Inspection on 07/09/09 for Victoria Lodge Care Home

This inspection was carried out on 7th September 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Victoria Lodge Care Home 09/09/08

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Extracts from inspection reports are licensed from CQC, this page was updated on 26/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Victoria Lodge Care Home 138 Thorne Road Edenthorpe Doncaster DN3 2LU Lead Inspector Valerie Hoyle Key Unannounced Inspection 7th September 2009 09:00 DS0000071783.V377478.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Victoria Lodge Care Home DS0000071783.V377478.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Victoria Lodge Care Home DS0000071783.V377478.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Lodge Care Home Address 138 Thorne Road Edenthorpe Doncaster DN3 2LU 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) 01302 884806 victoria.lodge86@yahoo.co.uk Mrs Saima Munir Raja Manager post vacant Care Home 24 Category(ies) of Dementia (14), Old age, not falling within any registration, with number other category (10) of places Victoria Lodge Care Home DS0000071783.V377478.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only Code PC 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 2. Dementia Code DE, maximum number of places 14 The maximum number of service users who can be accommodated is: 24 9th September 2008 Date of last inspection Brief Description of the Service: Victoria Lodge is situated on the outskirts of Doncaster in the village of Edenthorpe. The home provides accommodation for 24 older people some of whom may have dementia. A number of bedrooms have ensuite facilities while others have toilet facilities close by. The home has bedrooms on both the ground and first floor and these can be accessed by a passenger lift. There are three lounges, one is designated as a quiet lounge and there is a dining room. There are gardens and car parking at the front of the home and an enclosed garden at the rear of the building with a paved area with garden furniture and flower tubs planted in the summer. The home was registered by the Commission for Social Care Inspection in April 2008 and the registered provider is Mrs Saima Munir Raja. Information gained on the 7th September 2009 confirmed the current weekly fees are £398.72 for residential care. Additional charges include private chiropody, hairdressing, and outings. The home provides information to people who use the service and their relatives prior to admission into the home. Service Users Guides are available in all bedrooms or on request from the manager. Victoria Lodge Care Home DS0000071783.V377478.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 0 star. This means that the people who use the service experience poor quality outcomes. This unannounced inspection took place over 8 hours starting at 09:00 finishing at 17:00. The visit included a partial inspection of the home. Seven people who use the service, the manager Tamar Benett, three staff and two relatives were spoken to during this inspection, their views are included within this report. Three surveys were received from people who use the service; their comments are included within this report. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous reports may have been deleted or carried forward into this report as recommendations but only when it is considered that the people who use the service are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Occupancy at the home shows 14 of the 24 beds were occupied, this included 2 people who were staying at the home for a short stay. Two peoples care plans were looked at. Policies relating to medication, complaints, protection and handling of people’s money were looked at. Three recruitment and training records were looked at to assess how people were protected. Procedures and risk assessments relating to health and safety were looked at and discussed with the operational managers. The Annual Quality Assurance Assessment was sent to the home for the manager to complete. This was received in a timely manner. An AQAA is a self-assessment and a dataset that is filled in once a year by all providers whatever their quality rating. It is one of the main ways that we will get information from providers about how they are meeting outcomes for people using their services. The AQAA also provides us with statistical information about the individual service and trends and patterns in social care. Two requirements from the previous inspection dated 7th September 2008 remain outstanding; other requirements have been met or carried forward as recommendations What the service does well: Victoria Lodge Care Home DS0000071783.V377478.R01.S.doc Version 5.2 Page 6 People told us that they liked living at the home, and surveys confirmed most were happy with the care provided. People said they liked their bedroom and were encouraged to bring items of furniture which had helped them settle into the home. One person staying at the home for a short stay period said they would be happy to come back to the home to give relatives a rest. People told us they were aware of the complaints procedure and would feel happy to talk to the manager about their concerns. Two relatives said staff always made them feel welcome. They said staff did their best, although more staff would improve the care provided. What has improved since the last inspection? What they could do better: Medication procedures must be improved as medication was left unattended while the senior carer administered medicines to a person that was in their bedroom. The medication was not signed for as administered which means there is a significant risk that mistakes will take place that may cause harm to people who use the service. The arrangements to ensure the basic principles of privacy and dignity were not respected, as people were observed cuing outside the toilet after lunch and the door was left ajar. The home could improve the way people can have the opportunity to take part in activities, as there was little evidence to confirm how people were engaged. The programme of activities was not followed as staff fit in activities when they can, which was often limited due to their caring responsibilities. Mealtimes could be improved as the dining area looked institutional with all the tables pushed together creating a large seating area. Staff was very busy making it difficult to offer appropriate assistance. Choice was limited at mealtimes and people said they were unsure what was on the menu for the day. There is currently no set menu although the new cook has started to develop a menu. Records of meals provided could be improved, as they were not consistently completed. The completed records did not confirm choices offered or that the meals were nutritionally balanced. Victoria Lodge Care Home DS0000071783.V377478.R01.S.doc Version 5.2 Page 7 The home must review the infection control measures to control the spread of infection. There must be sufficient domestic staff to maintain a clean and hygienic environment as staff currently multi task which may affect the quality of care provided. There are no sluicing facilities at the home, and staff currently cleans commodes in baths used by people who use the service. Carpets must be replaced as identified during this inspection. Training in essential areas of moving and handling, infection control, first aid, health and safety, and fire safety remain outstanding from the previous inspection and must be arranged as soon as practicable. Staff must be alert to the signs of abuse and must be familiar with the procedures to follow if they suspect any incidents of abuse have taken place. This will help to protect people who use the service from abuse. The manager must review the staffing levels to ensure they are sufficient and competent to deliver appropriate care to people who use the service. This must include arrangements during the night. The home has established quality assurance systems, although some were not completed. The home surveys people who use the service, although outcomes of surveys were not available. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Victoria Lodge Care Home DS0000071783.V377478.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 Lodge Care Home DS0000071783.V377478.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were assessed before moving into the home to ensure their needs can be met. EVIDENCE: The home has an assessment document that was used to assess the needs of people who use the service, prior to admission into the home. A number of completed assessments were looked at and they contained basic information about the needs of the individuals. The assessment document contained information about the health and welfare of people, although the document used mainly tick boxes. The placing authority also undertakes their own assessment and together the information is used as the base to formulate care plans for people who use the service. Victoria Lodge Care Home DS0000071783.V377478.R01.S.doc Version 5.2 Page 10 Relatives confirmed that they had been involved in the admission of their relative and they told us that they had looked at other homes before making a decision about Victoria Lodge. They said staff helped their relative settle, which was important to them. They encouraged their relative to bring in their own possessions to make them feel at home. One person told us that they had moved from another home to be closer to relatives and the person was happy with the move. Victoria Lodge Care Home DS0000071783.V377478.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People generally had their health and personal care needs met, though improvements in medication systems and privacy and dignity are needed to ensure individual’s complete needs are understood and met. EVIDENCE: Two care plans were looked at to assess how staff supports people with their personal care. They contained sufficient details to ensure they could deliver the care people need. The manager told us that they had been working closely with the local social services department to ensure the plans were reviewed and reflected the current care needs. There was clear evidence that care plans had been evaluated although the evaluations were very brief. They did not describe outcomes and progress, and only confirmed that the plan was still Victoria Lodge Care Home DS0000071783.V377478.R01.S.doc Version 5.2 Page 12 current. Daily records and risk assessments were sufficiently detailed to ensure people could maintain their independence while remaining safe. Peoples healthcare needs were met and there was evidence to confirm regular visits from healthcare professionals. The staff had regular contact with the district nursing services, who offer advice and support. Records confirmed outcomes of visits from nurses and doctors and there was evidence that nutritional assessment been undertaken. People were observed having supplements to their diet which included high calorie fruit and milky drinks. Medication procedures were not followed which means people may be put at risk of harm. Racks of medication were left unattended while the staff member administered medication to someone in their bedroom. The records were not signed for until all the medication had been administered. This is poor practise and does not comply with the Royal Pharmaceutical Society guidelines. There is a separate store for controlled drugs although none are currently stored at the home. They keep records for medication that is to be returned, although July’s returns were not recorded and had not been returned. Records looked at were generally detailed although one persons medication had not been booked in correctly, therefore it was difficult to assess if they had received their medication as prescribed. Staff were observed interacting throughout the day; they appeared to be very busy meeting peoples needs. There was little choice being offered to people, including drinks offered and the television was turned on all day, although no one was asked which channel they preferred to watch. Most people sat in the main lounge although there was another lounge which was designated as an area for people with dementia. People’s privacy and dignity must be improved as three people being moved in wheelchairs were seen waiting outside the communal toilet, the toilet door was left ajar, which fails to maintain peoples dignity. Victoria Lodge Care Home DS0000071783.V377478.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had limited opportunities to take part in activities, mealtimes were organised although choice was limited. People were able to make choices about daily routines and where they spend their time. EVIDENCE: People had limited opportunities to take part in activities, as there was no staff designated to undertake the role. Relatives said that they have not observed activities taking place although they were given information that activities would be offered on a regular basis. Posters were displayed that stated activities that were scheduled, although there was little evidence to confirm the programme was followed. People said they could join in bingo although this was the only activity they joined in. Care plans looked at confirmed the lack of social stimulation, as most entries stated that people watched television. A game of bowls was observed during the afternoon of this inspection, although this activity was not listed on the programme. People said they had enjoyed a Victoria Lodge Care Home DS0000071783.V377478.R01.S.doc Version 5.2 Page 14 trip to Cleethorpes although the numbers were limited due escorts needed to keep people safe. People said they had a choice of sitting in the lounge or remaining in their bedroom. One person said “I like to stay in my room, staff brings my meals and I like to listen to my radio and TV”. People said they were able to get up and go to bed when they liked, although a number of people said they sometimes had to wait to go to bed when staff were really busy. Relatives said they were always made to feel welcome and staff were kind and caring. They said they visited at various times of the day and staff always seemed to be very busy. Relatives said that on occasions there did not appear to be sufficient staff on duty to meet people’s needs, in particular at meal times, and in the evening. There are two dining rooms, although only one was in use during this inspection. The room had tables organised so that all the tables were pushed together creating a large dining area. This arrangement should be reviewed as it does not promote individualised care. Breakfast and lunch were observed and staff was seen supporting people during the meal, however the meal took a long time to be served and there were periods when staff were not available to offer assistance. People said they did not know what was on the menu for lunch and the menu was not displayed. There appeared very little choice of meal and an alternative had not been prepared. The cook (only appointed two week ago) said she was arranging to implement new menus and was looking for local suppliers to provide the goods. Records looked at were poor, in particular actual food provided to people who use the service. Where records had been completed they confirmed that there was very little choice of meal offered to people. There was little evidence to confirm cooked breakfasts were available, although some people said they would ask if they wanted anything cooking. The teatime meal was mostly sandwiches as care staff had responsibility for preparing and serving the tea as the cook finished work early afternoon. Supper was not observed although people said they were served a hot drink and a biscuit. Supplies of dry stores and meat and vegetables were currently obtained from a local supermarket. There was no fresh vegetables and only bananas as the fruit available to people. Only frozen fish was available and the records did not show a balanced diet. Toad in the hole was provided for the main meal on the Sunday, as the cook said a joint of meat had not been ordered. Victoria Lodge Care Home DS0000071783.V377478.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were able to express their views although sometimes action was not always taken to resolve problem. Safeguarding procedures were generally followed although some staff needs training to ensure they are alert to the signs of abuse which will help protect people from harm. EVIDENCE: There is a complaints procedure and people said they were aware of the procedure and would speak to the manager if they had a problem. One person said they had made a complaint about no hot water in the morning, the person said the situation lasted for one week before it was resolved. The manager said she was aware of the complaint but said the problem was resolved the next day. There was no evidence available to confirm the complaint had been recorded or how the problem was resolved. Surveys confirmed people know how to make a complaint. One survey said they felt they were not listened to. Relatives said they were happy for the manager to deal with complaints, but also confirmed information about the hot water problem. The AQAA only contained very little information to assess how they manage complaints. The AQAA stated that one complaint had been received and the investigation records were held at the main office. The registered provider had sent us information about the outcome of the investigation. Victoria Lodge Care Home DS0000071783.V377478.R01.S.doc Version 5.2 Page 16 The manager was aware of the safeguarding procedures, although some of the staff had not received training to recognise signs of abuse. One member of staff on duty was unaware of the action to take if they suspected bad practise as they had not attended training. Shortfalls in staffs knowledge and skills with regard to safeguarding were identified in the last inspection of the service with the timescale for completion as 1st November 2008. The AQAA told us one referral had been made to safeguarding adult, although the outcome of the investigation was not available as it had not been concluded at case conference. The staff manages peoples money appropriately and records looked at were accurate. The money held on behalf of people is stored safely and the home carries out audits to ensure records and money are regularly checked. Victoria Lodge Care Home DS0000071783.V377478.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment is comfortable with furnishings in reasonable condition but some improvements are required to control the risk of infection. EVIDENCE: The home provides a physical environment that is appropriate to the specific needs of the people who live at the home. People said, they liked living at the home and enjoyed spending time is their bedroom. People said they were able to bring in possessions from their own home and one person said she was able to bring in her bed and bits of furniture which helped her settle into the home. Victoria Lodge Care Home DS0000071783.V377478.R01.S.doc Version 5.2 Page 18 There are two lounges, one which is designated an area for people with dementia. Most people sit in the main lounge and the furnishings in the communal areas were in reasonable condition. The grounds are well maintained and there is a seating area outside which leads from the lounge and is easily accessed by people. The home has no designated domestic staff, and care staff undertakes cleaning duties as well as providing care and support to people. This means that it is difficult to maintain a clean and hygienic environment for people to live. There are no sluicing facilities at the home and staff told us that they wash commodes in the baths, which potentially pose a health hazard for people bathing in these facilities. Carpets identified to the manager during this inspection must be replaced as cleaning regimes have failed to restore them to a good condition. Requirements regarding infection control measures had been made by Environmental Health Department. The manager told us that they were working to meet the requirements. Record looked at show staff had not received infection control training, although the manager said it was arranged for later this year. Victoria Lodge Care Home DS0000071783.V377478.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff lacks the skills and knowledge to keep people safe, as most training is out of date. Staff were recruited safely which helps keep people safe from harm. EVIDENCE: Staff rotas were looked at to determine if there were sufficient staff to meet the needs of people who use the service. Two care staff were on duty during the day and there was only one waking night staff, with a further staff sleeping on the premises in case of emergency. The staffing levels at all times of the day and night must be reviewed to ensure staff are in sufficient numbers, skills and competencies to provide the care and support to people. The manager must review the dependency levels to ensure their needs can be met. The lack of domestic cover and the catering arrangements (in the afternoon) means staff spends time away from their main caring roles. Senior staff had added responsibility to organise the shift and ensure medication was administered safely. This means there is only one staff member available to attend to people’s personal care, and could potentially put people at risk. Victoria Lodge Care Home DS0000071783.V377478.R01.S.doc Version 5.2 Page 20 The home has clear recruitment procedures and staff had been recruited to keep people safe. Three recruitment files were looked at and they contained the required two references and Criminal Record Bureau check and there was evidence that the manager had checked gaps in employment. Induction and training records were looked at. The induction programme meets the Skills for Care standards. New staff were supported by a more senior staff member until they can demonstrate they have the right skills and competencies. Records looked at showed that some health and safety documents had not been completed, although the manager said the instruction had been given to the staff. The manager said she had provided moving and handling training to a new member of staff, however the manager has not undertaken moving and handling training in the last two years and she does not hold any qualification to deliver training to staff. This may mean that staff may not receive current and relevant training to safely move people who use the service. Training records were poor. They contained little evidence to confirm any refresher training had taken place. The manager told us that she had identified a training provider however, staff delivering care to people need refresher training in first aid, infection control, moving and handling, health and safety and most required food hygiene training. One of the staff on duty was not aware of the action she would take if she had concerns about practise and lacked knowledge about the procedures to follow. Training shortfalls were identified as a requirement in the previous report with timescales of the 1st January 2009 not met. The home continues to support staff to undertake National Vocational Qualifications (NVQ); however numbers of staff trained to NVQ Level’s 2 in care is less than 50 . Victoria Lodge Care Home DS0000071783.V377478.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Health and safety procedures do not ensure people who use the service are kept safe. The financial interests of people are safeguarded. The home has quality assurance systems although most of the systems were not up to date. EVIDENCE: The manager has been in post since January 2009 although she has not submitted an application to Care Quality Commission. She holds the relevant management qualification and continues to work towards NVQ Level 4. The manager had completed and returned the AQAA (Annual Quality Assurance Assessment) although it contained very little quality information. The AQAA fails to provide a reasonable picture of the current situation within the service. Victoria Lodge Care Home DS0000071783.V377478.R01.S.doc Version 5.2 Page 22 It fails to demonstrate where improvements are required to improve the service. Some of the dataset information was not completed which was asked for on the day of the inspection. The manager works mostly off rota so that she can develop systems to develop the service. There were quality assurance systems although some had not been completed. Surveys to gain peoples views were undertaken although they had not been analysed to form a development plan. The manager was able to confirm that resident’s meetings takes place and a copy of the minutes were looked at. The registered providers undertaken a quality audit (Regulation 26) although completed records looked at contained only limited information. They do not focus on outcomes for people or identify areas for improvement. Records were stored appropriately, although essential records relating to the effective running of the kitchen were not maintained. This poses a significant health risk if cleaning regimes were not maintained. Records to demonstrate food supplied to people safely was not completed, which could pose significant health issues if there was an outbreak of food poisoning. People who use the service are able to manage their own finances, although some prefer the manager to assist with dealing with their personal allowances. A number of peoples personal allowance records were examined and checked, the records were accurate and there were clear auditing procedures. Accident reports were analysed by the manager to ensure risk assessments were developed where required. Safe working practices need to be improved, as the home was unable to demonstrate that a qualified first aider was available at all times. Infection control measures must be improved as the manager confirmed that there remained some outstanding requirements from a visit from Environmental Health department. Moving and handling training needs to be arranged as staff have only received training from the manager who does not hold a recognised training qualification Maintenance and service records looked at showed fire training had not been undertaken since May 2008. The manager told us that she had arranged this for late September 2009. During this inspection the fire alarm was activated due to a problem in the kitchen. The manager and the senior took appropriate steps to investigate the alarm, although the other member of staff did not follow the procedure and remained with the people who used the service. She had not undertaken fire training and therefore people could have been at serious risk from harm if there had been an emergency situation. One person who was being cared for from his bed (situated on the first floor) was shouting for information, although it was some time before staff responded to him. The rating in this outcome group reflects the lack of response to previous inspection report requirements where essential systems to maintain people’s safety have not been completed. The manager has not responded to gaps in peoples knowledge and competencies as health and safety training remains incomplete, which poses significant risk to people who use the service. Victoria Lodge Care Home DS0000071783.V377478.R01.S.doc Version 5.2 Page 23 Victoria Lodge Care Home DS0000071783.V377478.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 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 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 1 3 X X X X X X 2 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X 2 1 Victoria Lodge Care Home DS0000071783.V377478.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement Medication procedures must be followed to ensure people receive their medication safely. Medication must be signed for as soon as it has been administered. Medication must be stored correctly, when the person administering the medication is away from the trolley. To ensure vulnerable people are not put at significant risk from harm. People’s privacy and dignity must be respected at all times. Some practices observed during this inspection indicated that staff was not working to those principles. Staff must be alert to the signs of abuse and must be familiar with the procedures to follow if they suspect any incidents of abuse have taken place. This will help to protect people who use the service from abuse (Timescale not met 01/11/08) DS0000071783.V377478.R01.S.doc Timescale for action 02/11/09 2. OP10 12 02/11/09 3. OP18 13 02/11/09 Victoria Lodge Care Home Version 5.2 Page 26 4. OP26 23 Suitable arrangements must be made to ensure good Hygiene practices take place. This includes appropriate sluicing facilities, and replacing carpets where identified. To control the risk of infection and maintaining a clean, hygienic environment. The manager must review the staffing levels to ensure they are sufficient and competent to deliver appropriate care to people who use the service. There must be sufficient staff employed to maintain a clean and hygienic environment and sufficient to meet the standards relating to food, meals and nutrition. 01/12/09 5. OP27 18 01/12/09 6. OP27 18 01/12/09 7. OP30 OP38 18 Staff must receive refresher 01/12/09 training in first aid, moving and handling, health and safety infection control, and food hygiene, to ensure they have the required skills and competencies, to meet the needs of people who use the service. This will help protect people from harm. (Timescale not met 01/01/09) Records stored in the home must 01/12/09 be completed to ensure the effective running of the home. Records of food provided must be in sufficient detail to demonstrate people receive a balanced diet and records of cleaning regimes (kitchen) must confirm effective hygiene practices takes place. Staff must know what action to take in the event of a fire; this DS0000071783.V377478.R01.S.doc 8. OP37 17 9. OP38 23 02/11/09 Page 27 Victoria Lodge Care Home Version 5.2 will help protect people from harm. 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 OP12 Good Practice Recommendations People should have opportunities to engage in activities and records should be made to demonstrate the activities, and the people that have joined in the activity. Menus should be displayed in the dining area daily and should include the alternative choice of main course and dessert. Catering arrangements should be kept under review to ensure a varied menu can be provided for evening meal. This should include cooked hot food and an alternative dish. The manager should make an application to be the registered manager with Care Quality Commission. 2. OP15 3. OP31 Victoria Lodge Care Home DS0000071783.V377478.R01.S.doc Version 5.2 Page 28 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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