Inspection on 06/02/06 for Victoria Park Care Home

This inspection was carried out on 6th February 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 17/07/06

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 Unannounced Inspection 6th February 2006 10:30 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.V282103.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Victoria Park Care Home DS0000058110.V282103.R01.S.doc Version 5.1 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 Southern Cross Care Homes No 2 Limited Vacant 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.V282103.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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) Date of last inspection 27th July 2005 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. Victoria Park Care Home DS0000058110.V282103.R01.S.doc Version 5.1 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. Eight of twenty-nine service users and four relatives were spoken with. One visiting professional was contacted by telephone following the inspection visit. Written information supplied by the home prior to the inspection 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.V282103.R01.S.doc Version 5.1 Page 6 Care records need to be more thorough to show that risk assessments are being addressed properly, particularly in relation to falls and pressure sores. There was also no indication that care needs were discussed with residents or that they had access to their files. Medication procedures need reviewing to ensure that all staff are aware of the importance of completing medication administration record (MAR) charts accurately to minimise risk of errors. Staff training in dementia and more National Vocational Qualifications (NVQ) training would enhance the care offered. An application for the manager to be registered should be forwarded to the office of the Commission for Social Care Inspection as soon as possible. This is outstanding from the previous inspection in July 2005. Derby and Derbyshire Local Authority Social Services adult protection procedures should be available in the home to ensure that all staff are fully aware of action to take in the event of any incidents. Quality assurance procedures should be improved by obtaining a wider range of views, for example from visiting professionals. A record of why certain items of furniture are not supplied in bedrooms should be established. This would ensure that all residents had been offered the full range of furniture recommended by the National Minimum Standards. Residents’ views of the home would improve the information in the residents’ guide. 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.V282103.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria Park Care Home DS0000058110.V282103.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4. There was sufficient information available to enable prospective residents’ to make an informed choice about the home. The admission information available established that the home was able to meet residents’ needs. EVIDENCE: The statement of purpose and residents’ guide had been updated and contained comprehensive information for prospective residents. Both met all the legal requirements of the Care Homes Regulations 2001. However the residents guide would be further improved if it contained residents’ views of the home. A sample terms and conditions of residence (contract) was examined. This contained all the information required with the exception of the room to be occupied. 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. Victoria Park Care Home DS0000058110.V282103.R01.S.doc Version 5.1 Page 9 Relatives interviewed were satisfied with the care received and stated that care needs were met. A visiting professional contacted by telephone following the inspection stated that the home had worked hard to ensure that specialist needs were met and that they had a good grasp of individual care needs. Victoria Park Care Home DS0000058110.V282103.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9 and 11 Health care needs were generally met but inconsistencies in care planning and medication procedures could potentially put residents at risk. EVIDENCE: The three care files examined all had personalised care plans in place. However, there was no care plan or risk assessment on one file where a risk of pressure sores had been identified on admission information and another had no comprehensive information on how to address a high risk of falling. This was raised as an issue at the previous inspection in July 2005. 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 regular basis, although one file seen did not have this fully completed on a regular basis. Care was reviewed on a monthly basis. None of the files examined had any evidence, such as a signature, to show that care had been discussed with the resident or their relative. Victoria Park Care Home DS0000058110.V282103.R01.S.doc Version 5.1 Page 11 Medication procedures and medication administration record (MAR) charts for three residents were examined. There were several omissions on the charts such as missing signatures where a medicine had been administered, no identification of why a medicine had not been administered and no explanation of a code that was regularly used. Some medicines, such as Lactulose and Paracetamol suspension were being dispensed from one container for several residents. Hand written medication administration record (MAR) charts had not been signed and dated by two people. One MAR chart examined had different details to those on the container. There were written agreements in place for those residents who wished to administer their own medication. The medication refrigerator temperatures were recorded on a daily basis and showed that the temperatures were above the safe limits of 2-8 degrees C, having been frequently recorded as 10 degrees. There were also opened eye drops still in storage that had passed the expiry date. There were no controlled drugs on the premises with the exception of Temazepam, which was stored under controlled conditions. The written record corresponded with the amount of medicines being stored. Disposal of medicines had been amended following the introduction of new guidelines and a waste disposal company now removed medicines from the home. The policy on death and dying was examined and found to have all the relevant details on how to care for the dying and how to deal with a death. The manager was able to demonstrate in discussion that she and nursing staff had the skills to care for the dying and knew how to obtain specialist help if required. One member of the nursing team had undertaken palliative care training. Victoria Park Care Home DS0000058110.V282103.R01.S.doc Version 5.1 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 the following standard(s): 13 and 14 Contacts with the local community were maintained, which enhanced residents’ daily life. Advocacy services were not well used and access to files was not established which had the potential to limit residents’ control over their own lives. EVIDENCE: Relatives interviewed stated that they were able to visit at any time and were made to feel welcome. The written information in the home’s statement of purpose and residents’ guide also confirmed that visits could take place at any time. The manager stated that no one had an advocate and she was unsure of where to obtain one from, apart from using a solicitor. There was no information seen in the home that detailed how to obtain an advocate. There was also no evidence, such as a written agreement, to suggest that residents’ were aware of their care records or that they could access them. Victoria Park Care Home DS0000058110.V282103.R01.S.doc Version 5.1 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, although further information would improve this. 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 one complaint had been received in the last twelve months. The response to it was examined and showed that a comprehensive investigation had taken place and that the complaint had been dealt with objectively. The home had an adult protection policy in place and records showed that staff had undertaken training in adult protection in January 2006. However, the home did not have a copy of Derby and Derbyshire Local Authority Social Services adult protection procedures although it had the document on how to refer to the Protection of Vulnerable Adults list. The written information supplied by the home stated that there had been no incidents requiring an adult protection investigation. Victoria Park Care Home DS0000058110.V282103.R01.S.doc Version 5.1 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, 24 and 26 The home provided clean and comfortable accommodation for residents to enjoy. EVIDENCE: The home was clean, tidy and well maintained. 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. Odour in one bedroom had been eliminated and the home was odour free. One relative interviewed commented on the lack of odour in the home and stated that this had assisted them to make a positive choice about the home. Victoria Park Care Home DS0000058110.V282103.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 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. EVIDENCE: The written information supplied by the home included staff rotas for the period 16th January 2006 – 19th February 2006. These showed that there was one trained nurse on duty for the day shift from 8am-8pm and five care staff in the mornings until 2pm and four in the afternoons until 8pm. This was sufficient to meet residents’ needs. The written information supplied by the home stated that four out of twenty care staff had achieved a National Vocational Qualifications (NVQ) to level 2 or above. However, this did not meet 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 and adult protection courses were planned for 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. Victoria Park Care Home DS0000058110.V282103.R01.S.doc Version 5.1 Page 16 The only information missing was two written references from two of the files, where both staff had been employed for a long time prior to the requirement for written references to be available. However, it was recommended that a statement from the current employer or a character reference be obtained to ensure legal requirements were fully met. Victoria Park Care Home DS0000058110.V282103.R01.S.doc Version 5.1 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, 36, 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. Records were generally accurate and up to date but some aspects needed improvement to ensure safeguarding of residents’ rights. EVIDENCE: The manager was experienced in caring for older people and had been promoted from the post of deputy manager at the home. However, she was not yet registered with the Commission for Social Care Inspection. This was raised as an issue at the previous inspection in July 2005. In discussions, 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. Victoria Park Care Home DS0000058110.V282103.R01.S.doc Version 5.1 Page 18 The statement of purpose identified the owners’ quality assurance process. This stated that monthly visits would be undertaken by representatives of the company and an audit of the facilities would be undertaken at least six monthly. The manager stated that residents meetings and relatives meetings had also occurred. The gathering of information was informal through ‘thank you’ letters and verbal comments. Written comments seen stated that the home provided ‘loving care’. However, there was no information available from questionnaires or from visiting professionals. Three 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. Staff were supervised approximately two monthly and records of supervision were kept. Not all the information required by Schedules 2, 3 and 4 of the Care Homes Regulations 2001 was in place. For example, some health information was missing from residents’ files and staff files. This was raised as an issue at the previous inspection in July 2004. A valid insurance certificate and registration certificate were available. The written information supplied by the home showed that maintenance checks on equipment such as fire extinguishers, hoists and emergency lighting were up to date. 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. The manager stated that first aid was a priority for the next few months. Victoria Park Care Home DS0000058110.V282103.R01.S.doc Version 5.1 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 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 2 3 Victoria Park Care Home DS0000058110.V282103.R01.S.doc Version 5.1 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 OP7 Regulation 15 (1) Requirement A written plan must be prepared as to how the service users needs in respect of health and welfare are to be met. Previous timescale of 1.11.05 not met. Where the registered provider apoints a person to manage the care home he shall give notice to Commission. Previous timescale of 1.10.05 not met. A record of documents and information specified in Schedules 1 - 4 of Care Homes Regualtions 2001 must be maintained. Previous timescale of 1.11.05 not met. The registered person must consult with the resident when preparing a written care plan. There must be arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person must make the residents’ care records DS0000058110.V282103.R01.S.doc Timescale for action 01/04/06 2 OP31 8 (2) 01/04/06 3 OP37 17 (1), (2) & (3) 01/04/06 4 5 OP7 OP9 15 (1) & 12 (2) 13 (2) 01/06/06 01/05/06 6 OP14 15 (2) 01/06/06 Victoria Park Care Home Version 5.1 Page 21 available to them. 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 7 8 9 10 11 12 13 14 15 16 17 Refer to Standard OP7 OP24 OP31 OP37 OP1 OP2 OP8 OP9 OP9 OP9 OP9 OP9 OP9 OP9 OP9 OP14 OP18 Good Practice Recommendations Each need identified in assessment information should have a care plan. Reasons not to provide service users with all the items listed in this standard should be recorded in each individuals file The manager should make an application to register with the Commission. Service users records must contain all the information as detailed in Schedule 3. Residents’ views of the home should be incorporated into the residents’ guide. The terms and conditions of residence should state which room is to be occupied. All routine observations such as blood pressure and temperature should be recorded regularly. Medication administration record (MAR) charts should clearly define what administration codes mean. Reasons for not giving a medication should always be recorded. All medication administration record (MAR) charts should be accurately signed. Hand written medication administration record (MAR) charts should be signed and dated by two people. All medicines should be administered only from a container clearly labelled with the residents’ name. All medication administration record (MAR) charts and dispensing information should correspond accurately. The medication refrigerator temperature should always be within 2-8 degrees C. Eye preparations should be discarded within their expiry date. The manager should make information available on how to contact advocacy services. The home should obtain a copy of Derby and Derbyshire DS0000058110.V282103.R01.S.doc Version 5.1 Page 22 Victoria Park Care Home 18 19 20 21 OP28 OP29 OP30 OP33 Local Authority Social Services adult protection procedures. 50 of care staff should be qualified to National Vocational Qualifications (NVQ) Level 2. Two written references should be in place on all staff files. Staff should receive training in caring for people with dementia The views of visiting professionals should be sought for quality assurance purposes. Victoria Park Care Home DS0000058110.V282103.R01.S.doc Version 5.1 Page 23 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. Extracts may not be used or reproduced without the express permission of CSCI Victoria Park Care Home DS0000058110.V282103.R01.S.doc Version 5.1 Page 24 - 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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