Inspection on 10/08/06 for Victoria Residential Care Home

This inspection was carried out on 10th August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Victoria Residential Care Home 25/04/07

Victoria Residential Care Home 21/02/06

Victoria Residential Care Home 24/11/05

Victoria Residential Care Home 15/11/04

Victoria Residential Care Home 19/05/04

Victoria Residential Care Home 23/07/02

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

CARE HOMES FOR OLDER PEOPLE Victoria Residential Care Home 166 Church Street Wallasey Wirral CH44 8AL Lead Inspector Andrea Morris Key Unannounced Inspection 10th August 2006 09:30 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 Residential Care Home DS0000018952.V299147.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 Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Residential Care Home Address 166 Church Street Wallasey Wirral CH44 8AL 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) 0151 638 7863 Dr David Charles Downward Sheila Ann Hodgin Care Home 56 Category(ies) of Old age, not falling within any other category registration, with number (56) of places Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2006 Brief Description of the Service: Victoria Care Home is a large, three storey building situated in Wallasey, Wirral. The building was originally the nurses’ home for Victoria Central Hospital. The home provides care for 56 residents. All rooms are comfortably furnished and of single occupancy. There are no en-suite facilities. The home has three large living rooms and two dining rooms, included is a smokers’ lounge. The home is well maintained and in good decorative order. Victoria Care Home has many aids and adaptations to meet the needs of residents and there are two passenger lifts. The home does not have a garden; there is a small car park to the front of the premises. The home has a mini bus, which in fine weather is used for many outings. The home is situated near to local amenities in Liscard, which has a park, shops, pubs and churches. The home is on the bus route to Birkenhead. Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection that was carried out by the inspector and the Commission for Social Care Pharmacist. During the inspection the lead inspector examined care files, staff personnel records and looked at certificates relating to Health and Safety. A tour was made of the home. The inspector spoke with residents, relatives, staff member and the manager. The pharmacy inspector examined the homes medication including the policies that were currently being used. What the service does well: What has improved since the last inspection? Since the last inspection there has been an improvement to the general standard of risk assessments. There is an ongoing re-decoration programme to ensure all areas of the home remain in good condition. Medication management has improved; this must continue to ensure residents’ safety is maintained. Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Victoria Residential Care Home DS0000018952.V299147.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 Residential Care Home DS0000018952.V299147.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): 1, 2, 3, 5, 6 Potential residents are assessed prior to admission, this ensures their care needs can be met. EVIDENCE: There has been no statement of purpose and service user guide since the last inspection. Copies of the documents are available upon request from the manager. All residents upon entering the home are issued with a written contract, this clearly defines the terms and conditions of residency. Either the manager or the deputy manager completes pre-admission assessments for every potential resident. Any resident considering moving into the home is encouraged to visit preadmission. If they choose they can stay for an afternoon or a meal at no additional cost. Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 9 Residents who spoke with the inspector stated they liked living in the home, as they were able to choose what they did, and they found staff friendly and helpful. The home does not provide intermediate care. Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 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, 10, 11 Risk assessments are well recorded and reviewed on a regular basis, however care plans lack detail and do not reflect individual resident needs, thus placing residents at potential risk of harm. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home currently uses pre-populated care plans, these care plans must be personalised to reflect individual needs are being addressed. Care plans are basic and not all residents have care plans to address current issues i.e. one resident is not eating and requires a nutritional care plan to address the care required. All care plans must be reviewed on a monthly basis; this ensures residents are receiving the appropriate care. Risk assessments are formulated to minimise potential risks to residents, these are documented well, and reviewed on a monthly basis. Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 11 The medication held within the home was checked and regulated by the Commission for Social Care Inspection, recommendations have been included in this report to address any needs identified. A number of residents and their relatives spoke with the inspector during the visit, the comments made were positive, one resident stated she had been ‘living in the home for some time and staff were lovely’. Relatives stated they were always made to feel welcome, they stated they were happy with the care their relative received. Residents confirmed that they were able to choose how they spent their day, most residents enjoyed spending time in one of the lounges, some residents on the day of the inspection were sitting at the front of the building chatting. The home has an adequate policy relating to care of the dying, a recommendation has been made that staff receive training in care of the dying. Medication was generally handled well. Records were clear and accurate, however the home must remember to record all medication leaving their custody. Dose changes had been recorded clearly, although on occasions the amendments obscured previous records. Changes should be rewritten and signed by two members of staff to ensure changes are recorded correctly. Medication Administration Record charts should be stored confidentially when not in use to protect residents’ privacy and dignity. Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 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): 12, 13, 14, 15 Activities are varied and provided on a daily basis, this assists residents to lead socially fulfilling lives. EVIDENCE: The home offers a variety of activities on a daily basis. Residents who spoke with the inspector stated that they particularly enjoyed the many outings to places such as Chester, New Brighton and other local areas. The home has its own minibus and its own car, these are used to ensure residents are able to maintain contact with the local community. On the day of the inspection many residents were sat on the front, they were able to chat to local people passing by. The home records all activities undertaken by residents. The home on occasions invites entertainers to the home. The home enjoys visits from the local Roman Catholic Church on a weekly basis. Residents who are of Church of England denomination are assisted to the local church on a weekly basis by other church attendees. Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 13 The home operates an open visiting policy, residents are able to receive their visitors in private. Residents stated that staff respected their privacy. Relatives who were visiting the home also confirmed that the home provided a pleasant and relaxed environment and that made the visiting very pleasant. The menus for the home were viewed, the menus are on a four weekly cycle. Residents confirmed the food was good and they enjoyed the meals. Residents also confirmed that they were able to select an alternative choice from the daily choices if they wished. The daily menu is displayed in the dining room of the home. Any resident who needs to access any special diet is catered for and provided with a varied diet to ensure their dietary needs are met. Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Staff receive training in adult protection, this assists to protect residents from any potential risk of harm or abuse. EVIDENCE: The home has an adequate complaints policy that was last up dated in July 2006. All complaints/concerns received into the home are recorded and action taken to address the issue raised is documented accordingly. There have been no complaints made about the home to the Commission for Social Care Inspection. Residents on entering the home are enrolled on the electoral role; this enables them if they wish to retain their right to vote. Residents can either access the postal voting system, or if they prefer visit the local polling station. The home also displays information on independent advocacy agencies, a member from the Aged Concern visits the home on a monthly basis, this affords residents the opportunity to discuss issues independently if they choose. The homes adult protection policy is adequate; the home also has a copy of the Wirral Adult protection policy. Staff receive training in adult protection training on an annual basis. All staff including the ancillary staff are in receipt of recent training in adult protection. Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 15 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, 21, 22, 23, 24, 25, 26 The home is well maintained and provides an environment that is homely this assists residents with settling into their environment. EVIDENCE: The home is well maintained and regular re-decoration is carried out on all areas of the home. Residents are able to access the outside of the home via use of wellmaintained ramps. The home benefits from wide corridors and large lounges, which are used by the majority of residents. The home has sufficient bathrooms, which are maintained to a high standard. The home has the use of two hoists that staff receive training in to ensure safe handling and moving of residents. Hoists are regularly serviced and certificates were available for inspection. Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 16 All residents have their own rooms. Many rooms were viewed and all found to be decorated to a good standard and personalised with residents own effects. The home during the tour was found to be clean and free from any unpleasant odours. Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 17 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, 30 Staff are well trained in all aspects of care, this assists in providing care appropriate to resident needs, thus promoting safety of residents. EVIDENCE: The rota was checked and found to be staffed appropriately. Staff are currently covering shortfalls from sickness and holidays. The home uses very little agency staff, all agency staff used are checked and information relevant is submitted to the home prior to the staff member commencing shift. 52 care staff have completed their NVQ in care, some staff are due to commence on the programme in September 2006. A selection of staff personnel files were examined and found to be maintained to a reasonable standard, however a requirement has been made to address the two documents missing from the files seen. Staff training files are maintained to an adequate standard. Staff have recently received training in Moving and Handling, Adult protection, Nutrition and Care of Substances Hazardous to Health (COSHH). Further training is planned to be held within the forth coming months includes Food Hygiene, First Aid and Fire safety. Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 18 Staff on commencement of employment are taken through an induction process, this includes working along side an experienced staff member as well as attending specified training. All induction training is recorded on the homes induction record also held in staff personnel files. Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 19 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, 32, 33, 36, 37, 38 The home is managed by an experienced manager, who provides leadership and guidance to staff. This assists in promoting good standards of care. EVIDENCE: An experienced manager who holds the NVQ4 in management manages the home. The manager provides staff with support and guidance to assist in promoting good standards of care. The home provides a pleasant and friendly atmosphere for all residents and visitors. Residents and visitors to the home confirmed they found the staff friendly and very approachable. ‘Staff are willing to assist wherever necessary’. Staff in the home receive regular supervision sessions with their line manager, records are maintained and available for inspection. Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 20 Residents meetings are held on a 6 monthly basis, records are retained in the home with actions that have taken place following the meeting. All residents and their families are given copies of the homes quality questionnaire which are retained and actions that are appropriate taken to address issues raised by residents and their families. The home certificates relating to Health and Safety were found to be in date and all available for inspection. It was noted however, during the tour that fire door wedges had been used to keep fire doors open, these were all removed and destroyed by the manager at the time they were identified. A requirement has been made to ensure this practices does not continue and to ensure residents safety is maintained at all times. The home has reviewed its current policies and procedures in January 2006. Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 21 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 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 N/a N/a 3 3 2 Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15(1) Requirement The registered person shall prepare a written plan as to how the service user’s needs in respect of his health and welfare are to be met. The registered person must ensure that full and accurate records are kept of all medicines received, administered and leaving the care of the home. The registered person shall not employ a person to work at the care home unless he/she has obtained in respect of that person the information and documents specified in paragraphs 1 to 7 of schedule 2. Timescale for action 31/08/06 2. OP9 13(2) Sch 3 (i) 01/09/06 3. OP29 19(1)(b)(i ) 31/08/06 4. OP38 23(40(a) The registered person shall take 20/08/06 adequate precautions against the risk of fire. Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations You should review medication policies and procedures in line with Royal Pharmaceutical Society of Great Britain guidelines to cover all aspects of medicines management. Sticky labels supplied by the pharmacy should not be attached to Medication Administration Record charts. Staff must ensure liquid medications are poured accurately. A second member of staff should witness/countersign all hand written entries on Medication Administration Record charts Verbal dose changes and new medication should be accurately entered onto Medication Administration Record charts with staff signature, date and authority where appropriate. Verbal dose changes should be confirmed in writing by the prescriber Medicines must be stored at the appropriate temperature. A record of temperature must be maintained for all areas where medicines are kept (fridge should be monitored daily) Manufacturers Patient Information Leaflets should be available for medicines in the custody of the home Medication Administration Record charts should be stored confidentially when not in use It is strongly recommended that all care staff receive formal training in care of the dying to promote good standards of care. 1. OP9 2. OP11 Victoria Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Residential Care Home DS0000018952.V299147.R01.S.doc Version 5.2 Page 25 - 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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