA) at National Vocational Qualification (NVQ) level 4. She is well supported by a staff team of approximately 72 people, including registered nurses, a deputy manager, team leaders for the non-nursing units, senior carers, plus a full time administrator. Members of care staff confirmed that they are regularly supervised (bimonthly) and have an annual appraisal. Good accounting procedures are followed, with receipts and signatures being obtained for all financial transactions involving the personal monies of people who use the service, in which the home is involved, wherever practicable. Relatives help look after the personal monies of people who use the service in some cases, and in others’, the commissioning Local Authority may be involved. In those situations where the home looks after people’s monies, such as pocket monies, clear individual accounts and records are maintained. These are subject to regular, independent audit. Comprehensive paper and computer records are maintained. People who use the service have ready access to their money, even at short notice. Comments received from staff and management confirmed that there are good health and safety policies, procedures and practices that promote the health, safety and welfare of people who use the service and staff. The manager and senior staff members take lead roles in facilitating Health and Safety risk assessments and audits across the home. There is a Health and Safety committee of a cross-section of staff that meets monthly, plus a full time maintenance officer who is directly involved in monitoring systems and equipment. All relevant staff members do refresher training in Health and Safety, such as moving and handling, fire safety and food hygiene. This helps reinforce the registered provider’s written policies on Health and Safety. Health and Safety issues are also discussed at monthly staff meetings and in 1 to 1 staff supervision sessions. Many people who use the service and/or relatives and staff expressed satisfaction with the way the home was run and the good standards that were evident in many instances. For example, most people commented that the home was always fresh and clean and they were pleased with the improvements carried out in recent months. It is good that there are named photographs of staff members in groups, strategically placed at key points, as this helps identify staff roles and responsibilities and aids communication with people who use the service. The manager routinely invites comments and suggestions for improvements from people who use the service and visitors to the home, via a suggestion box, regular meetings, surveys and consultations. She makes a weekly report to the registered provider who visits the home at regular intervals, including monthly visits as required under regulation 26 of the Care Homes Regulations. DS0000070099.V374079.R01.S.doc Version 5.2 Page 24 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 4 4 4 X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 DS0000070099.V374079.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4(1) Requirement The statement of purpose and supporting information available within the home must contain current and accurate information about the home. The registered provider must comply with the numbers and category of care as detailed on the certificate of registration. This will ensure that people who use the service are provided with correct information and that care is provided for the category and numbers of people registered. A number of baths/showers/washbasins and sinks must be fitted with equipment to ensure that the water is not in excess of 43 degrees centigrade. This will promote safety to people who use the service. Bath and shower water temperatures must be checked and recorded in line with the Health and Safety Executives recommendations ensuring more safety in these areas for people DS0000070099.V374079.R01.S.doc Timescale for action 28/02/08 2. OP19 13/23 31/12/07 3. OP19 13/23 31/12/07 Version 5.2 Page 26 who use the service. 4. OP19 13/23 Paper towels must in dispensers and liquid soap for hand washing purposed must be in appropriate fixtures within toilets/bathrooms and showers. The numbers and skill mix of staff must remain under review to ensure that the appropriate numbers, qualification, experience and skill mix of staff are on during and able to meet the needs of the people who use the service and category of care provided. New staff must not commence employment until all of the employment checks have been completed as specified within Schedule 2. These records must be available within the care home. This will ensure protection to people who use the service. The management arrangements must be formalised and there action must be taken for there to be a manager registered with CSCI. 31/12/07 5. OP27 19(1) 28/02/08 6. OP29 19(1) 31/12/07 7. OP31 8(1) 30/03/08 8. OP38 13/23 07/02/08 The registered provider must ensure that the maintenance and service of equipment is up to date and copies of certificates available within the service. This will ensure that the people are provided with a safe place to live and work. The work that has commence to ensure that all staff undertake mandatory training needs to continue and records needs to fully detail this. All new staff DS0000070099.V374079.R01.S.doc Version 5.2 Page 27 must complete an induction, which covers topics, which ensure the health, safety and wellbeing of the people who live and work at the home. 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 needs assessments and care plans should continue. Residents care plans should be developed further to ensure that appropriate assessments and care plans are in place and meet the needs of more complex and challenging people. Risk assessment tools should be fully completed by appropriate individual, such as bed rails assessments. Accident analysis should also take place, which may identify potential risks and the need for additional measures to be in place. 3. OP9 Where medication is handwritten on to the Medication Administration Record, this should be signed for by one staff member and signed and witnessed by another. Ongoing competency assessment should be carried out on a regular basis for all staff responsible for the administration of medication. 4. OP12 The activities programme should continue to be developed and there should be increased opportunities to be involved in a range of social activities which meet their individual as well as collective needs. The menu should remain under review to ensure satisfaction with the food provided and that it is balanced, nutritious, varied and sufficient in quantity. 2. OP8 5. OP15 DS0000070099.V374079.R01.S.doc Version 5.2 Page 28 6. OP16 The complaints procedure needs some additional information, as the information about who to contact was not available. The actual system for recording complaint and concerns should be reviewed to ensure that staff have access to the forms used and that they are being appropriate recorded, addressed and audited. 7. 8. OP18 OP19 All staff should receive training in protection of vulnerable adults and records need to be in place to detail this. An up to date refurbishment programme detailing timescales should be available. This should include the planned refurbishment of the lift, the refurbishment of a number of bathrooms, toilets and shower rooms and the boxing in of some exposed pipe work. Consideration should be given to improving the environment within the EMI nursing unit. 9. OP30 There should be an up to date programme that details the training in place for staff. Staff need to undertake training that gives them the knowledge and skill to meet the needs of the people they are caring for. All staff who do not have NVQ level 2 in care must complete the common foundations standards as specified by Skills for Care. 10. 11. OP33 OP35 Quality assurance systems should continue to be implemented. The system for managing resident’s personal allowances should be looked at in line with Regulation 20 Care Homes Regulation 2001. All staff should receive formal supervision six times per year. 12. OP36 DS0000070099.V374079.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 DS0000070099.V374079.R01.S.doc Version 5.2 Page 30 - 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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