Inspection on 17/07/06 for Victoria Park Care Home

This inspection was carried out on 17th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

Other inspections for this house

Victoria Park Care Home 18/06/07

Victoria Park Care Home 06/02/06

Victoria Park Care Home 07/02/05

Victoria Park Care Home 24/05/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Victoria Park Care Home Manners Road Ilkeston Derbyshire DE7 5HB Lead Inspector Janet Morrow Key Unannounced Inspection 17th July 2006 10:15 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 Park Care Home DS0000058110.V303158.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 Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Park Care Home Address Manners Road Ilkeston Derbyshire DE7 5HB 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) 01159 440774 None Southern Cross Care Homes No 2 Limited Mrs Patricia Ann Jopp Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Victoria Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Variation to admit one (named) service user under the age of 65 years in the category PD as named in the notice of proposal letter. One place for named service user under 65 years of age (CB) One named individual (EMT) with dementia - see Notice of Registration. 6th February 2006 Date of last inspection Brief Description of the Service: Victoria Park Care Home overlooks open parkland and is situated close to the town centre of Ilkeston, eight miles from Nottingham and ten miles from Derby. The home is a converted building providing facilities for thirty-nine elderly service users and is registered to admit residents with nursing and personal needs. There is a main day room and lounge area situated on the ground floor. The first floor of the home is served by a passenger lift and there is also staircase access to this floor. There are seventeen single bedrooms (five with en-suite facility) and eleven double bedrooms (none with en-suite facility). Some of these double rooms are being used as single rooms. The scale of fees for 2006 was in the range £360 - £550 per week, and was calculated on whether nursing or residential care was provided. Victoria Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and took place over 6 hours. Care records and staff records were examined. A partial tour of the premises took place. Nine of thirty-two residents currently accommodated and two relatives were spoken with. One visiting professional and one relative were contacted by telephone following the inspection visit. Written information supplied by the home informed the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Victoria Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 Page 6 Further improvements to care planning and medication administration procedures would enhance the care provided and provide greater consistency and minimise risk of errors. Although portable air-conditioning units were authorised during the visit, a long-term solution to high temperatures in the communal areas of the home is required. Temperatures were registered at 32 degrees C (90 degrees F) at the time of the inspection making it very uncomfortable for residents, staff and visitors. 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 Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 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 Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 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): 3 and 4 The admission information available established that the home was able to meet residents’ needs. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Three residents’ records were examined and all showed that assessment information was received from external professionals and the home also conducted their own assessment and background information prior to admission. Relatives and residents interviewed were satisfied with the care received and stated that care needs were met. Victoria Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 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): 7, 8, 9 and 10 Health care needs were generally met but further improvements to care planning and medication procedures would enhance the care provided. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Three care files were examined and all had personalised care plans in place. Residents and relatives had not signed the care plans but the manager stated that the home was in the process of sending out letters to say that access to care files was available and there was a notice on display that stated care information was available on request. Risk assessments for pressure sores, falls and nutrition were available on the files seen and details on how to address the need were recorded. However, greater detail would enhance the care: for example, the manager stated that music to movement was used as a therapy for residents at risk of falling but this was not recorded on the care plan; one resident whose primary needs were related to mental health did not have a specific care plan to address mental health needs although reference to this was made in other care details relating to communication and a safe environment. Victoria Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 Page 10 Access to health facilities such as chiropody, dental and optical services were recorded in the files examined. Routine observations such as weight, blood pressure and temperature were recorded on a monthly basis. Medication administration record (MAR) charts were examined. These showed that the record was being accurately signed and that the dispensing system corresponded with the MAR chart. However, there was one handwritten chart that had not been signed and dated by two people and there was no explanation of what one code (F) actually meant. The medication refrigerator temperatures were recorded on a daily basis and showed that the temperatures were within the safe limits of 2-8 degrees C. Residents’ privacy and dignity was maintained and relatives interviewed described staff as ‘pleasant’. Warm relationships were observed between staff and residents. One relative praised the staff for always ensuring that residents’ dignity was maintained when using the hoist. Victoria Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 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): 12, 13, 14 and 15 Activities, meals, community contacts and the exercise of choice were well managed, which enhanced residents’ daily lives. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Relatives interviewed stated that they were able to visit at any time and were made to feel welcome. The manager had obtained information about an external organisation that provided an advocacy service and had referred individuals to this where appropriate. This helped residents maintain control over their lives. Both residents and their relatives interviewed confirmed that that the routines of the home were flexible and it was observed that residents’ had the choice of staying in their own rooms, going out or participating in activities. An activities co-ordinator was employed by the home for three days per week and arranged various activities such as bingo, manicures and quizzes as well as outings. The manager stated that she was hoping to increase the number of hours available for activities to be able to provide a greater amount of stimulation. Two members of staff had been on training courses for head and hand massage and the manager reported that residents had enjoyed the benefits of this. The serving of the lunchtime meal was observed. Residents spoken with stated that they enjoyed the food and although there was no choice on the menu, Victoria Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 Page 12 individual preferences were taken into account and an alternative supplied for those who did not like what was on offer. Menus were examined and showed that the food was wholesome and nutritious. The kitchen was clean and tidy and food stocks were good. The dining area was hot and most residents were eating meals from over-bed tables by their armchairs. Those residents requiring assistance to eat were helped in a sensitive manner. Victoria Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 Page 13 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): 16 and 18 Complaints were handled objectively and residents were protected by the home’s policies and procedures Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home had a clear complaints procedure, which was on display and stated that complaints would be dealt with in twenty-eight days. The written information provided by the home showed that no complaints had been received in the last twelve months. The complaints record confirmed this. There had also been no complaints received at the office of the Commission for Social Care Inspection. Those residents and relatives spoken with stated that they would go to the manager if they had any concerns and were confident of a courteous response. Staff had undertaken training in adult protection and the manager was booked on a course with the Local Authority in September to be trained in providing adult protection courses for staff at the home. A copy of the Derby and Derbyshire Local Authority Social Services adult protection procedures was available in the home. The written information supplied by the home stated that there had been no allegations of abuse since the last inspection in February 2006. Victoria Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 Page 14 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, 20, 25 and 26 The home was well maintained but high temperatures were a problem, which made the accommodation uncomfortable for residents. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home was clean, tidy and well maintained and was odour free. Bedrooms were individually decorated to a good standard and personalised. Those residents interviewed were pleased with the contents of their rooms, although not all had all the items detailed in Standard 24, such as two comfortable chairs or a table to sit at. There was no written explanation of why these items had not been provided. This was recommended at the previous inspection in February 2006. The laundry had washing machines with sluicing facilities and a sluicing disinfector had been provided. Victoria Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 Page 15 The written information provided by the home stated that infection control training had taken place for staff in December 2005 and a policy on infection control was in place. The major concern with the environment was the excessively high temperatures in the communal areas. Three thermometers were registering temperatures of 32 degrees C (90 degrees F). This was extremely uncomfortable for residents, staff and visitors. Everyone spoken with commented on the heat and said how uncomfortable it was. One visitor had changed their relative’s shirt due to being wet and uncomfortable and had washed them to try and help them cool down. In view of the comments made and observation of the temperatures, the regional manager of the company was contacted and urgent action to remedy the problem was requested. It was confirmed later during the visit that portable air conditioning units for the lounges would be delivered the following day. However, a longer-term solution to prevent recurrence of this problem should be considered as a priority. Victoria Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 Page 16 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, 28, 29 and 30 There were sufficient staff deployed to meet residents’ needs but additional qualifications would enhance the care provided. Recruitment procedures were robust, which ensured that residents were protected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The staff rota for 17th –23rd July 2006 was examined and showed that there was one nurse on each shift plus the manager during the day and six care staff in the mornings and four in the afternoons, sometimes five. The manger stated that there had been no recent problems with covering shifts, although staff interviewed stated that there were occasions at weekends when a shift was short. The written information supplied by the home stated that ten out of twenty care staff had achieved a National Vocational Qualification (NVQ) to level 2 or above, which meant the home was meeting the target of having 50 of care staff qualified to NVQ2. The training information provided by the home stated that mandatory health and safety training had been undertaken as well as courses relevant to the needs of the residents such as palliative care and Indian head massage. Care planning, customer care, dementia care and adult protection courses had taken place or were planned in 2006. Three staff files were examined and showed that all the information required by Schedule 2 of the Care Homes Regulations 2001 was in place including Criminal Record Bureau checks, identity information and health information. The only information missing was one written reference from one file. Victoria Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 Page 17 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, 33, 35, 37 and 38 There was sufficient guidance and direction to staff to ensure that policies and procedures were followed properly, which ensured residents’ safety and that the home was run in their best interests. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The manager was experienced in caring for older people and had been promoted from the post of deputy manager at the home. She had become registered with the Commission for Social Care Inspection in June 2006 and had started the Registered Managers Award training in June 2006. In discussion, she was able to demonstrate that she was familiar with the conditions associated with old age and had plans on how she wanted to develop the home. Quality assurance processes were in place and the company undertook monthly visits to audit the quality of care provided. These reports are forwarded to the Commission for Social Care Inspection. The manager stated Victoria Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 Page 18 that residents meetings and relatives meetings had also occurred. Written comments from two relatives in a survey undertaken in May 2006 were seen and gave positive feedback stating that the home was ‘beautifully clean’ and that residents were ‘always nicely dressed’. However, there was no information available from visiting professionals. This was recommended at the last inspection in February 2006. Two residents’ financial records were examined and were found to be in order. The records corresponded with the cash held and receipts were available for individual purchases. Cash was stored securely. The written information supplied by the home showed that maintenance checks on equipment were up to date. For example, fire extinguishers had bee checked in May 2006, hoists in January 2006 and emergency lighting in February 2006. The information also stated that staff had undertaken training in health and safety areas such as fire safety, infection control, food hygiene and moving and handling in the last twelve months. Those staff interviewed confirmed this. Victoria Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 Page 19 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 3 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X 2 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 X 3 3 Victoria Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement There must be arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Improvements made but previous timescale of 01/05/06 not fully met. Timescale extended. Ventilation, heating and lighting suitable for residents must be provided in all parts of the home that are used by residents. Timescale for action 01/09/06 2. OP25 23 (2) (p) 01/08/06 Victoria Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 Page 21 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 OP24 Good Practice Recommendations Reasons not to provide residents with all the items listed in this standard should be recorded in each individuals file. This is a previous recommendation and had not yet been implemented. Residents’ views of the home should be incorporated into the residents’ guide. This is a previous recommendation and was not assessed on this occasion. The terms and conditions of residence should state which room is to be occupied. This is a previous recommendation and was not assessed on this occasion. Medication administration record (MAR) charts should clearly define what administration codes mean. This is a previous recommendation and had not yet been implemented. Hand written medication administration record (MAR) charts should be signed and dated by two people. This is a previous recommendation and had not yet been implemented. Two written references should be in place on all staff files. This is a previous recommendation and had not yet been implemented. The views of visiting professionals should be sought for quality assurance purposes. This is a previous recommendation and had not yet been implemented. Care plans should contain more specific detail on how care needs are to be met. The high temperatures should be rectified and a long-term solution to excessive heat should be implemented. 2. OP1 3. OP2 4. OP9 5. OP9 6. 7. OP29 OP33 8. 9. OP7 OP25 Victoria Park Care Home DS0000058110.V303158.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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