Inspection on 10/01/07 for Victoria Residential Care Home

This inspection was carried out on 10th January 2007.

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 05/03/06

Victoria Residential Care Home 02/11/05

Victoria Residential Care Home 18/01/05

Victoria Residential Care Home 13/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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 295 Washway Road Sale Manchester M33 4EE Lead Inspector Sue Jennings Key Unannounced Inspection 10:00 10th January 2007 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 DS0000005634.V301972.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 DS0000005634.V301972.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Residential Care Home Address 295 Washway Road Sale Manchester M33 4EE 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 973 1175 0161 973 6489 Trinity Merchants Limited Ms Eileen Margaret Hamlett Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Victoria Residential Care Home DS0000005634.V301972.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All service users fall within the category of old age but may in addition have a physical disability. Within the overall numbers a maximum of 8 service users within the category of dementia over 60 years of age (DE(E) or DE) may be accommodated. 5th March 2006 Date of last inspection Brief Description of the Service: Victoria is a residential care home that is registered to provide care for up to 17 residents whose primary care needs are due their old age. Victoria is one of three care homes owned by Trinity Merchants Limited. Ms Eileen Hamlett is the registered manager at the home. The home is situated in the Sale area of Manchester and is within easy reach of local shops, public transport and the motorway network. Victoria is a large two storey detached property that is set in pleasant grounds. Accommodation comprises of fifteen single bedrooms, four of which offer ensuite facilities, and one double room. The home has two assisted bathrooms and a stair lift to help residents to bedrooms on the first floor. There are two large lounges and a separate dining room. There are gardens to the rear and front of the property with car parking to the front of the home. The home operates a non-smoking policy. Victoria Residential Care Home DS0000005634.V301972.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by the Commission for Social Care Inspection in relation to this home prior to the site visit. The visit was unannounced and took place over the course of 4 hours on Wednesday 10th January 2007. During the course of the site visit time was spent talking to the senior care assistant in charge of the shift, 4 residents and 3 members of staff to find out their views of the home. The manager was spoken to during a follow up visit to the home. As key standard 35 had not been assessed at the previous two inspections a further visit to the home was carried out on Thursday 18th January 2007 when the manager was present. During this visit the management of resident’s finances within the home was examined. The inspector spent time examining records and the residents and staff files. A tour of the building was also made. The requirements from the previous inspection had been addressed and there was evidence that the home was continuing to work hard to develop the service. During this inspection the key National Minimum Standards were assessed. Fess for accommodation range from £410.00 to £450.00 per week. What the service does well: The home had a comfortable and homely atmosphere. The home carries out an assessment of need on all prospective residents before an offer of a place is confirmed. Residents are able to attend religious services either in the local community or a minister of their chosen faith can visit them in the home if preferred. There is an ongoing training and development programme for staff. There is an activity programme in place with dedicated staff. Victoria Residential Care Home DS0000005634.V301972.R01.S.doc Version 5.2 Page 6 The home has a complaint procedure and information about how to make a complaint is included in the home’s statement of purpose and function. Staff are aware of the local Adult Protection procedures. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Victoria Residential Care Home DS0000005634.V301972.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 DS0000005634.V301972.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 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home undertakes an assessment of prospective residents care needs prior to their admission. Information is available to help people make a decision about moving in. EVIDENCE: The home has a Statement of Purpose and a Service User Guide that provides sufficient information for people to make an informed choice about moving in. Five of the resident’s files were examined. For residents placed by local authorities, copies of the social worker’s assessment of needs were kept on that individual’s file. Assessments were obtained from health professionals if they had been involved in the admission and no service users were admitted to the home without their care needs having been assessed. Victoria Residential Care Home DS0000005634.V301972.R01.S.doc Version 5.2 Page 9 The home carried out a pre and post admission assessment and a care plan was formulated during this time. The registered manager was in the process of reviewing admission and care planning documentation and developing a more detailed assessment document. Residents told the inspector that they were quite satisfied with the care they received in the home. The home does not provide intermediate care. Victoria Residential Care Home DS0000005634.V301972.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of the residents were being met at the home. EVIDENCE: A sample of care plans was examined and contained details about the individuals needs and gave staff instructions about how to meet needs. The home used the good practice of recording residents’ personal preferences and numbering each aspect of the care plan for ease of reference. All residents were registered with a local GP. Care plans gave clear records of the visits of health care professionals. Risk assessments were on file. Daily records were kept in the care plans. These gave details of the care delivered in line with the information recorded in the care plans. Victoria Residential Care Home DS0000005634.V301972.R01.S.doc Version 5.2 Page 11 Care plans and risk assessments were being reviewed on a regular basis, however it was recommended that review sheets be amended to clearly identify changes. Review sheets examined appeared to contain information that should have been recorded in the daily record. A number of residents spoken to said that staff treated them with respect and that when being given personal care dignity was maintained. One resident said, “The girls are lovely”. Some of the residents were unable to comment on the quality of care provided due to levels of dementia and short-term memory loss. Therefore care staff were observed during the site visit and found to be respectful, sensitive and caring. One resident was cared for in bed, the senior care in charge stated that quarterly reviews were carried out by district nurses for this resident to ensure that the home continues to meet their needs. It was recommended that comprehensive records be kept on the care plan to record these reviews and to identify any change in needs. The resident looked very comfortable and well cared for. Specialist equipment was in place to meet the needs of residents. The medication trolley was securely anchored to the wall in the lounge. Medication is dispensed in a monitored dosage system (NOMAD). Sample signatures and initials of staff administering medication were held. Medication Administration records were up to date with no gaps in recording. Where medication had not been administered the reason was recorded. Medication was signed for on receipt into the home and the amount received recorded, providing a clear audit trail for the safe handling of medication. Victoria Residential Care Home DS0000005634.V301972.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were able to maintain contact with family and friends and were able to exercise choice and control over their lives. Meals served at the home appeared to be nutritious, well balanced and offered a healthy and varied diet for residents. EVIDENCE: The home has an open visiting policy and residents confirmed that the home welcomed visitors. Staff were observed to sit and talk to residents and the atmosphere in the home was relaxed and friendly and staff were observed to listen to residents questions and to take time to respond appropriately. There were no residents from minority ethnic groups accommodated at the time of the site visit however the staff demonstrated a good understanding of equality and diversity and detailed how they meet religious and cultural needs. Ministers of various faiths visited the home and one resident was able to go to church. Victoria Residential Care Home DS0000005634.V301972.R01.S.doc Version 5.2 Page 13 The home offered a range of activities to service users, which included weekly craft classes and weekly visits by a physiotherapist who provided armchair exercises. The hairdresser was at the home on the day of the site visit. One resident spoken to said, “I have my own telephone so that I can keep in touch with my family, my daughter pays for it”, “I go out at least once a week”. It was noted that two residents had a telephone fitted in their bedrooms. The residents are offered three meals a day, which are taken within normal times across the day. Hot and cold drinks and biscuits are offered throughout the day and supper is provided during the evening. Menus seen in the home appeared to offer a varied diet and a choice was offered. The meal on the day of the site visit was Chicken drumsticks chips and mixed vegetables, the alternative was ham salad. The sweet was rice pudding. The meal was well presented and looked appetising and residents spoken to said it was very tasty. Residents spoken to said the “meals are lovely” and “there is always plenty to eat here”. Victoria Residential Care Home DS0000005634.V301972.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a complaints procedure and the home’s policies and procedures served to protect the residents from abuse. There is an ongoing programme of staff training. EVIDENCE: The homes complaints procedure was displayed in the entrance hall. This contained the time limits for making a complaint. There had been no complaints since the last inspection. Residents spoken to said that they ”would speak to one of the girls” if they needed to and felt confident that the problem would be resolved in a satisfactory manner. The home had a policy on the Protection of Vulnerable Adults and had also subscribed to using Trafford Social Services Adult Abuse policy and procedures. All staff were checked against the Protection of Vulnerable Adults list (POVA) prior to commencing work. All staff were made aware of the basic principles of local Adult Protection procedures as part of the homes induction training. Staff spoken to were aware of the action required in the event of an allegation of abuse being made. Victoria Residential Care Home DS0000005634.V301972.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s environment, including the standard of hygiene, was generally well maintained both internally and externally. Specialist equipment was made available as required by individual residents to meet their needs. EVIDENCE: Radiator covers were fitted in all areas. This was to make sure that none of the residents could touch the actual radiator reducing the risks of accidental burns. It was evident that some bedrooms had been re-decorated however some of the communal areas were in need of re-decoration. A recommendation is made that the provider carries out an audit of communal areas with regard to developing a programme of re-decoration. Victoria Residential Care Home DS0000005634.V301972.R01.S.doc Version 5.2 Page 16 A sample of bedrooms was seen, these were also furnished and equipped to a comfortable standard; many had been personalised by the residents’ relatives. A tour of the building was carried out. The bedrooms were clean and tidy and there were no unpleasant odours detected. There were sufficient toilets situated around the home. They were clearly idetified and close to the communal areas and bedrooms. The dining room was bright and airy looking out onto the garden and provided a comfortable environment for residents to sit and eat. Aids and adaptations had been provided for residents. Residents who had identified needs in the area of mobility were referred to the physiotherapist via their general practitioner for a professional assessment. An emergency call system was fitted to all bedrooms and communal areas so that residents could summon help if needed. There was a small lawned garden to the rear of the property and a small patio area which provided a secluded and safe area for residents to walk or sit out. The washing machine was broken at the time of the site visit, the senior carer stated that large items of laundry had been taken to the sister home to be washed. The engineer had been to the home and was due to replace the machine’s motor on 11th January 2007. Victoria Residential Care Home DS0000005634.V301972.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff appeared sufficient to meet the needs of the residents accommodated. Recruitment procedures were robust to fully protect residents. EVIDENCE: Staff spoken to said that supervision was ongoing and if they had a problem they would contact the manager to discuss it with her. There was no formal supervision planned. There were twelve (12) residents accommodated at the time of the site visit. The numbers and skill mix of the staff, at the time of inspection appeared to be sufficient to meet the needs of the number of residents accommodated. Staffing rotas were examined and sufficient staff were on duty to meet residents needs. During lunch time staff were observed assisting some residents with eating their meals. This was carried out sensitively and with respect. The training records showed that new staff received induction training . This includes adult protection, First Aid, Health and Safety, Food Hygiene, Moving and Handling and Control of Substances Hazardous to Health (COSHH). Victoria Residential Care Home DS0000005634.V301972.R01.S.doc Version 5.2 Page 18 A number of residents at the home have dementia and it was reported that training relevant to the specialist care needs of people with dementia was planned for all staff. This is in partnership with Trafford Care Consortium. The responsible individual said that all managers are booked onto a 2-day residential course on dementia care led by Age Concern. The staff files were held centrally at the head office and were examined during a site visit on 23.7.06. Staff files examined showed that new staff had been checked against the Protection of Vulnerable Adults (POVA) list and an enhanced Criminal Records Bureau check obtained. Appropriate references were also obtained. Victoria Residential Care Home DS0000005634.V301972.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, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had systems and procedures in place which safeguard and protect residents. The home is run in the best interests of residents. EVIDENCE: The manager was on leave during this site visit. Ms Eileen Hamlett has over fifteen years experience in residential care services. She has been the registered manager at Victoria since March 2005 and holds an NVQ qualification in management and care. Care staff told the inspector that the manager was very supportive and that Ms Hamlett had an open and approachable management style with both service users and staff. Victoria Residential Care Home DS0000005634.V301972.R01.S.doc Version 5.2 Page 20 The senior care on duty assisted with providing information and access to records during the site visit. The home holds a small petty cash fund to provide for 2 residents personal monies. There are 3 residents who manage their own finances and generally relatives/representatives helped residents with their financial affairs. Records examined showed that receipts were kept for all purchases made on behalf of residents and a log of the balance kept. However, the recording system was not robust enough. Entries were made on loose sheets of paper; receipts were kept with the sheets but were not attached and could get misplaced. Loose leaf sheets can be easily lost and in order for the home to keep secure records a more appropriate method of recording was needed. A requirement has been made that the home must develop a more appropriate recording system. It was suggested that the home purchase an inexpensive petty cash style book for this. The home’s certificate of registration was publicly displayed. The home is currently registered to accommodate up to 17 older people 8 of whom may also have dementia. A certificate of public liability insurnace was displayed in the hallway. Informal supervision arrangements were in place. Staff spoken to confirmed they had handovers at the change of each shift. If they had any difficulties during their work they could approach the manager or other senior member of staff on duty. Formal supervision arrangements were not in place at the home and a recommendation is made that formal supervision is provided on a regular basis. Notices are displayed in the laundry regarding COSSH regulations. A Health and Safety policy was seen. Fire safety equipment is inspected at the frequency required by the Fire Authority. Practical fire drills are carried out as required. The home displayed a fire risk assessment that was dated and signed. All accidents are recorded and records are filed correctly within the residents’ individual files in accordance with the Data Protection Act 1998. Fire alarm systems and means of escape are tested on a weekly basis by staff in the home and annually by the company’s Fire Officer. Victoria Residential Care Home DS0000005634.V301972.R01.S.doc Version 5.2 Page 21 Fire training drills are regularly carried out ensuring staff are aware of the procedures to be followed and thus reducing the risks to residents in the event of a fire in the home. Victoria Residential Care Home DS0000005634.V301972.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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 X 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 N/A X N/A X 3 X X 3 Victoria Residential Care Home DS0000005634.V301972.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 OP35 Regulation 17 (1)(a)&(b) Schedule 4 Section 9(a). Requirement The registered person must ensure that records relating to residents finances are kept securely in the home. This relates to the homes system of recording transactions made on behalf of residents. Timescale for action 23/02/07 Victoria Residential Care Home DS0000005634.V301972.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 OP7 Good Practice Recommendations The responsible person should ensure that regular reviews be undertaken by the district nurses, and comprehensive records kept in relation to the resident who is cared for in bed. The responsible person should ensure that care plans and risk assessments are reviewed on a monthly basis and a clear record kept of any changes to the plan. The responsible person should ensure that staff received training relevant to the specialist care needs of people with dementia. 2. 3. OP7 OP29 Victoria Residential Care Home DS0000005634.V301972.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Victoria Residential Care Home DS0000005634.V301972.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!