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Inspection on 16/03/06 for Victoria Nursing Home

Also see our care home review for Victoria Nursing Home for more information

This inspection was carried out on 16th March 2006.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The staff team work well together, have a good relationship with all the people who live at the home and show a good understanding of the needs and wants and wishes of each individual resident. There is a stable staff group, the majority of which have worked together for a long time and know the residents well. This ensures residents enjoy a continuity of care that helps them feel comfortable and safe. Residents spoken with felt well cared for and stated they were very pleased with the individual care and support received. One resident said that she was `very happy with the staff` who were `all very good` The privacy and dignity of the residents is upheld management and staff demonstrated they have a good understanding of the individual needs and wishes of the residents. The routines of the day appear flexible and are designed around the individual living patterns of the residents.

What has improved since the last inspection?

Staff are being appropriately vetted prior to commencing employment, all staff have a Criminal Records Bureau or POVA first check carried out before commencing work at the home. The number of staff that have attained an NVQ qualification has increased, there is now over 50% of the support workers that hold an NVQ qualification. A senior staff member has attained the Registered Managers Award and the registered manager/person has commenced on this course of study. Lockable storage has now been provided for residents in their bedroom.

What the care home could do better:

Up to date records of residents` monies showing all transactions and balance held must be maintained and available for inspection. Some areas of the home are in need of redecoration and some carpets are in need of replacing. Privacy locks should be fitted to resident`s bedroom doors. The Pharmacy Inspector audited the medication procedures and found a number of mistakes had been made in the administration of medication and record keeping. Systems must be in place to ensure residents receive their medication as prescribed. The pharmacist inspector`s findings will be addressed in a separate letter to the registered manager/person. Any member of staff working in the home with only a POVA first clearance must be supervised at all times. Records of fire drills and fire systems checks must be available for inspection. The staff rota must show the designation of each staff member.

CARE HOMES FOR OLDER PEOPLE Victoria Nursing Home 9 Anson Road Victoria Park Manchester M14 5BY Lead Inspector Mrs Lillian McMullen Unannounced Inspection 16th March 2006 11:00 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 Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 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 Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Victoria Nursing Home Address 9 Anson Road Victoria Park Manchester M14 5BY 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) 0161 224 0302 Homesend Limited Mr Adrian Webb Care Home 21 Category(ies) of Dementia (0), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (0) Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users accommodated shall be 21 all of whom require nursing care. Service users shall be above pensionable age and require care by reason of mental disorder or dementia. Registration is subject to compliance with the minimum nursing staffing levels indicated in the Notice previously served in accordance with Section 25 (3) of the Registered Homes Act 1984 issued on 8 December 1999. 2nd June 2005 Date of last inspection Brief Description of the Service: Victoria Nursing Home registered in July 2002 to provide accommodation with nursing care for a maximum of 21 older people. All of the residents had been assessed as having mental health needs. The home is operated by Homesend Limited with Mr Adrian Webb, the manager and the responsible individual. The home was situated in the Victoria Park area of Central Manchester close to local shops, public houses, Manchester Royal Infirmary and other social areas and amenities. The home was close to public transport routes to the City Centre and South Manchester. The home consisted of a large converted semi-detached building, adjoining Surrey Lodge Health Centre and set within its own grounds. The home offered accommodation on three floors with all communal spaces being on the ground floor. The accommodation comprised of 5 single and 8 double bedrooms. The private accommodation continued to offer the residents at least 10 square metres. There were four communal areas, which included a smokers lounge, a radio lounge, lounge/dining room and a quiet sitting area next to the office/medication room. Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of just over five hours on a midweek day. The inspector spoke with the registered manager, the administrator, three senior staff members and a support worker. In addition, several residents living at the home were spoken with either individually or collectively in the lounge and dining room area of the home. A number of records and policies and procedures were also examined and a full tour of the building took place that included communal areas and kitchen and laundry facilities. The pharmacist inspector undertook an audit of the home’s medication procedures. The majority of the core standards regarding Care Homes for Older People had been assessed at the last inspection that took place in June 2005. The outstanding three core standards were assessed at this inspection along with a reassessment of the requirement and recommendations identified at the last inspection. What the service does well: What has improved since the last inspection? Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 6 Staff are being appropriately vetted prior to commencing employment, all staff have a Criminal Records Bureau or POVA first check carried out before commencing work at the home. The number of staff that have attained an NVQ qualification has increased, there is now over 50 of the support workers that hold an NVQ qualification. A senior staff member has attained the Registered Managers Award and the registered manager/person has commenced on this course of study. Lockable storage has now been provided for residents in their bedroom. 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. Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 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 Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: All the above core standards were assessed at the previous inspection. Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 and 10 There are serious concerns that medication is not being administered safely. The home could not provide evidence that medication was being administered safely. Nurses did not always know what doses of medication the residents were currently prescribed. Nurses were not administering medication in line with NMC guidance. Residents’ privacy is upheld and staff practice ensures that personal dignity is maintained. There are serious concerns that medication is not being administered safely. The home could not provide evidence that medication was being administered safely. Nurses did not always know what doses of medication the residents were currently prescribed. Nurses were not administering medication in line with NMC guidance. EVIDENCE: The pharmacist inspector did a Specialist Visit on the 16th March 2006. A small sample of residents’ medication records was looked at. The concerns which Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 10 arose from the small sample were so serious that immediate action had to be taken during the inspection in order to safeguard the health of residents and an Immediate Requirement Notice was left at the conclusion of the inspection in order to ensure the health and safety of residents. It is essential that nurses work within the NMC guidelines at all times. A letter went out on 17th March 2006 detailing her findings and a copy of this letter is available on request. The requirements and recommendations made by the pharmacist inspector are included in the requirements and recommendations listed below. The inspector was confident that every effort is made to ensure residents’ personal privacy and dignity is maintained. There are five double rooms and seven single rooms. Privacy screening is in place in bedrooms where residents share, however, due to most of the residents having been used to long term institutional care or having lived a transient lifestyle in most cases, residents have made a positive choice to share accommodation. Residents who share a bedroom are offered a single room as they become available. Visitors are welcome at any time and residents are free to entertain their guests as they please. A small visitors area is available on the first floor should they wish privacy. The home’s admission procedure ensures residents are asked for their likes, dislikes and preferred term of address. Staff are informed of the measures to take to ensure that every possible effort is made to protect personal privacy and dignity. Residents can choose who assists them with bathing and tasks of a personal nature. Due to their past life histories, residents relate to individual staff members and do not like to share time. An example, given to the inspector, was one resident will not settle for the day unless he has had a one hour period at the start of the day on a one to one basis with a staff member. A staff member explained that if this time is not built into the resident’s daily routine the resident would display some very difficult and challenging behaviour. Routines are flexible and built around the daily living patterns of the residents. Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: All the above core standards were assessed at the previous inspection. Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: All the above core standards were assessed at the previous inspection. Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 The standard of decoration and cleanliness was poor. EVIDENCE: Whilst it is acknowledged that some refurbishment work is planned and new dining room furniture has been ordered a number of areas of the environment require attention. These were fully discussed with the registered manager/person and the observations made at the time of the inspection are: • Some windows did not have window restrictors on and risk assessments need to be in place. • Room 14, the carpet required attention and there was a smell of urine. • Room 3 (bathroom) requires refurbishment. • Top hall stairs and landing, the carpet requires replacing. • Room 4, Carpet requires attention, no lampshade was in place and the self-closing device on the door was causing damage to the plasterwork. • Room 4 (bathroom) requires refurbishment. • Floorboards outside rooms 7 and 8 are loose and require attention. Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 14 • • • • • • • • • • Room 11, a bed base was (unused) being stored, this requires removing or a mattress found and the bed made up. Room 9 No curtains were in place. Dining room, the hatch area was dirty and tiles were damaged. A number of bins were full and required empting. Extractor fans in bathrooms were dirty and required cleaning. The top cellar step was damaged and requires attention. The unused items around the bin area, (mattress and cardboard) requires removing. A number of lampshades were missing and some were dirty, Skirting boards and woodwork was damaged and in some areas dirty. Privacy locks should be fitted to bedroom doors. This is outstanding from the previous inspection. The inspector was pleased to note that the homeowner has plans to refurbish all the bathrooms together with a bedroom on the top floor. Whilst these plans will without doubt improve the facilities the inspector advised that it would be responsible to seek advise from the Health and Safety Executive in order to prioritise the work required. There is an infection control and personal hygiene policy in place, which is given to all staff to read during their induction period. Some of the staff have received formal training in infection control the inspector advised that all staff must receive training in this subject. The inspector further advised that the infection control nurse should be asked to visit in order that specialist advice can be provided on controls that minimise the risk of infection. Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 in part. Suitable measures for the protection of residents are not in place. EVIDENCE: Whilst the home is proactive in obtaining Criminal Record Bureau and POVA first checks prior to staff commencing employment. On the day of the inspection one staff member with only a POVA first check was noted to escorting a resident to hospital unsupervised. The registered manager/person was informed that all staff without a full Criminal Record Bureau check must be supervised at all times. All Criminal Record Bureau checks were examined by the inspector, in some cases only letters from the umbrella body responsible for processing the paperwork stating the disclosure number and that the individual person had been cleared was available. The inspector advised that the full record supplied by the Criminal Record Bureau should be available for inspection by a representative of the Commission for Social Care Inspection prior to being destroyed. A staff rota was available however, this did not show the designation of the individual staff member. The number of staff that have attained an NVQ qualification has increased and it was pleasing to note that now in excess of 60 of the support workers have now achieved this qualification. Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 and 38 The systems in place did not demonstrate that residents’ finances were protected. EVIDENCE: No up to date records were available to confirm that residents ‘personal finances are monitored and protected. Only a collective spreadsheet showing what invoices had been issued was available. The individual records produced at the time of inspection were not current. The registered manager/person stated that all records were now on computer and agreed to forward confirmation to the Commission for Social Care Inspection, current records of resident’s personal monies. The inspector requested that this information contained evidence of all transactions and balance held on behalf of the residents. Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 17 The registered manager/person stated that the caretaker is now undertaking regular fire drills and fire safety checks, however he was not in the building and the records were not accessible. A senior member of staff has now completed the Registered Managers Award in addition the registered manager/person said he has also embarked on this course of study. Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X 2 X 2 STAFFING Standard No Score 27 2 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 2 X X 2 Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 19 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 OP19 Regulation 23(2) Requirement The Responsible Individual must ensure that all areas of the home are well maintained and kept in a reasonable state of decoration and repair. (Previous timescale not met – 01/10/05) 2. OP24 16 The Responsible Individual must ensure that residents’ privacy is promoted at all times. In this respect suitable privacy locks must be fitted to bedroom doors subject to the risk management process and residents’ involvement in this process. (Previous timescale not met – 01/10/05) 3. OP27 17(2) Sch 4 The manager must ensure that the duty records clearly identify the grade of each staff member and the duty period worked. (Previous timescale not met – 01/10/05) 31/03/06 30/04/06 Timescale for action 30/04/06 Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 20 4. OP29 19 & Sch 2 The Responsible Individual must take immediate measures to ensure that staff members with only, a clear POVA first check is supervised at all times. The manager must ensure that fire drills are regularly conducted and recorded. (Previous timescale not met – 01/10/05) 17/03/06 5. OP38 23 31/03/06 6. OP35 17 Records of residents’ personal finances must be maintained and available for inspection. The registered person must ensure that all nurses adhere to NMC guidelines when administering medication. The registered person must ensure that medication policies are updated to reflect current legislation and ensure safe practice. A copy of the revised policies must be sent to the Commission. The registered person must ensure that all records relating to medication are accurate and up to date. The registered person must ensure that all medication is administered as prescribed. That nurses do not alter doses without consent from the prescriber. 30/04/06 7. OP9 13(2) 16/03/06 8. OP9 13(2) 16/04/06 9. OP9 13(2) 16/03/06 10. OP9 13(2) 16/03/06 11. OP9 13(2) The registered person must 16/03/06 ensure that ordering systems are reviewed to ensure that medication is available for administration and does not run out. DS0000021660.V285139.R01.S.doc Version 5.1 Page 21 Victoria Nursing Home 12. OP9 13(2) The registered person must ensure that medication is stored securely at all times. The registered person must ensure that all nurses administering medication must access training and have their competency to administer medication assessed. The registered person must ensure that suitable lockable facilities are provided for residents who are assessed as able to self medicate. The registered person must ensure that medication is labelled correctly by discussing the issues outlined in the report with the supplying pharmacy. 16/03/06 13. OP9 13(2) 01/04/06 14. OP9 13(2) 01/04/06 15. OP9 13(2) 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP31 OP19 OP26 Good Practice Recommendations It is recommended that the home manager complete the Registered Managers Award. Advice should be sought from the health and safety executive in order to prioritise maintenance work. Advice should be sought from the infection control nurse to assist in putting in controls that minimise the risk of infection. Victoria Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 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 Nursing Home DS0000021660.V285139.R01.S.doc Version 5.1 Page 23 - 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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