Inspection on 03/12/07 for Victoria House Care Centre

This inspection was carried out on 3rd December 2007.

CSCI found this care home to be providing an Adequate 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 25/11/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Victoria House Care Centre Park Road North Middlesbrough TS1 3LD Lead Inspector Jackie Herring Announced Inspection 3rd December 2007 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 Victoria House Care Centre DS0000070099.V356263.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 Care Centre DS0000070099.V356263.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 Miss Deborah Elizabeth McKinley Care Home 68 Category(ies) of Dementia (58), Old age, not falling within any registration, with number other category (10) of places Victoria House Care Centre DS0000070099.V356263.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 This is the first inspection of the service since owned by Key Healthcare 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. Victoria House Care Centre DS0000070099.V356263.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 1 star star. This means the people who use this service experience adequate quality outcomes. This is the first time Victoria House Care Centre has been inspected since owned by Key Healthcare and was registered on 6 June 2007. It was an announced Key Inspection as such all of the key standards related to older people were looked at. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use the services, and that it does what the Care Standards regulations say it must. The visit to the home was conducted in two and a half inspection days, all announced. During the visit to the home, a number of records were looked at, including records of people who use the service, along with medication records, staff records, training records and maintenance information. Time was spent talking to people who use the service, a relative and staff. Time was also spent walking around the home, observing interactions and generally finding out what Victoria House Care Village was like for residents and staff. Discussion also took place with the manager and there was brief discussion with the provider. A number of resident and relative surveys were sent to the home for completion, however none were returned. The manager has completed the Annual Quality Assurance Assessment (AQAA), the services self assessment of how well they think they are meeting standards. This was received prior to the inspection and it was then used as part of the inspection process. Some of information has been reflected within the report to support the judgements made. Following the change of ownership, the Responsible Individual and Managing Director met with a Regulation Manager to discuss a number of areas they had identified as in need of improvement, which had not been identified in the previous inspections. It was agreed that Key Healthcare should forward a plan detailing the areas they had identified and how they were addressing them. It was also agreed that the first inspection would be an announced inspection to give the providers an opportunity to meet with the inspector and to go through the plan and the developments that had taken place. The plan was not received prior to the inspection being conducted despite several requests for it. Victoria House Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 Page 6 It is however clear from discussions that have taken place with the provider and manager that Key Healthcare is committed to developing and improving Victoria House Care Centre. Since change of ownership, there has been a further change in manager; the proposed manager at the time of inspection had been in post for approximately four weeks. It was acknowledged by the manager that there was work to do within the home and they were in the process of prioritising this work. What the service does well: What has improved since the last inspection? What they could do better: A number of areas have been identified as in need of further improvement, some of which related to health and safety. There is the need to ensure that where people have access to hot water outlets, the water does not exceed 43 degree centigrade and that the hot water to baths and showers is tested and recorded more frequently. Maintenance and service certificates need to be available within the home and systems in place detailing the ongoing servicing of equipment. The planned refurbishment programme needs to continue, with improvement also needed to some shower, bathing and toilet areas. Staff recruitment needs to be strengthened in line with the company’s own policies and procedures, as do the records detailing staff training. All new staff Victoria House Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 Page 7 also need to have received an induction, which again needs to be detailed within their files. Staff numbers, skill mix and qualification of staff needs to be reviewed to ensure that these are appropriate to meet the nursing and personal care needs of residents along with category of care. The statement of purpose needs to be updated and the service needs to be delivered in accordance with the category and numbers as detailed within the certificate of registration. The work that has commenced on further developing the care records needs to continue, as does the improvement to the activities for residents within the home. 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 Care Centre DS0000070099.V356263.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 Care Centre DS0000070099.V356263.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): Standards: 1, 3 & 6 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. People’s needs were assessed before moving to the home and they were assured those needs would be met. The information required within the home needs to be reviewed and be fully reflective of the current service and needs to be accurately reflecting the current registration of the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Information is available about Victoria House Care Centre within the home. This information does not reflect the current registration criteria of the home; it details what may be provided in the future after some formal changes to registration. There was discussion with the acting manager about this and the need to ensure that information is up to date and accurate. For example, it specified that a 15 bedded younger persons dementia unit is operating. Also the numbers of beds specified do not reflect the current registration certificate. A review of the registration certificate took place, this needs to be discussed further and some possible alterations made. The statement of purpose needs Victoria House Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 Page 10 to be updated to detail the current manager and management structure of the home. The AQAA states, “The Home Manager visits each resident at home, or in hospital prior to admission and completes a robust pre-admission assessment”. This is then shared with the Named Nurse, who is allocated dependant upon complexity of need of the people who use the service. This was evidenced during the inspection where the manager was making arrangements to assess a number of people who had made enquiries and had packs containing pre admission assessments. Intermediate care is not provided at Victoria House Care Centre. Victoria House Care Centre DS0000070099.V356263.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): Standards: 7, 8, 9 & 10 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. People receiving the service are happy with the way in which care is delivered by staff. However records detailing how health and personal care is to be delivered and associated risks need more detail and information. Medication records are generally good and only staff who have received the appropriate training have any involvement with medication. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Five sets of records of people who use the service were looked at during this inspection, one each from different units within the home and included some newer people and people who had live at the home for some time. During discussion with the manager, it was confirmed that Key Healthcare had introduced new assessment and care record documentation as they had identified that improvements were needed to the existing records. The manager said there was still work to do in this area and further staff training was also needed. One of the records looked at was very well completed, with a good level of information. In another of the files looked at, the personal and Victoria House Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 Page 12 social assessments had been completed however no risk assessment tools had been completed and there were no care plans in place. In care plans of people who use the service who have more complex needs the care plans need to be developed further with clear needs statements and more thoughtful interventions. There is the need to detail the action taken following any challenging behaviour incidents and to update the assessment and care plans detailing the effectiveness of the actions taken. This was discussed both with the manager and one of the qualified nurses. There was a little bit of concern about the dependency needs of residents, one member of staff said, “It is hard at the moment as there is not enough staff, not really meeting needs adequately and the residents are much more dependant than the assessments indicate”, “I have spoken to the new manager about this and did receive a positive response”. Within the standard personal information contained within the care records, resuscitation is recorded. It was agreed that this should be looked at in more detail to ensure that the correct procedures are followed and the appropriate legal documentation is in place to support resuscitation plans. Where bed rails are used, there is the need to ensure the assessment is comprehensively completed and where a decision to use this equipment is made, it involves key people, such as people who uses the service, relative, named nurse, key worker and manager. Whilst accidents are being recorded there is no current analysis in place, which would assist in identifying a number of potential areas of risk, which may then need to be assessed and care planned for. Staff confirmed that they had access to care records and that they completed the daily log, activities sheet and personal hygiene records. They also confirmed that there was input from GP’s, chiropodist, optician and district nurses as required. Staff also spoke with knowledge about the people who use the service and meeting people’s individual needs. The medication systems were looked at and in the main were good. There is however the need to ensure that where items are handwritten on Medication Administration Records, these are signed and witnessed, ensuring accuracy. There is also the need to develop some ongoing competency assessments for those staff responsible for the administration of medication ensuring ongoing safe practice. Staff who were spoken to about medication were knowledgeable and confirmed they had received the appropriate training. They were well able to describe the ordering and returns procedures. Victoria House Care Centre DS0000070099.V356263.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): Standards: 12, 13, 14, 15 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. People who use the service have some opportunity to take part in activities. They are supported to live in a flexible environment where there is choice of routines and independence. The food provided is of a satisfactory quality and meets the dietary and cultural needs of the people who use the service. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: During discussion with staff, residents and relatives, it was confirmed that recently there had been an improvement to the level of social and recreational activities available to the residents. People did however think that this was still at the early stages and much more was needed. There has been the recent appointment of a dedicated activities co-ordinator; this will inevitably have a positive impact upon the range of activities on offer. Evidence of some of the activities was seen on display in areas of the home. Staff commented that they believed this was more widely developed in certain units of the home more than in others. Staff said, “Activities have started to improve, but more is needed, residents need to get out and about a bit more”. A resident said, “I spend my day just watching the television, I can’t even go to the corner shop or the park”. One of the residents really enjoyed a food tasting session that had taken place. Very positive comments were received about the support Victoria House Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 Page 14 given from another activities co-ordinator and people were generally looking forward to more activities. Staff spoke of flexibility in terms of the routine. On the inspection days, people who use the services were observed not getting up until mid morning, other residents were joining in with an activity and some residents were sat in the lounge watching morning television. The atmosphere was relaxed and calm. Visitors are free to visit the home when they want to and were observed visiting on the different inspection days. People’s religious needs are well met within in the home. There is a consecrated chapel within the home and a mass in held every Saturday morning for all religious denominations. There are mixed views about the meals at Victoria House Care Centre. New menus had recently been introduced; staff said that the meals provided were not always as detailed within this menu. Some of the comments received related to the portion size, which on some occasions was thought not to be big enough and there was little opportunities for second helpings if people wanted any. Victoria House Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 16 & 18 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. A complaints procedure is available within the home, however this does not contain all of the information needed. It is unclear if complaints are being fully recorded or logged. Some staff have had training around safeguarding adults, but records are not in place to show that all staff have had this training We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Limited information was available about concerns and complaints within Victoria House Care Centre. The complaints file did not contain any information about complaints being received and the manager was not aware of the situation in regard to any complaints or concerns. The complaints procedure, whilst on display needs to be updated as the second page, which contains the contact details was not on display and the procedure also needs to include details of the local authority and funding agencies. No formal complaint forms are available in the various units, staff said they would record any complaint received within the people who use the service’s notes and write it down on a letterhead and inform their line manager. This was discussed with the manager and it was agreed that more formal processes needed to be in place. A resident said, “I have never had any complaints, I fell safe here and they are all nice”. It was unclear how up to date all staff were with protection of vulnerable adults training, as the training records were not fully up to date. Staff said they were Victoria House Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 Page 16 clear about the action they would take should such an incident arise and some confirmed they had received training on the topic of abuse and action to be taken. Victoria House Care Centre DS0000070099.V356263.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): Standards: 19 and 26 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. The home provides an environment that is generally appropriate to the specific needs of the people who live there, although improvements could be made for one group of people. People are able to personalise their bedrooms and the home is warm, clean and comfortable. There have been improvements to the environment, which are continuing and there is the need to take additional steps to promote the health and safety of people. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Victoria House Care Centre is a large Victorian property, with a more modern extension, that has been in place for a number of years. The home provides care to older people, older people with dementia and older people with dementia who require nursing care. There are a number of different units within the home. The home is generally very spacious, with wide corridors and a good amount of communal space and spacious lounges and dining areas. The home was clean, bright and odour free. There was evidence of recent redecoration and the acting manager highlighted new carpets. A Victoria House Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 Page 18 number of bedrooms were visited and there was much evidence of personalisation. People’s bedrooms are of a substantial size. Staff spoke very highly about the improvement to the environment since the recent change of ownership. A person who uses the service said, “the environment is much better and the chairs are much nicer, it is comfortable and warm and I think it is fine here”. The manager informed the inspector that a substantial amount of redecoration had taken place within the home since Key Healthcare took over ownership of the home; it was however acknowledged that there was further work to do. The inspector requested a plan that showed what refurbishment had taken place since Key Healthcare had purchased the home earlier this year and also a plan that detailed the future refurbishment programme, including time scales. This was so that it could be included within the inspection report with a view to clearly showing the commitment of the organisation in identifying areas for development and to making those improvements. This plan was not received prior to writing the report. Some areas needed immediate action to be taken to promote the safety of residents within the home. A number of water outlets to which residents had access were not thermostatically controlled including showers and bathrooms in the Lodge. It was confirmed during the inspection that these would be attended to as a matter of priority. It was also identified that Key Healthcare had already installed a number of these valves since the change of ownership and thought this work had been completed. A number of sinks and handbasins to which people who use the service had access were not thermostatically controlled; this was evident within the small unit kitchen areas and some of the sluice areas. A sample of maintenance records were looked at and it was noted that water temperatures are being recorded monthly rather than weekly. It is recommended that the baths and shower be checked weekly rather than monthly in accordance with the recommendations made by the Health and Safety Executive. A number of the toilet/showers/bathrooms, areas need to be updated to create more homely, domestic and comfortable areas for residents to use. Some exposed pipe-work in one of the ground floor shower room need to be boxed in for additional safety. Paper towels in a number of toilets and bathrooms were not in dispensers and there were toiletries left in bathrooms, potential risks. A number of hand towels were in use in toilets, which are a potential for cross infection. Liquid soap should be available in fixed containers. The lift is not working properly as identified by the proprietor prior to the inspection and a new lift is to be installed in the very near future. Evidence of lift maintenance was in place. Victoria House Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 Page 19 The provider said that the current laundry facilities are not suitable for purpose and currently the flat linen and towels are laundered by an external service. It was confirmed that plans are underway to develop and better the in-house laundry. The nursing unit does not provide the best environment for the residents and potential risks were identified in the way of the padded support pillars along one of the corridors and in the main lounge area. There was also very little outlook for people who lived in this part of the home. The manager said that they were in the process of reviewing the use of some of the units and thought that some of these would be changed in line with meeting the needs of the residents. This needs to be completed in line with the registered categories and numbers as specified within the registration certificate. Victoria House Care Centre DS0000070099.V356263.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): Standards: 27, 28, 29 & 30 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. People are generally satisfied with the care they receive, but there are times when they may have to wait or may not have their needs fully met. There is some shortfall in the recruitment procedures and this does not fully ensure that people are protected. The manager recognises the need to ensure all staff are well trained although records to support this need further development. Staffing numbers and skill mix needs to be reviewed to ensure that the required skill and experience is in place to fully meet the needs of the people who use the services. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA detailed that 66 of care staff are qualified to NVQ level 2 and a large number of other staff have commenced this. A number of staff have also completed NVQ 3 and the deputy manager has NVQ 4 and the registered managers award. A number of staff had worked at the home for a substantial number of years. They spoke of previous training they had received and spoke very highly of a dementia care course some of them had completed. It was also confirmed that all Senior Care Assistants and Team Leader have completed safe handling of medication training. Six sets of staff files looked at. One staff member commenced with one reference and prior to CRB. There was no CRB check available for one of the staff members. There were no references available for another staff member. Victoria House Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 Page 21 There was no up to date Personal Identification Number available for one of the qualified nurses. The supervision system was discussed and it was identified both through the records and discussion with staff that a limited amount of formal staff supervision had taken place, for example, one supervision session per year was recorded in four sets of files looked at. There was no indication of Skills for Care induction for new staff who do not have their NVQ Level Two. For a number of other staff who had commenced employment since Key Healthcare there was no evidence of induction contained within their files. The new manager did show evidence of staff induction since she had commenced at Victoria House Care Centre some four weeks ago. Training records was rather scant information and it was unclear how up to date staff were with their mandatory training. The acting manager did say that they were in the process of trying to pull the records together and also confirmed that she is in the process of rolling a programme of training out to all staff. A number of staff have received training in dementia care. Staff who were spoken to in The Lodge said they had not received this training as yet. The acting manager has completed a course in Dementia Care at Teeside University to enhance her knowledge and skill in this area. There are concerns about the staffing levels within the home; which people who use the service, relative and staff member’s express. One person said, “I sometimes have to wait as long as an hour to go to the toilet because there are no staff available and I need two to help me”. This person gave other examples of times they had to wait before being helped, which were shared with the manager. A relative spoken to said, “The staff are very nice, friendly and approachable but in general there are not enough staff, they are run off their feet and I have concerns about the level of observation and supervision of residents”. Staff spoken to said, “I feel stretched at times, some of the residents need the support and assistance of two staff member and this is not always available, you feel pulled in too many directions”, “We have a good staff team, we are just a bit understaffed at the moment”. “There are some difficulties, you can’t always give the residents the attention and it is difficult to give any quality time”. One person who uses the service said that she had not had a bath for two weeks because staff were not available. A further staff member said, “It is generally OK, some days not able to manage and unable to give some of the care, particularly to the more agitated residents, I get a little worried at times particularly about resident’s who need more 1:1 care. The following information was given in regard to the staffing levels; the ground floor unit has 1 care staff, although two people need the help and support of Victoria House Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 Page 22 two staff. First floor has two units. The EMI unit has 2 care staff. The Older Persons unit, which currently has three people who use the service, has one care staff but these people do need the support of two staff. Within the EMI nursing unit there is a qualified nurse and two care staff. The duty rota was looked at but this did not clearly show the staff on duty and needed to be amended to accurately reflect the staff on duty on a day to day basis. The staff on all of the units described above, without exception said there was little time to deliver real quality care to the people who live there, that they did little more than meet the basic care needs. Observations took place during the inspection and it was noted that staff were extremely busy, had little time to sit and spend time with the people who lived there and were busy covering each other on the other units during breaks and to support staff to meet the needs of the people. The inspector had to intervene with two of the people who live there on the second inspection day to ensure their safety. The details of this were given to the acting manager. Interactions was observed between people who live there and staff and there were clearly very good relationships and staff were observed to be very reassuring. A complaint had previously been received about insufficient staffing levels. Staff said they had been issued with a memo from the company to state that CSCI were satisfied with the staffing levels of the home. The inspector confirmed the staffing levels needs to be determined primarily by the needs of the people who use the service; the layout of the building also needs to be considered, as does the number of people within each of the units. The providers and not CSCI determine staffing levels. Currently within the EMI nursing unit, there are no Registered Mental Nurses. Care is currently prescribed and delivered by Registered General Nurses. At the time of the inspection no evidence was available to demonstrate the additional training, experience and skill the current qualified staff had in relation to meeting the nursing needs of people with dementia. It was agreed that a summary of this information would be forwarded to CSCI for inclusion within the inspection report to support judgements made, this has not as yet been received. Victoria House Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 Page 23 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): Standards: 31, 33, 35 & 38 were looked at during this inspection. People who use the service experience adequate quality outcomes in this area. The manager has the required qualification and experience to manage Victoria House Care Centre although is not registered for this post with CSCI. A number of areas require further development to ensure good management systems are in place and that health and safety is fully promoted. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There is currently a proposed manager in post, who confirmed that they were in the process of completing the application to register with CSCI. She is currently the registered manager for another care home also operated by Key Healthcare and has the required knowledge and skill to manager Victoria House Care Centre. The organisation have very good management systems as seen in one of the sister homes. These management systems still need to be fully introduced within Victoria House Care Centre, the delay may have resulted from a change of manager and there being no manager in post for a Victoria House Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 Page 24 short while. A staff member said, “It is different now the new manager is here, she is proactive and sorts problems out and the home is becoming much more organised”. Staff said that what was good about the home was, “The care that was given to the residents and the teamwork”, “Care is delivered well by a friendly staff team”. People who use the service and relatives were also complimentary about the staff and the care provided. The system for management of people’s personal allowances was not looked at, but was discussed with the acting manager who confirmed that is was the same as their sister home. It was identified that particular system needed to be looked at as it currently it pays a very small amount of charges and also earns a small amount of interest. The full range of policies and procedures were not looked at during this inspection, they were however detailed within the AQAA. There was discussion with the manager about the policies and procedures and she confirmed that copies of these would be made available within each of the units, as currently they are only available within the manager’s office. Details of maintenance and service certificates were not contained within the AQAA and they were not available during the site visit and neither was a plan that detailed when equipment was last serviced and when next due. It was requested that these certificates be forwarded to CSCI, however at time of sending out the draft inspection report not all had been received despite being chased up on different occasions. There is the need to have this information available within the care home. Weekly fire checks and regular fire drills take place. The manager confirmed that she was in the process of having the mandatory training such as fire, health and safety and moving and handling delivered to staff, although at time of inspection she could not confirm how up to date all staff are with this training. Victoria House Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 Page 25 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 2 X 3 X X N/A 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 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 2 X 2 X 2 2 X 2 Victoria House Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 who use the service. DS0000070099.V356263.R01.S.doc Timescale for action 28/02/08 2. OP19 13/23 31/12/07 3. OP19 13/23 31/12/07 Victoria House Care Centre Version 5.2 Page 27 4. OP19 13/23 5. OP27 19(1) 6. OP29 19(1) 7. OP31 8(1) 8. OP38 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. 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 must complete an induction, which covers topics, which ensure the health, safety and wellbeing of the people who live and work at the home. 31/12/07 28/02/08 31/12/07 30/03/08 07/02/08 Victoria House Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 Page 28 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 e 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. 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. 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. 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. 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 DS0000070099.V356263.R01.S.doc Version 5.2 Page 29 2. OP8 3. OP9 4. OP12 5. 6. OP15 OP16 7. 8. OP18 OP19 Victoria House Care Centre 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. 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. 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. 9 OP30 10. 11. 12. OP33 OP35 OP36 Victoria House Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Care Centre DS0000070099.V356263.R01.S.doc Version 5.2 Page 31 - 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!