CARE HOMES FOR OLDER PEOPLE
Victoria Residential Care Home 295 Washway Road Sale Manchester M33 4EE Lead Inspector
Helen Dempster Unannounced Inspection 2nd November 2005 01:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 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.V263393.R01.S.doc Version 5.0 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.V263393.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. All service users fall within the category of old age but may in addition have a physical disability. 18th January 2005 Date of last inspection Brief Description of the Service: Victoria provides residential accommodation with personal care for up to seventeen (17) service users within the category of old age (OP), but any service users may additionally have a physical disability (PD). Trinity Merchants Limited owns the home. The home is situated on the main road near to Sale town centre. It is close to shops, other local amenities and local public transport. Victoria is a large two-storey property that is set in pleasant grounds. There is a patio area with seating to the rear of the property. The rest of the garden is laid mainly to lawn with mature trees and shrubs surrounding the property. This is well maintained and easily accessible. The home has fifteen single and one double bedroom and four single bedrooms are en-suite. There is a stair lift to the first floor. Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out on 2 November 2005 from 1 pm to 5.40pm. Time was spent talking with the manager, staff and residents. This included discussing welfare matters relating to the residents the home supported and examining documentation in relation to the running of the home, the management arrangements, staffing, care planning and the residents’ satisfaction. The term of address preferred by the users of the service was confirmed as “residents”. It was felt this best reflected the function and purpose of the service. What the service does well:
The home was assessing residents’ needs before and after admission. Some good practice in care planning was seen. This included recording residents’ personal preferences and numbering each aspect of the care plan for ease of reference. A choice of G.P was offered wherever possible and clear records of the visits of doctors and nurses were maintained. Without exception, those residents who expressed a view said that they were treated with respect and that their privacy and dignity was respected. The home has an open visiting policy and residents confirmed that the home welcomed visitors. Posters on the office window informed residents of key events e.g. Christmas entertainment and the home provided weekly craft sessions, movement to music, reminiscence, talking books, hairdressing and simply talking to people. Overall, the home was found to have a good standard of furnishings and fittings and was attractive, clean and comfortable. Some residents had their own telephone and all bedrooms were personalised. Staffing levels at the time of inspection were meeting residents’ needs and residents were happy with the staff. The manager was open and co-operative and had a good rapport with residents and staff. Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better:
Care plans set out an individual plan for each resident, but not all aspects of residents’ needs were documented sufficiently and risk assessments needed developing. Overall, medication practice was appropriate. However, the need for each resident’s care plan to include a section on the administration of medication, including when required” (PRN) medication, which confirms why medication is prescribed and in what circumstances and for what conditions PRN medication is given was discussed. Sample signatures of staff administering medication also needed to be held. There was a need to obtain professional advice in order to review menus to ensure that a balanced diet is offered, to provide alternative menu choices and to maintain a formal record to confirm that choice was offered to the residents. A clear complaints procedure was available to allow residents to raise concerns but a record of complaints needed to be held. Staff were not familiar with the “Protection of Adults from Abuse Policy”. This limited knowledge had the potential to compromise residents’ safety. Organisational procedures limited the manager’s knowledge of staff training as the manager did not have access to staff files or training information. A requirement was made to the effect that the manager accesses this information and completes an audit of training of her staff. The safety of residents and staff could be compromised by the shortfalls in the fire safety precautions being operated at the home. This included not having an up to date fire risk assessment and not consistently undertaking and recording fire safety checks. Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 Page 7 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.V263393.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Residents’ needs were assessed and documented. EVIDENCE: In response to a requirement made at the previous inspection, the home had made the most recent inspection report available to residents and visitors to the home. The home had a pre and post admission assessments. The pre admission assessment was used to take basic information about prospective residents, who were visited prior to admission by a representative of the home. A more detailed needs assessment was then completed on the admission of the new resident. For residents placed by local authorities, copies of the social worker’s statement of needs were kept on that individual’s file. The file of a resident admitted 13 days prior to the inspection was seen. The manager said that she had assessed this individual in hospital prior to admission and they pre and post admission assessments were in place. Other examples were viewed and overall, needs assessments were detailed and clear, but the manager planned to further review the headings on the needs assessment form in the context of Standard 3. The home does not provide intermediate care.
Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 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 Care plans set out an individual plan for each resident, who were treated with respect. However, not all aspects of residents’ needs were documented sufficiently and risk assessments needed developing. Overall, medication practice was appropriate. EVIDENCE: Overall, care plans included the information needed to meet residents’ needs. Some good practice was evident including documenting residents’ personal preferences and numbering each aspect of the care plan for ease of reference. However, there was a need to review the content of the care plan in the context of Standard 3 and 7 of National Minimum Standards for Older People. This included completing a nutritional assessment for all residents and details of oral health and footcare. Risk assessments were in place to address the risk of falls and some good practice was evident, including the use of a detailed and practical hazard list concerning the environment. However, while a review of the care plan was being completed on a monthly basis, they needed to be linked with a review of the risk assessments and reviews should take place when a change in needs is
Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 Page 11 evident. Risk assessments also needed to be completed concerning all aspects of daily living and a requirement was made accordingly. A choice of G.P was offered wherever possible and clear records of the visits of health care professionals were maintained. Overall, medication practice was appropriate. Controlled drug balances were accurate and some good practice was evident including obtaining the GP’s approval in writing for the use of homely remedies and recording some details of personal preferences in taking medication. However, the need for each resident to have a care plan for the administration of medication, including when required” (PRN) medication, which confirms why medication is prescribed and in what circumstances and for what conditions PRN medication is given was discussed and a requirement was made accordingly. Sample signatures of staff administering medication were not held. A requirement was made accordingly. Without, exception, those residents who expressed a view said that they were treated with respect and that their privacy and dignity was respected. Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 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 and 15. Visiting arrangements were appropriate and residents’ recreational interests were documented and accommodated where possible. Residents enjoyed their food, but menus needed reviewing and alternative choices needed to be offered and documented. EVIDENCE: The home has an open visiting policy and residents confirmed that the home welcomed visitors Social interests were recorded in the care plan and posters on the office window informed residents of key events e.g. Christmas entertainment. The manager said that residents were also consulted informally about activities. The home provided weekly craft sessions, movement to music, reminiscence, talking books, hairdressing and simply talking to people. The home had flexible mealtimes and the menu offered a varied diet to residents who said that the food was good but that the menu did not have choices. The main meal was served at lunchtime. There was a need to obtain professional advice in order to review menus, especially evening menus, to ensure that a balanced diet is offered. One example was toasted teacakes and jam tarts as an evening meal. There was also a need to provide alternative menu choices and to maintain a formal record to confirm that choice was offered to the residents and a requirement was made accordingly. This was
Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 Page 13 discussed with the manager who said that she had been doing the cooking at the home for 12 months, as the home did not have a cook. However, the home had recently appointed a cook and the manager said that this would help this process because the cook had already been talking to residents about what they wanted. Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 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 A clear complaints procedure was available to allow residents to raise concerns but a record of complaints needed to be held. In addition, staff were not familiar with the ‘Protection of Adults from Abuse Policy’. This limited knowledge had the potential to compromise residents’ safety. EVIDENCE: The home had a complaints policy and procedure. Some residents did not seem to be familiar with this procedure, but the manager said that it is forwarded to the relatives of all new admissions. A complaints record, to detail the investigation and outcome of complaints, was not being held. A requirement was made accordingly. The home has an internal policy on the protection of adults from abuse and a copy of Trafford Council’s Protection of Adults from Abuse Policy was readily available at the time of inspection. The staff members were not familiar with this policy and the manager was advised that it needed to be a working tool that all staff were familiar with. She said that she would ensure that all staff read it and signed to say they understood it. A requirement was made to the effect that staff must be familiar with the contents of this policy. The manager said that staff training, provided by the local council, was due to be attended in November 2005 and January 2006. Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 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. Overall, the home was clean, tidy and comfortable, with a good standard of furnishings and fittings. EVIDENCE: A partial tour of the premises was undertaken. Overall, the home was found to have a good standard of furnishings and fittings and was attractive, clean and comfortable. Some residents had their own telephone and all bedrooms were personalised. Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 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 and 30. Staffing levels at the time of inspection were meeting residents’ needs and residents were happy with the staff. Organisational procedures limited the manager’s knowledge of staff training. EVIDENCE: The staffing rota for week ending 24/10/05 was examined. This demonstrated that the home met the recommended minimum guidelines set by the previous registration authority, Trafford Metropolitan Borough Council. Two carers and a manager were deployed to meet the residents’ needs from 7.30am to 10pm. Two night carers on waking duty were deployed until 7.30am. Residents said that the staff were good. It was not possible to assess Standards 28 and 29, or to fully assess Standard 30, as the manager did not have access to staff files or training information. The manager stated that staff files were locked up and only one of the directors of the organisation and the registered manager of another residential home owned by the organisation had access. A requirement was made to the effect that the manager accesses this information and that it is available for inspection by the CSCI. A requirement was also made to the effect that the manager completes an audit of training of her staff to ensure that training, including mandatory training, is up to date. A recommendation made at the previous inspection to the effect that the home should produce a plan to show how 50 of care staff will be trained to NVQ Level II by 2005 had not been addressed and has been repeated.
Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 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 and 38. The manager had a good rapport with residents and staff. However, the safety of residents and staff could be compromised by the shortfalls in the fire safety precautions being operated at the home. The organisation needed to arrange monitoring visits to the home. EVIDENCE: At the time of inspection, the manager had completed her NVQ 4 Management Qualification. She had a good rapport with residents and staff. At the time of inspection, the Responsible Individual for the organisation was unable to conduct monthly-unannounced visits to the home due to ill health. The organisation must therefore appoint a representative for the Responsible Individual to conduct these visits and produce a report, in writing, concerning the conduct of the home. A copy of these reports, produced in accordance with Regulation 26 of the Care Homes Regulations must be forwarded to CSCI each
Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 Page 18 month. Following the inspection, a discussion was held with one director, who said that he visited the home on a regular basis to monitor practice, but did not produce a report of these visits. After advice was given, he said that a report would be produced in future. At the time of the visit, the home did not have an up to date fire risk assessment, which accurately reflected the situation at the home. The most recent test of the fire alarm was recorded as 31/10/05 and these tests were not being undertaken on a weekly basis. In addition, the home was not consistently undertaking and recording checks of the means of escape and emergency lighting. Immediate requirements were made to the effect that the advice of the fire department must be sought on the completion of a fire risk assessment for the home and fire safety checks must be consistently undertaken of the fire alarm, means of escape and emergency lighting and the outcomes recorded in the fire log book within 48 hours of the inspection. Some good practice was evident in that monthly fire drills were being undertaken and staff were signing the record personally to confirm their involvement. Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 2 Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 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 13 & 15 Requirement The content of the care plan must be reviewed in the context of Standard 3 and 7. This also includes: a) Each resident having a nutritional assessment and oral care and foot care details. b) Risk assessments being reviewed as part of the monthly review of the care plan. Risk assessments must be in place to assess all risks applicable to an individual resident. These must be subject to consistent review to take account of any changes. A care plan for the administration of medication, including “when required” (PRN) medication, which confirms why medication is prescribed and in what circumstances and for what conditions PRN medication is given must be in place for each resident. Timescale for action 15/12/05 2 OP7 13 & 15 15/12/05 3 OP9 13 15/12/05 Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 Page 21 4 OP9 13 Sample signatures of staff administering medication must be held. The menu must be reviewed so that all meals are nutritious and alternative menu choices must be provided and a record maintained to confirm that choice was offered to the residents. A complaints record, which details the investigation and outcome of complaints, must be held. Trafford Council’s Protection of Adults from Abuse Policy must be readily available to all staff as a working tool and all staff must be familiar with its contents. The registered person must ensure that the recommendations made by the environmental health officer on 1.3.04 are completed. 02/12/05 5 OP15 16 15/12/05 6 OP16 22 15/12/05 7 OP18 13 02/12/05 8 OP19 23 15/12/05 9 OP29 18 The registered person must ensure that each member of staff has two written references. Staff files and training information must be available for inspection by the CSCI. The manager must complete an audit of training of her staff to ensure that training, including mandatory training, is up to date. 15/12/05 10 OP30 18 15/12/05 11 OP30 18 15/12/05 Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 Page 22 12 OP33 26 The Responsible Individual for the organisation must appoint a representative to conduct monthly-unannounced visits to the home and must produce a report, in writing, concerning the conduct of the home. A copy of these reports, produced in accordance with Regulation 26 of the Care Homes Regulations must be forwarded to CSCI each month. The fire risk assessment must be dated and be subject to consistent review so that it accurately reflects the risks from fire at the home. The advice of the fire department must be sought concerning this Fire safety checks of the means of escape and fire alarm must be conducted on a weekly basis and the outcome recorded in the fire logbook. Monthly tests of the emergency lighting must be undertaken and the outcomes recorded. 15/12/05 13 OP38 23 04/11/05 13 OP38 23 04/11/05 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 OP28 Good Practice Recommendations The registered person should ensure that a plan is produced to show how 50 of care staff will be trained to NVQ Level 2 by 2005. Victoria Residential Care Home DS0000005634.V263393.R01.S.doc Version 5.0 Page 23 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
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