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Inspection on 02/06/05 for Victoria Nursing Home

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

This inspection was carried out on 2nd June 2005.

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 home accommodated a number of very dependent people with longstanding mental health issues. The staff practice appeared non-judgemental and the residents were encouraged to remain as independent and self-caring as possible. The residents said that they usually enjoyed the meals provided by the home. The majority of the residents spoken with appeared to be aware of how to make a complaint as well as being aware that the complaint procedure was contained within the Service Users` Guide. The residents reported that the staff members were friendly, generally cheerful and helpful. The staffing levels at the home appeared to be adequate to meet the assessed needs of the residents. The home`s management of the residents` mental health needs continues to be to a high standard as does the homes involvement with Psychiatrists, Community Psychiatric Nurses and other primary healthcare personnel. In general the risk assessments were linked to the plans of care and reviewed at least monthly.

What has improved since the last inspection?

The staff members appeared to be cheerful and were seen to be responsive to the residents` needs. The staff appeared to have an awareness of the residents` assessed needs, their choices and preferences. The home`s staffing levels appear to have consistently met the levels required. Some effort has been made to improve the home`s environment and additional natural light is now available by way of the skylights provided at the head of the staircase. A gardener was at the home during the inspection and he was pruning the trees and shrubs that have traditionally reduced the amount of natural light entering the building. The garage had been re-roofed and the windows etc sealed. A secure side entrance door had been fitted to provide additional storage facilities for equipment etc not in regular use. An adjustable height bed had been provided to meet the changed needs of one resident.

What the care home could do better:

The content within the staff members` personnel files was not consistent and some files examined failed to contain the information intended to protect residents from potential harm and abuse. There evidence in the individual plans of care to show that activities had been undertaken. No named individual member of staff had specific responsibility for planning social and recreational activities. The provider stated that the residents would discuss their social care needs on a one to one basis with care assistant staff and that they usually controlled their own activities with some support and guidance from staff members. Several areas of the home are in need of decoration and refurbishment. Much of the shared furniture was passed its best. Several carpets needed to be thoroughly deep cleaned or replaced.

CARE HOMES FOR OLDER PEOPLE Victoria Nursing Home 9 Anson Road Victoria Park Manchester M14 5BY Lead Inspector Gary Largent Unannounced 2 June 2005 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 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 F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Victoria Nursing Home Address 9 Anson Road Victoria Park Manchester M14 5BY 0161 224 0302 0161 224 0302 victorianursing@btconnect.com Homesend Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Adrian Webb Care Home 21 Category(ies) of Dementia registration, with number Mental Disorder - Over 60 of places Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The maximum number of service users accommodated shall be 21 all of whom require nursing care. 2 Service users who require care by reason of mental disorder or dementia shall be aged 60 years or over at the time of admission. 3 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. Date of last inspection October 2004 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 service users at least 10 square metres. There were four communal areas, which included a smoker’s lounge, a radio lounge, lounge/dining room and a quiet sitting area next to the office / medication room. The home was accommodating 17 residents at the time of the inspection. Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector based at the Manchester, Salford and Trafford office of the Commission for Social Care Inspection did the home’s unannounced inspection. The Inspection took place over 7 hours on 2nd June 2005. Nine residents were spoken with during the inspection in addition to a number of staff members and the home’s management team. No visitors were available at the time of the inspection. The residents were generally positive in their comments regarding the home and the standards of care and accommodation provided. The inspection included a tour of the home where the living conditions were inspected. There were no obvious areas of high risk to the residents’ health and safety. Care, medicine, accident, staff rotas, fire, complaint and other records were inspected in addition to staff personnel files. Two requirements were made at the time of the inspection as these were believed by the inspector to need immediate action to be taken by the registered organisation to ensure the continued safety of the residents. Several requirements were made at the previous inspection for improvement and had not been fully addressed. These requirements have been repeated within this report. What the service does well: The home accommodated a number of very dependent people with longstanding mental health issues. The staff practice appeared non-judgemental and the residents were encouraged to remain as independent and self-caring as possible. The residents said that they usually enjoyed the meals provided by the home. The majority of the residents spoken with appeared to be aware of how to make a complaint as well as being aware that the complaint procedure was contained within the Service Users’ Guide. The residents reported that the staff members were friendly, generally cheerful and helpful. The staffing levels at the home appeared to be adequate to meet the assessed needs of the residents. Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 6 The home’s management of the residents’ mental health needs continues to be to a high standard as does the homes involvement with Psychiatrists, Community Psychiatric Nurses and other primary healthcare personnel. In general the risk assessments were linked to the plans of care and reviewed at least monthly. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 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 standard(s) 3 and 4 The home was able to meet the assessed specialist needs of the residents and to confirm its ability to do so. EVIDENCE: All of the residents been thoroughly assessed before their admission to the home. The assessments were individual and included mental health, medical and social histories. Risk assessments had been completed in relation to pressure sore development risk, oral healthcare needs and a falls history. The risk assessments had resulted in the creation of associated plans of care. The home’s clinical manager conducted all pre-admission assessments. The pre-admission assessments were supported by those completed by a social worker and NHS nurse or by way of a multi-disciplinary team assessment. The plans of care had been developed from the pre-admission assessment. Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 9 The home had a system of confirming, in writing, its ability to meet the assessed needs of prospective residents. The home employed sufficent staff to meet its needs and those of the residents. A placement review held six weeks after admission to the home and the residents’ monthly reviews measured the home’s success in meeting the residents’ assessed needs. Evidence was kept to demonstrate that residents and / or their representatives were invited to care plan reviews. The home had regular contact with community psychiatric nursing services and there were records of the involvement with other specialist professionals, e.g. the tissue viability nurse specialist etc. The home did not provide intermediate care facilities. Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 11 The plans of care set out in detail the actions to be taken to meet the residents’ assessed needs. The home’s policies supported the residents at the end of life. EVIDENCE: The plans of care were developed from the home’s pre-admission assessments and those of the care manager, the NHS nurse and any multi-disciplinary team. The plans of care set out the actions needed to meet the needs of the resident. The plans were reviewed monthly and contained appropriate risk assessments. Where the involvement of the resident or their representative had not been possible a copy of revised care plans were provided, with the residents consent, to the next of kin / representative and comments were invited regarding the plans. All residents were registered with local General Practitioners. The home encouraged the residents to maintain their self-care and social skills. The home’s philosophy of care was based on the principles of independence, respect and dignity. The residents’ care files contained details of the arrangements made to enable them to visit opticians, dentists, chiropody and other primary healthcare services. The home provided details of how independent advocacy services could be accessed. Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 11 Records were maintained in relation to ordering, storage, administration and disposal of medication. The home used homely remedies and maintained a log of their use. The home used a bottle system in preference to a multi-dose medication delivery system. The home maintained medication profiles on behalf of each resident. Medication reviews were regularly held. The home had a policy in relation to the management of death and dying including the need to respect the wishes of residents and their families. The home’s policy stated that terminally ill residents were permitted to remain at the home surrounded by familiar sights, sounds and surroundings where this was their recorded wish. Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 12, 13, 14 and 15 There was little evidence of structured activity within or external to the home. Although the residents were able to come and go at will there was little recorded evidence of their contribution to the decision making process. EVIDENCE: The pre-admission assessment format had details of the residents’ interests and social histories. The residents confirmed that they were involved in oneto-one discussions in relation to their social care needs. The manager reported that his efforts to hold monthly resident meetings had not been successful. The residents appeared to be able to come and go from the home as they wished and to retain control regarding the choices associated with daily living, subject to risk assessment. Meal times etc were flexible and responsive to the residents’ recognised needs and wishes. A newsletter was periodically published by the home. The residents were able to receive visitors in private and to determine which visitors they received or otherwise. There was evidence that one resident had withdrawn visiting rights from an individual. This was recorded within their plan of care and subject to review. The home permitted visiting at any time of day or night. Information about visiting and maintaining community contact were recorded within the welcome pack, brochure and the resident guide. This Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 13 written information was available to the resident and his family members at the time of admission to the home. The residents’ right to self-determination and choice were included within the home’s philosophy of care. Details of how to access independent advocacy services were included within the Service Users Guide. The residents appeared to be encouraged to bring personal and familiar items into the home at the time of their admission and a property list was maintained detailing such items. The home’s policies enabled the residents to access their individual files and records, in keeping with the Data Protection Act 1998. Where residents were unable to express individual choice any decision made on their behalf appeared to have been based upon the information gathered both before and at the time of the residents admission to the home and upon the staff’s personal knowledge of the resident or, where appropriate, in consultation with an independent advocate. Meal times were flexible and were served at intervals no greater than five hours. Supper was served at 7.30pm and again at approximately 10.00pm. The residents confirmed that they were able to receive food throughout the night as they wished. Special diets e.g., medical, spiritual and other dietary needs were available. The meals provided appeared to be varied, nutritious and wholesome. The menu contained a main meal choice and an alternative choice in addition to a list of readily available snack alternatives. The care staff recorded daily meal orders from the residents and the chef retained a list of the residents’ likes, dislikes and preferences. These were recorded within the residents’ care files. Those residents requiring assistance with eating were offered such assistance in a sensitive and respectful manner. Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 16 and 18 The home was able to deal with and handle complaints well.The home’s policies and procedures offered the residents a degree of protection from abuse. EVIDENCE: The home’s complaint procedure formed part of the home’s Service Users’ Guide. It contained the contact details of the Commission for Social Care Inspection (CSCI). The home undertook to respond to all complaints within a 21-day timeframe. A record was maintained of all complaints received, the outcomes and actions taken in light of the complaint. The home had received 2 complaints during the year before this inspection. The Commission for Social Care Inspection had received 2 complaints. The home had been involved in 1 Protection of Vulnerable Adults from Abuse investigation. 1 complaint was found to be malicious, 2 were partly upheld and 2 were not upheld. The home had an Adult Protection Policy and procedure in addition to the Manchester Multi-Agency Protection of Vulnerable Adults from Abuse (POVA) procedure. The home’s adult protection policy and the Whistle Blowing policy were in keeping with the Department of Health (DOH) guidance, “No Secrets” and the Public Disclosure Act 1998 respectively. The home had had no allegation of abuse since the last inspection. The home had a policy to safeguard residents from financial abuse. The home’s code of conduct prevented staff members from accepting any gifts, assisting in the making or witnessing of wills or benefiting from bequests. Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 15 The home provided accommodation and care for older people with mental health issues, commonly presenting with behavioural disturbances. The home did not use systems of physical control or restraint. The management of aggression formed part of the home’s induction programme and ongoing training. Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 16 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 standard(s) 19 and 24 The general standard of decorative finish to the home was poor. The provisions for maintaining the residents’ privacy in bedrooms was inadequate. EVIDENCE: At the last inspection a requirement was made that all areas of the home must be well maintained and kept in a reasonable state of decoration and repair and that suitable privacy locks should be fitted to bedroom doors. The requirement remained outstanding. Three bedrooms had however been decorated. The home was accessible by ramp access and a passenger lift provided access to all levels of the home. The home had received some refurbishment attention since the most recent inspection e.g., the roof had been insulated and repaired. The garden areas were accessible to all residents. Accommodation was provided in a mix of single and double bedrooms. The home had no en-suite facilities. Some areas of the home décor were not to a good standard, however the home had a programme of redecoration and refurbishment. Three of the homes bathrooms needed to be refurbished. The Responsible Individual stated Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 17 that this was scheduled for completion by 1 October 2005. The carpet to the staircase and landing areas are to be replaced by the same date. The Responsible Individual needed to take action to ensure that suitable privacy locks are fitted to bedroom doors. When fitted the keys must be made available to the residents subject to risk assessment. The Responsible Individual must ensure that each resident has a lockable space available within his / her private accommodation. Refurbishment of the bedrooms had started and the Responsible Individual confirmed that as each room was upgraded it would have a lockable space provided. Bedside cabinets had been purchased and were being stored until the bedrooms had been decorated. Since the last inspection the home has had a complete new roof, new guttering and new facia boards. Skylights had been fitted to some areas of the roof to increase the available natural light to staircases etc. Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The home’s recruitment practices were unacceptably poor. The practices did not adequately protect residents from potential abuse. EVIDENCE: At the time of the inspection the home met its specific condition of registration relating to staffing levels. The home employed 7 RMN (Registered Mental Nurses), two who had also qualified as Registered General Nurses (RGN) in addition to one nurse who was trained solely as an RGN. The home maintained records of those staff having been on duty at any time of day and night. The duty records however did not differentiate between grades of staff and identify the trained nursing staff. The home employed catering, laundry and administration staff to support the residents. Four members of the care staff had achieved the NVQ level II at the time of the inspection. The Responsible Individual stated that a further 4 care assistant staff had enrolled on the NVQ level II course. 1 staff member had already achieved the NVQ level II had subsequently enrolled on the NVQ level III course. The Responsible Individual stated that at least 50 of the care assistant staff would achieve the Level II qualification by the end of 2005. The home manager had not undertaken the Registered Manager’s Award however the deputy home manager had begun such a course in February 2005. It was anticipated that the deputy manager would be promoted upon the retirement of the current manager. Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 19 The home’s recruitment procedures were not appropriately applied at all times. The employment practices were potentially harmful to those residents accommodated at the home. The inspection of staff files demonstrated that employment references had not been consistently received on behalf of recent staff appointments to the home. In addition, a member of trained nursing staff was working at the home despite the Responsible Individual’s awareness that no CRB enhanced declaration or POVA first check had been received regarding the staff member. Gaps in employee’s work histories had not been adequately investigated. An Immediate Requirement Notice was made for the provider to urgently address these potentially dangerous practices. All employees received a statement of their terms and conditions of employment. The home did not use volunteers. The home’s training and development programme met the National Training Organisation (NTO) workforce training targets. The home’s training and development records were able to demonstrate that all new staff members received foundation training to NTO specifications within 6 months of their appointment and induction training within 6 weeks. All staff appeared to receive a minimum of 3 paid days training per year including in-house training. All staff had a personal training and development profile based upon their individually assessed training needs. Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33 and 38 The home had clear lines of accountability which was known to staff and residents. The home had developed systems to ensure it obtained the views of residents on the service delivery. EVIDENCE: The recommendation made at the previous inspection in relation to the manager’s enrolment on a course leading to the Registered Managers’ award was still outstanding. The home’s deputy manager enrolled on such a course in February 2005. The home manager was a Registered Mental Nurse (RMN) and a Registered General Nurse (RGN). He had achieved the Community Psychiatric Nursing Certificate. He had approximately 15 years experience of managing a care home for older people. The manager and his senior staff group appeared to be familiar with the conditions and diseases associated with old age. There were clear lines of accountability in the home and these were illustrated within the Statement of Purpose and Function. Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 21 The home had a quality management system in place. The Responsible Individual confirmed that the reintroduction of an anonymous resident feedback questionnaire, which was supplemented by a visitor’s questionnaire. The home operated to an annual development plan based on a cycle of planning, action and review. The Responsible Individual stated that the home was working towards achieving the Investors In People award. The results of the resident questionnaire were not published within the home’s Statement of Purpose. The Responsible Individual stated that fire drills were up to date however these were not recorded and a requirement has been made. The responsible individual stated that all maintenance and insurance certificates were up to date. The home was in the process of changing the providers of pest control services. The home had a moving and handling policy and all staff received training regarding this aspect of their work. Food hygiene training was ongoing and this was linked into the home’s control of infection policy. Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 2 x x x x 2 x x STAFFING Standard No Score 27 2 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x 2 x x x x 2 Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 19 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. The Responsible Individual must ensure that suitable privacy locks are fitted to bedroom doors. The keys must be made available to the residents subject to the risk management process. The Responsible Individual must ensure that each resident has a lockable space available within his / her private accommodation The manager must ensure that the duty records clearly identify the grade of each staff member and the duty period worked. The Responsible Individual must take immediate measures to ensure that no staff member is permitted to work at the home without, at least, a clear POVA first check conducted via the Criminal Records Bureau (CRB). The Responsible Individual must take immediate measures to ensure that no staff member is appointed to the home without access to appropriate Timescale for action 01/10/05 2. 24 16 01/10/05 3. 24 23 01/10/05 4. 27 17(2) Schedule 4 19 & Schedule 2 01/10/05 5. 29 Immediate 6. 29 19 & Schedule 2 Immediate Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 24 employment references. 7. 38 23 The manager must ensure that fire drills are regularly conducted and recorded. 01/10/05 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. 4. 5. 6. Refer to Standard 11 12 14 28 31 Good Practice Recommendations The policies regarding death and dying should be amended to include reference to the terminal care pathways. Residents should be encouraged to participate in meetings etc where they are able to exert a degree of control regarding the management and conduct of the home. Records should be maintained of the residents contribution to decision making and choice selections. It is recommended that the provider arrange appropriate staff training to ensure that at least 50 of the care staff achieve the NVQ II, or equivalent, by the end of 2005. It is recommended that the home manager completes the Registered Managers Award by the end of 2005. Victoria Nursing Home F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 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 F55 F05 S21660 Victoria Nursing Home V230782 020605 Stage 4.doc Version 1.30 Page 26 - 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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