Inspection on 21/02/06 for Victoria Residential Care Home

This inspection was carried out on 21st 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 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 10/08/06

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 Unannounced Inspection 21st February 2006 10:00 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 DS0000018952.V284261.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 Residential Care Home DS0000018952.V284261.R01.S.doc Version 5.1 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.V284261.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th November 2005 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.V284261.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out over 6 hours. The inspector spoke to the manager, deputy manager, the administrator, several residents and staff members. A tour was made of the home. A selection of documentation was examined including resident care files, medication charts, staff personnel files, finance records and certificates relating to Health and Safety. What the service does well: 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 DS0000018952.V284261.R01.S.doc Version 5.1 Page 6 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.V284261.R01.S.doc Version 5.1 Page 7 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, 4, 5, 6 All residents prior to admission are visited to ensure their needs can be met. EVIDENCE: The home has amended the Statement of Purpose as directed in the last inspection. The service user guide remains the adequate. All residents who enter the home are issued with a written contact, which clearly defines the terms of residency. The manager or deputy carry out a pre-admission assessment, this assists the home with maintaining a resident’s needs appropriately. Residents are able to visit the home prior to entering the home. Potential residents are encouraged to stay for a few hours or a meal if they prefer at no additional cost. Victoria Residential Care Home DS0000018952.V284261.R01.S.doc Version 5.1 Page 8 There was clear evidence that the home accesses information and support from other healthcare professionals. Records are clearly maintained to a good standard. The home does not provide intermediate care. Victoria Residential Care Home DS0000018952.V284261.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Medication must be recorded accurately so to assist in protecting residents from harm. EVIDENCE: Care files are formulated for all new residents. A sample was examined, it was found that care plans were relevant however some lacked detail, the manager and deputy advised that care files were currently being reviewed and the necessary changes would be included. Residents are risk assessed on a variety of areas of care. Evidence was seen of the risk assessments being reviewed on a regular basis. Medication held in the home was not accurate in the records maintained. There was no second signature on handwritten entries. Medication received into the home was not recorded and no clear audit trail could be made. Controlled drugs are not recorded correctly. Handwritten entries are abbreviated and could lead to mistakes being made. Victoria Residential Care Home DS0000018952.V284261.R01.S.doc Version 5.1 Page 10 Residents stated they were happy and staff treated them with respect. said they enjoyed living in the home. The home has an adequate policy on care of the dying. They Victoria Residential Care Home DS0000018952.V284261.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Residents are encouraged to maintain contact with family and friends, thus assisting in promoting social well being. EVIDENCE: Activities carried out on a daily basis are recorded in the activity book. The home provides a varied activities programme and residents during the inspection were seen to enjoy a game of bingo in the main dining room. The home operates an open visiting policy. Families are encouraged to visit openly. One visitor stated she was very happy with the care her relative was receiving. Staff were witnessed to offer choices to residents. Residents stated they could choose how they spend their day, and staff respected any decision they made. The menu for the home is on a two weekly rota. The menu is kept under regular review and amended to cater for the residents’ choice. An alternative to the daily choices can be provided as per request. Residents stated they enjoyed the food. The daily menu is displayed on the board in the main dining area. Victoria Residential Care Home DS0000018952.V284261.R01.S.doc Version 5.1 Page 12 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 Not all complaints are documented therefore there is no evidence that residents’ concerns are listened too. EVIDENCE: The complaints book was examined and no complaints were listed. There is a requirement for all complaints to be recorded along with the outcome reached in order to prove all complaints are listened too and action is taken appropriately. Residents on entering the home are registered on the electoral role. Any resident wishing to vote can either access the postal vote system or if they prefer attend the local polling station. Staff will assist if no relative is available. Residents are able to receive their post un-opened. A member of staff assists residents requiring help. Staff are reminded of the code for confidentiality during staff meeting and at induction. Some staff have since the last inspection received adult protection training. The remaining staff are due to attend the training by May 2006. The home has a copy of the Wirral No Secrets File (Wirral Policy on Adult Protection). Victoria Residential Care Home DS0000018952.V284261.R01.S.doc Version 5.1 Page 13 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, 24, 26 The home is maintained to a high standard; therefore providing a pleasant environment for residents to live in. EVIDENCE: The home is well maintained. There has been some re-decoration since the last inspection. The main entrance is inviting and many residents enjoy sitting in the area. The lounges and dining rooms are well maintained. Residents are able to access the grounds by use of ramps. The home has lifts, which are serviced on a regular basis. The grounds are maintained to an adequate standard. A selection of residents’ rooms were visited during the tour of the home. All were found to be personalised and residents confirmed they were encouraged to bring in personal affects to assist in making their own personal room homely. Victoria Residential Care Home DS0000018952.V284261.R01.S.doc Version 5.1 Page 14 The home is found to be clean and hygienic. There were no unpleasant odours noted within the home. Victoria Residential Care Home DS0000018952.V284261.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, 30 Staff receive regular training; this assists in providing high standards of care. EVIDENCE: A selection of staff personnel files were examined, there has been some improvement in the contents of the files, however some lacked identification evidence and no health checks had been obtained as required in Schedule 2 of the National Minimum Standards. 52 staff hold an NVQ2 or above in care. Further staff are waiting to commence on the NVQ programme later in the year. Staff rotas were checked and found to be staffed appropriately. The home does not use agency staff on a regular basis. Staff receive training on a regular basis. Training that staff have received recently include Moving and Handling, Fire, Basic Hygiene, Adult protection. Training is provided both in house and from external sources. The domestic staff are planned to receive COSHH training by June 2006. Victoria Residential Care Home DS0000018952.V284261.R01.S.doc Version 5.1 Page 16 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, 34, 35, 36, 37, 38 The manager provides leadership to staff; thus assisting in promoting adequate standards of care. EVIDENCE: The manager is registered with the Commission for Social Care Inspection. Both the Manager and Deputy Manager hold the NVQ4 in management. Staff confirmed the manager provides leadership, and support to staff. Both relatives and residents stated the manager was approachable. Residents’ finances are maintained in the home. Records are kept but all entries are not clearly defined and records must reflect accurately the transfers of all money. Victoria Residential Care Home DS0000018952.V284261.R01.S.doc Version 5.1 Page 17 Staff receive supervision on a regular basis. Records are maintained to a good standard. The homes policies and procedures have been reviewed since the last inspection. The fire records and Health and Safety certificates are maintained and all were found to be in date. Fire training and drills are carried out on a regular basis. Victoria Residential Care Home DS0000018952.V284261.R01.S.doc Version 5.1 Page 18 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 3 8 3 9 2 10 3 11 N/a DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 3 3 N/a N/a N/a 3 N/a 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 N/a 3 2 3 3 3 Victoria Residential Care Home DS0000018952.V284261.R01.S.doc Version 5.1 Page 19 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 OP9 Regulation 13 (2) Requirement Timescale for action The registered person shall make 03/03/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. a) All handwritten entries must have 2 signatures on each entry. b) Medication sheets must record total stock of each medication for each resident c) All medication brought into the home must be counted and recorded d) Controlled drugs must be recorded correctly e) Handwritten entries must be written in full and no abbreviations such as BD used. 2 OP16 22 (3) The registered person shall ensure that any complaint made under the complaints procedure DS0000018952.V284261.R01.S.doc 30/03/06 Victoria Residential Care Home Version 5.1 Page 20 is fully investigated. 3 OP29 19(1)(b)(i ) 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. 30/03/06 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 Refer to Standard OP18 OP37 Good Practice Recommendations It is strongly recommended that all staff including ancillary staff receive annual adult protection training. It is recommended that the manager appoints a person to carry out the weekly fire alarm tests in the absence of the maintenance man. Victoria Residential Care Home DS0000018952.V284261.R01.S.doc Version 5.1 Page 21 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.V284261.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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