CARE HOMES FOR OLDER PEOPLE
Victoria Nursing Home 9 Anson Road Victoria Park Manchester M14 5BY Lead Inspector
Val Bell Unannounced Inspection 27 June, 10 and 13 July 2007 10:00 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.V337656.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 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 DE Dementia (21) registration, with number MD Mental Disorder (21) of places Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following categories of service only. Care home with Nursing - code N, to people of the following gender:Either. Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE Mental disorder, excluding learning disability or dementia - Code MD The maximum number of people who can be accommodated is: 21 Date of last inspection 5th February 2007 Brief Description of the Service: Victoria Nursing Home was 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 is 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 is 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. 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. There is no set fee charged for admission to this home as each care package is individually priced according to the person’s assessed needs. However, the minimum amount charged currently is £600 per week. Additional charges are made for hairdressing, newspapers and clothes. Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 5th February 2007 and supporting information in the form of a self-assessment provided by the manager prior to a visit to the home. The February inspection was undertaken to monitor serious concerns relating to medication administration and health and safety that were identified in an earlier inspection on 6th December 2006. Action had been taken to address the serious concerns and significant improvements had been made to the quality of the service provided. This inspection has focussed on identifying whether those improvements have been maintained. Site visits to the home form part of the overall inspection process and the lead inspector conducted three visits on 27th June and 10th and 13th July 2007. The opportunity was taken to look at the core standards of the National Minimum Standards (NMS). This inspection will also be used to decide how often the home needs to be visited to make sure that the required standards are being met. During the visits time was spent with people living in the home and discussions were held with three members of support staff, two nurses, the registered manager and the administration and training manager. Relevant documents, systems and procedures were assessed and a tour of the home was undertaken. Ten satisfaction surveys were completed and returned to the Commission by people living in the home and their relatives. What the service does well:
Robust assessment and admission procedures ensure that people referred to the home have the right information to make a decision on whether the home will be the right place for them to live. The home provides a person-centred service that respects the different needs and aspirations of each individual living in the home. Staff work very hard to make sure that people continue to lead the lifestyle of their choice and staff are deployed to ensure that people get the right amount of support when they need it. People are encouraged and supported to participate regularly in community life by spending quality time on trips out of the home with the key person responsible for co-ordinating their care. The following comment was taken from a satisfaction survey completed by a relative, “My uncle is limited to what he can take part in so arrangements have been made for him to go to Old Trafford cricket ground with a carer as a special treat, which is wonderful for him. He has also been brought to my house in a taxi with a carer and enjoyed meals here.” This is one of many examples of the positive comments made about this service and it provides
Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 Page 6 evidence of good communication and support for people to maintain family contact. This was commended as an area of best practice. Robust policies and procedures for investigating complaints, safeguarding vulnerable adults and health and safety compliance ensure that the welfare and safety of people living in the home is protected. Good relationships have been developed with external health and social care professionals and this enables the people accommodated to have timely access to health and social care services when needed. The following two comments were taken from satisfaction surveys, “I find that the staff at the home are very considerate and helpful. My mother has settled in here very well. I have always been informed re my mother’s state of health and if necessary have been contacted by telephone or by email” and “Any changes in medication are discussed with me as well as any change in condition or behaviour. I attend appointments with my uncle when he sees his psychiatrist. The home always sends a member of staff with us. He receives all the medical care required for all his needs. I am able to trust 100 that my uncle has the best care possible at this home.” What has improved since the last inspection? What they could do better:
Three requirements and three good practice recommendations were made during this inspection. Since the previous inspection the home’s registration category had been reviewed following an application made by the home to admit a person under the age of 65. Consequently, the home must review and update the Statement of Purpose to reflect the current registration category. This will ensure that people referred to the home for admission have accurate and up to date information. It was pleasing that the improvements identified at the February inspection had been maintained in relation to the administration of medication. However, it was identified at this inspection that nursing staff administering medication were not following good practice guidelines in the way medication should be administered. There was no evidence to suggest that the procedure being used to dispense, administer and record medication had adverse effects for people living in the home, although there was the potential for errors that could place people at risk. A new medication system is being introduced at the
Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 Page 7 end of July 2007 so the registered manager was required to review the administration procedures in compliance with current good practice. The third requirement relates to the supervision of staff. The manager said that supervisions were informal and no records had been kept of those sessions. It is important that the manager is able to provide written evidence of the support given to the staff team in terms of monitoring their performance and how their identified development needs are to be addressed. It is also important that staff have dedicated time with their lines managers to express their views and have them recorded. The three good practice recommendations related to the following. Care plans were very detailed and described the outcomes for people receiving care and support. One minor shortfall was noted in that a care plan had not been updated with current information relating to the use of a pressure mattress. Secondly, assessment documentation should be reviewed and updated to reflect when decisions will need to be taken on behalf of people in line with the requirements of the Mental Capacity Act. The third recommendation relates to the seating arrangements in the homes communal areas. Chairs in the lounges were positioned against walls and this gave these areas an institutional atmosphere. The manager said that group seating had been tried on several occasions, but people living in the home consistently moved the chairs back to their original positions. Residents and their relatives should be consulted about the seating arrangements in the lounge areas and their views on the current situation and whether this could be improved should be recorded. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Victoria Nursing Home DS0000021660.V337656.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 Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People admitted to the home can be confident that their needs will be thoroughly assessed and that their wishes and personal preferences will be respected. EVIDENCE: An application to vary the home’s registration category had recently been approved. Consequently, the Statement of Purpose must be reviewed and updated to reflect the current registration and a copy of the revised document must be forwarded to the Commission. The information files belonging to three people living in the home were examined. These contained comprehensive assessments of need that had been subject to regular review and updating. Risks identified during the assessment process had been considered and plans implemented to manage the risks safely. Social needs assessments and personal life histories had been
Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 Page 10 undertaken by the activities co-ordinator. By learning about each person’s life experiences staff were able to understand their diverse needs and this facilitated meeting each individual’s social needs in a person-centred way. This was identified as an area of good practice. The manager had been trained and was aware of his responsibilities in relation to the recent implementation of the first part of The Mental Capacity Act, which legislates on decision-making for people who may lack capacity. Nursing staff had been booked on future courses and their learning would be rolled out to other staff working in the home. A monitoring system would be in place to ensure compliance with the legislation. A good practice recommendation was made to consider the capacity that people have during the needs assessment process and for this information to be recorded in detail. The home did not offer an intermediate care service. Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home have their personal and healthcare needs consistently met in a private and dignified way. EVIDENCE: Nursing, personal care and social care plans had been drawn up from assessments of needs in consultation with individuals’ living in the home. Three care plans were examined during the inspection. Nursing care plans contained comprehensive information that was up to date and the records provided evidence of good follow up after attending health appointments. Similarly, good records were held of the personal care that people had received. Moving and handling risk assessments were very detailed and nutritional screening, including monthly weight monitoring was in place. Daily records detailed individuals’ mood and wellbeing and paid attention to ensuring that care was provided in a dignified and private way. Records also provided evidence that people are encouraged and supported to make choices that affect their activities of daily living. Careful consideration had also been given
Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 Page 12 to individuals’ mental wellbeing. One of the care plans contained specific instructions on the person’s mood and behaviour patterns and how staff should recognise triggers and manage the behaviours. Records provided evidence of good responses to health concerns with timely referrals and regular check-ups arranged with primary healthcare professionals. From concerns raised by staff about a person’s skin integrity he was quickly referred to the tissue viability nurse and was provided with a pressure-relieving mattress. A minor shortfall was noted in that the care plan had not been updated to reflect this. The following comments were taken from completed satisfaction surveys that were returned to the Commission. “I find that the staff at the home are very considerate and helpful. My mother has settled in here very well. I have always been informed re my mother’s state of health and if necessary have been contacted by telephone or by email” “Any changes in medication are discussed with me as well as any change in condition or behaviour. I attend appointments with my uncle when he sees his psychiatrist. The home always sends a member of staff with us. He receives all the medical care required for all his needs. I am able to trust 100 that my uncle has the best care possible at this home.” Medication records were examined and found to be accurate and up to date and a full audit trail was in place. The stock of four medicines was checked against the medication administration records and the balances were accurate. Medication was stored securely in a locked cabinet in the clinic room. The manager said that the medication system was being changed to the Boots blister system at the end of July. On the first day of inspection the nurse-incharge was observed to dispense and administer the lunchtime medication from unnamed containers. Once the medication had been administered the nurse returned to the clinic room to sign the medication administration records. The nurse was asked about this and he confirmed that administering medication in this way was not good practice as medication should be dispensed individually and signed for at the point of administration. At a later visit the manager confirmed that this system had become custom and practice as the logistics of administering it individually were difficult due to the layout of the home and the specific needs of the people living there. There was no evidence that people had suffered ill effects but there is a potential for risk of harm in using this system. The manager must discuss this with the new pharmacist and agree how medication will be administered in line with good practice guidance. Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home are respected as individuals with diverse needs. They are supported and encouraged to maintain a community presence, personal relationships and engage in activities that provide stimulation and interest. EVIDENCE: There was evidence in the records to demonstrate that people living in this home are respected for their diverse needs, such as religion, ethnicity, culture etc. The activity co-ordinator was an arts graduate and had also completed a creative therapy course. She had carefully researched each person’s background to find out what their preferred lifestyle was and then formulated social care plans, with their full participation by asking them how they would like to spend their leisure time and their preferred way of achieving their goals. This is a person-centred approach and is commended. Daily records detailed the social and leisure activities of interest that people engaged in on a regular basis. These records were outcome focussed and attention had been paid to recording individuals’ personal experiences of
Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 Page 14 activities and family visits. Staff rotas had been organised to ensure that sufficient staff were available to manage planned activities. People were respected for their individuality and it was evident that numerous opportunities had been provided for people to enjoy one-to-one activities with staff. One person commented, “I enjoy going out for walks, visits to the pub and cafes with a member of staff. It’s good to get out and I enjoy the conversations that we have.” A relative made the following comment in a satisfaction survey returned to the Commission, “My uncle is limited to what he can take part in so arrangements have been made for him to go to Old Trafford cricket ground with a carer as a special treat, which is wonderful for him. He has also been brought to my house in a taxi with a carer and enjoyed meals here.” Two people living in the home made the following comments, “I enjoy listening to music in my room and I have a CD player and TV for my personal use. I go with staff on trips and for walks in the park,” and “Staff take me out for short trips to the park and the pub.” Staff work hard to promote and maintain contact between the people living in the home and their families and friends. A relative commented, “I visit my uncle at all different times of the day and night and I have observed all that goes on in this establishment. The carers are the best you could get. They are exceptional.” This is evidence of best practice in person-centred care and is commended. The home employs two chefs to cater for the dietary needs of people living in the home. Both chefs had current food hygiene certificates. A member of the management team had achieved a National Vocational Qualification at level 3 in Implementing Food Safety Management Procedures from the Chartered Institute of Environmental Health. The food safety management procedures (Hazard Analysis Critical Control Points (HACCP)) that control the risks to food safety were implemented in the home in March 2007. Nutritional needs had been carefully assessed and this information had been passed onto the kitchen staff who were able to cater for special needs such as diabetic, soft and cultural diets. A set menu was in place and this provided variety and healthy options. People were afforded choice at mealtimes and where options had been chosen this was consistently recorded. The following are comments relating to the quality of catering made by people completing satisfaction surveys returned to the Commission. “My mother enjoys the food served and very rarely leaves something on her plate.” “I like the dinners here. The dinners are nice. I like sweet food and staff will take me to the shops to buy chocolates and cakes of my choice.” Three people living in the home also said that they enjoyed the meals and could choose something different to that on the menu. Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust policies and procedures for managing complaints and safeguarding people from harm, respect the rights of individuals’ to live in a safe environment. EVIDENCE: The home had a complaints policy and procedures for investigating and managing complaints. The procedure had been provided to people referred to the home and was displayed on a wall in the office. No complaints had been received in the previous twelve months. The following two comments were taken from satisfaction surveys that were returned to the Commission. “I’ve never had to complain. I would talk to the boss” and “I am able to approach management at any time if there are concerns regarding any issue with my uncle.” Manchester local authority’s policy and procedures for safeguarding adults from abuse had been adopted in the home and staff received induction and refresher training on abuse awareness and the procedures to follow if abuse was alleged or suspected. The manager said that an incident some time ago when an agency worker was observed to have struck a resident was reported correctly by one of the nurses and the correct safeguarding procedures were followed. This provided evidence that staff understand how to protect the welfare and safety people living in the home.
Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although the manager acknowledges that improvements are needed to the interior of the home, people are afforded a comfortable, clean and safe living environment. EVIDENCE: The manager had been successful in his bid to secure a ‘Dignity and Care Grant’ and planned to use the capital to upgrade the bathrooms and convert one of them into a wet room. This will afford people more choice in the way their personal hygiene needs are met. Due to the special needs of the people accommodated the homes interior suffers from constant wear and tear. The manager stated that he would like to speed up the refurbishment programme but there are several barriers to this happening. The consequences of the behaviour of some people living in the
Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 Page 17 home, are that monies intended for renewal and refurbishment are constantly being diverted to repairs. Exacerbating this situation is the fact that the home’s local authority has capped funding in this financial year. Additionally, the manager said that they often carry vacancies for up to three months while commissioning partners decide who will take responsibility to fund a person’s care. However, it was evident from records and a tour of the home that no compromises had been made in the area of health and safety and the home received a commendation from Greater Manchester Fire Service for good practice in the area of fire safety. The standard of re-decoration and refurbishment will be closely monitored at future inspection. It was pleasing to see that people living in the home had been encouraged to personalise their bedrooms to reflect their personal taste and interests. Comments from three of the satisfaction surveys completed were, “My room is cleaned each day. I enjoy chatting to the cleaners” and included in surveys completed by two relatives “The home is usually fresh and clean. It could do with modernising” and “My uncle has lived in the home for almost eighteen months and he is very comfortable and settled there.” Several rooms had been re-decorated and had new flooring installed during the previous twelve months and the dining-room furniture had been replaced. Re-decoration is planned for a further five rooms with new flooring to be installed in two bedrooms over the next twelve months. The manager was asked if he had considered re-arranging the seating in the lounge areas as chairs were lined up around the walls, which gave these rooms an institutional atmosphere. The manager explained that they had previously tried on several occasions to re-arrange seating into small groups. However, people living in the home constantly moved the chairs back to their original positions. A good practice recommendation was made to consult residents and their relatives about this and to record their views on the current situation and whether this could be improved. Laundry facilities were sited in the basement and were suitable to meet the assessed needs of people accommodated. The home’s policy and procedures for preventing infection had been developed from guidelines issued by Manchester Primary Care Trust. Staff had been trained in infection control procedures. Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A skilled and experienced team of staff meet the personal care, social and healthcare needs of people living in the home. EVIDENCE: Sufficient staff had been deployed to meet the assessed needs of people accommodated on the three days of this inspection. The home employs an experienced and qualified administration and training manager, qualified nursing staff, mental health support workers and ancillary staff. The home has exceeded its target with 57 of support staff qualified at National Vocational (NVQ) level 2 or above in care and a further 21 were currently working towards this qualification. However, the manager felt that much of the content of the NVQ programme was irrelevant for support staff working in the nursing home environment. He was looking into an alternative qualification with a focus on mental health for support workers. The personnel files belonging to newly recruited members of staff were examined. The files were in good order and contained evidence that the required pre-employment checks were being undertaken prior to confirming people in post. On appointment, new staff undertake a basic induction programme in line with ‘Skills for Care’ guidance and are supernumerary
Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 Page 19 during their first two weeks. During this time their performance is appraised from a task analysis perspective and this identifies the skills that they need to develop. Their competency is assessed between four to six weeks after appointment and if satisfactory their appointments are confirmed as permanent. The manager intends to implement the new ‘Vetting and Barring Scheme’ due to come into force in Autumn 2008. All staff have access to a variety of training provided by the home and evidence was provided of the training undertaken in the previous twelve months. Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of people living in the home are listened to and action is taken to monitor and review the quality of service provision so that improvements can be made in their best interests. EVIDENCE: The registered manager had 34 years experience in caring for older people with mental ill health and 17 years experience of home management. However, his nursing registrations were no longer current and he did not have a suitable management qualification. It was recommended at the previous inspection that he undertake study to achieve the Registered Managers Award. The manager had taken the decision for the deputy manager to apply for registration as the manager and the application was pending at the time of
Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 Page 21 writing this report. The deputy manager is a Registered Mental Nurse with 20 years nursing experience and has successfully achieved the Registered Managers Award. People admitted to the home are surveyed to ensure that they have enough information to make an informed choice about whether the home would be the right place for them to live. Three months after admission these people are surveyed again to find out if they are satisfied with the service they receive. The inspector was told that the manager intends to implement the ‘Blue Cross Mark of Excellence Quality Assurance’ system when the new version is complete. This will ensure that a comprehensive quality monitoring system is in place to identify where improvements can be made in the best interests of people using the service. The financial affairs of people living in the home were either managed by the local authority or their individual families. The manager stated that staff supervision was informal and not recorded. The manager is required to provide evidence that staff working in the home are supervised appropriately and that detailed records are held to demonstrate that their performance is being monitored and their development needs are addressed. Policies and procedures have been subject to annual reviews and updated to comply with current legislation and good practice guidance. Policies and procedures to that protect the health and safety of people living and working in the home had been adhered to and an independent practitioner had conducted annual health and safety audits. Staff had received induction and refresher training in mandatory areas of health and safety. A sample of records was examined, including fire safety checks, water testing, electrical equipment checks and hoist maintenance and these were found to be up to date. However, it was identified that the home had not been issued with a Landlord’s Gas Safety Certificate, although gas equipment had been serviced regularly. Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 3 3 Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement The Statement of Purpose must be reviewed and updated to reflect the recent variation in the homes registration category. This will ensure that people referred for admission to the home are provided with accurate and up to date information. A copy of this amended document must be forwarded to the Commission. The manager must review the system of medication administration in use and take action to ensure that a safe system is implemented in line with good practice guidance. Staff working in the home must be supervised regularly and a written record held of the supervision meeting. Qualified nursing staff must receive clinical supervision. This will ensure that staff performance is formally monitored in the best interests of people accommodated. Timescale for action 13/08/07 2. OP9 13(2) 13/08/07 3. OP36 18 (2) 13/10/07 Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 Page 24 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 OP3 Good Practice Recommendations The manager should review the needs assessment documentation to include consideration of the capacity that people have and this information should be recorded in detail. The care plan identified during the inspection should be updated to include the intervention and equipment used for the prevention of pressure sores. Residents and their relatives should be consulted about the seating arrangements in the lounge areas and their views on the current situation and whether this could be improved should be recorded. 2. OP8 3. OP20 Victoria Nursing Home DS0000021660.V337656.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Old Trafford M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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