Inspection on 24/11/05 for Victoria Residential Care Home

This inspection was carried out on 24th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Victoria Residential Care Home 25/04/07

Victoria Residential Care Home 10/08/06

Victoria Residential Care Home 21/02/06

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 24th November 2005 08:30 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.V266631.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 DS0000018952.V266631.R01.S.doc Version 5.0 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.V266631.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2004 Brief Description of the Service: Victoria Care Home was 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.V266631.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over 8 hours. The inspector spoke to the manager, deputy manager, resident’s and staff. A tour was made of the home. Documentation was examined including residents’ files, staff personnel files, policies and procedures, certificates relating to Health and Safety, and fire safety records. What the service does well: What has improved since the last inspection? What they could do better: Staff training needs to be addressed to ensure all staff receive the mandatory training in Food hygiene, Fire and Moving & Handling annually. Activities carried out with residents’ needs to be recorded to evidence what is happening in the home. Staff must comply with the policies and procedures in relation to medication administration to ensure the safety of the residents is maintained. Supervision sessions need to be arranged for all staff to ensure they receive the 6 sessions per year as determined in the Care Standards Act. Victoria Residential Care Home DS0000018952.V266631.R01.S.doc Version 5.0 Page 6 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.V266631.R01.S.doc Version 5.0 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.V266631.R01.S.doc Version 5.0 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, 4, 5 All residents admitted to the home are in receipt of a written contract this ensures they are aware of their terms and conditions, therefore safeguarding their welfare. EVIDENCE: The Statement of Purpose and Service User Guide contained information that was concise and easy to read. It is available upon request from the manager. There is need to change the wording from National Care Standards Commission to Commission for Social Care Inspection. All residents admitted to the home are in receipt of a written contact which clearly states the terms and conditions. All residents are assessed prior to admission by either the Manager or Deputy Manager, the documentation needs to be clearly identified in order to assess which is the pre-admission paperwork and that of the admission documentation. Victoria Residential Care Home DS0000018952.V266631.R01.S.doc Version 5.0 Page 9 The home accesses specialist input from professionals such as Dietician, Diabetic nurse, domiciliary dentist. All professional visits are documented well in a separate file held in the managers’ office. The home encourages potential residents to view the home, any person can stay for a few hours if they wish and have a meal at no extra cost. Victoria Residential Care Home DS0000018952.V266631.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, 10, 11 Care plans and risk assessments are reviewed on a monthly basis, this ensures that residents are protected. EVIDENCE: Individual care plans are in place, they are pre-printed and cover all aspects of personal, health and social care. Evidence was seen that care plans are reviewed on at least a monthly basis. Risk assessments are in place, they also include risk assessments following accidents that a resident may have had. Risk assessments must also be reviewed on a monthly basis to assess their relevance. However there was little daily documentation to support what daily care was being delivered to each resident. Residents who spoke with the inspector stated they felt their privacy was maintained and could receive visitors in the quiet lounge or in their room if they wished. It was found that in the main the medication was well controlled, there was no evidence of over stocking of medication. However, medication with a short shelf life i.e. eye drops were not dated on day of opening. Most of the Victoria Residential Care Home DS0000018952.V266631.R01.S.doc Version 5.0 Page 11 signatures were present, however one set of medications had been signed for and were still in the blister packs having not been administered. The home had an up to date returns book, which is completed by the Deputy Manager. The home needs to address where medication has had to be hand written onto the drug sheets. Two staff must sign the entry to confirm it is correct as this helps safeguard residents. The home has an adequate policy on death and dying. However a recommendation is to be made that states that all policies and procedures for the home be reviewed, as they are nearly 3 years old. Victoria Residential Care Home DS0000018952.V266631.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, 14, 15, 16 Residents social activities must be recorded to ensure they are given the opportunity to lead a balanced life. EVIDENCE: Care staff assist residents in social activities. The manager has started a social history of individual residents which is planned to be included into the homes Activity plan. The home has a mini bus, which it uses to take residents out on regular trips. There was evidence of activities being organised in the home, however, there is no up to date documentation to support the action. Residents who spoke to the inspector stated they liked the Keep fit and Bingo. Some stated they also enjoyed the visiting entertainers who come in on a monthly basis. The home has planned the Christmas Party for 10 December, residents and their families are encouraged to attend. An open visiting policy is in operation in the home. The kitchen is well organised, the main meal is served at midday. The inspector observed the midday meal being served; it was well presented, staff were noted to be calm and not rushing residents. Assistance was given to residents who required help. The menu is on a two weekly cycle; the chef reviews the menu as needed to ensure the majority of preferences are catered Victoria Residential Care Home DS0000018952.V266631.R01.S.doc Version 5.0 Page 13 for. Residents who spoke to the inspector stated that if they chose not to have the daily menu the chef would prepare an alternative. The menu is displayed on the notice board out side the dining room. Victoria Residential Care Home DS0000018952.V266631.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, 17, 18 The home has a good complaints procedure which helps safeguard and protect residents. EVIDENCE: The home has a complaints procedure that includes how to contact the Commission for Social Care Inspection. Complaints that are of a minor level are recorded in a complaints book and the outcomes clearly stated next to the complaint. All other complaints are documented on the homes complaints form, which also documents the outcome of each complaint. Residents are all listed on the electoral role register, any resident who wishes to vote is assisted to the local polling station if that is their preference or they can use the postal voting system. Staff received abuse training during their induction. Some staff has received additional abuse training. The manager stated there are plans for all staff to have additional abuse training in the New Year. During the inspection, a couple of residents highlighted that they did not feel staff treated them well, there were comments made that some staff ignored them or they were made to feel a nuisance. The inspector spoke to the manager regarding these comments and the manager has agreed to carry out an investigation and report back to the inspector in writing of the findings. Victoria Residential Care Home DS0000018952.V266631.R01.S.doc Version 5.0 Page 15 All other residents stated they felt happy and safe with the staff looking after them. Victoria Residential Care Home DS0000018952.V266631.R01.S.doc Version 5.0 Page 16 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, 23, 24, 25, 26 The home is of good decoration, residents rooms are personalised so to ensure residents feel safe and secure. EVIDENCE: There has been a great improvement in the decoration of the home. There was evidence that all available rooms had been redecorated, along with the corridors being re-painted. There had been marked improvements to the communal toilets and the draft in the front door had been fixed. There had been radiator covers fixed on all corridor radiators and those radiators in the large lounge are due to be renewed to match those recently fitted. The main areas of the home where found to be homely, there is a large settee in the reception area. Adequate lighting was available. Victoria Residential Care Home DS0000018952.V266631.R01.S.doc Version 5.0 Page 17 There were 3 bedrooms (Rooms 7, 25, 32) that are in urgent need of cleaning, due to a strong smell of urine being evident. Room 25 Carpet needs to be replaced. Evidence was seen of residents’ rooms being personalised, the Deputy stated they encourage all visitors to bring in residents’ personal effects to aid a person into settling into the home. Victoria Residential Care Home DS0000018952.V266631.R01.S.doc Version 5.0 Page 18 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 The homes recruitment procedure is not adequate to protect residents. Lack of information could place residents at risk. EVIDENCE: The home is well staffed; the Manager and Deputy Manager take an active hands on role. Rotas were examined and it was noted that all shifts were appropriately covered with no need of agency staff. Currently the home is not up to the 50 of staff holding an NVQ 2 or above in care however there are 8 with the certificate and 6 more are due to complete in early 2006, this will give the home the 50 . Training is ongoing in the home, however not all staff have received mandatory training in fire, food hygiene and Moving and Handling. Several staff have recently completed a course ‘Working in Care Induction Standards’ this course covers all aspects of Health and Safety relating to care. The manager has recently made contact with learn direct to assist with staff training for 2006. A selection of staff personnel files were examined, there was evidence that CRB (Criminal Records Bureau) checks had been carried out but no staff had Victoria Residential Care Home DS0000018952.V266631.R01.S.doc Version 5.0 Page 19 been POVA (Protection of Vulnerable Adults) checked. The inspector gave the Manager information on how to access information on POVA. Not all files contained evidence of staff members ID. References from previous employment must be sort when considering a person for employment. Victoria Residential Care Home DS0000018952.V266631.R01.S.doc Version 5.0 Page 20 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, 34, 35, 36, 37, 38 The home ensures all Health and Safety aspects are protected through having up to date certification. EVIDENCE: The Registered Manager is an experienced manager who has completed the NVQ4 and Registered Manager’s Award. Staff who spoke with the inspector stated the manager was approachable and friendly. All residents who also spoke with the inspector stated the manager and deputy were both helpful and approachable. The manager holds meetings for residents and their families on a 6 monthly basis. The manager also holds regular staff meeting to address issues relating to care and to the running of the home. Victoria Residential Care Home DS0000018952.V266631.R01.S.doc Version 5.0 Page 21 The home sends out a quality questionnaire to both residents and their relatives on an annual basis. Residents are encouraged to handle their own finances if possible. The home does not act as appointee to any resident. Any resident who is not able to manage their own finances are referred to Wirral Social Services. There was some evidence that staff received supervision but not six times a year. The manager has not received any supervision since being in post. The Registered Provider visits the home regularly but has not completed a visit as per Regulation 26; this must be done on a monthly basis and a copy sent to the Commission for Social Care Inspection. The certificates relating to Health and Safety including the Gas certificate were viewed and found to be in date. The home has an up to date Insurance Liability certificate. The fire book was also examined and found to be up to date; the home held weekly fire drills to ensure all staff are aware of the fire procedure. Victoria Residential Care Home DS0000018952.V266631.R01.S.doc Version 5.0 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 3 2 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 N/a N/a 3 3 3 Victoria Residential Care Home DS0000018952.V266631.R01.S.doc Version 5.0 Page 23 Yes Are there any outstanding requirements from the last inspection? 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 9 Regulation 13 (2) Requirement Timescale for action The Registered Person shall 01/12/05 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The Registered Person shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. The Registered Person shall not provide accommodation to a service user at the care home unless, the needs of the service user have been assessed by a suitably qualified person The Registered Person shall keep the care home free from offensive odours. 01/12/05 2 OP18 13 (6) 3 OP3 14 (1) 01/12/05 4 OP26 16(k) 31/12/05 Victoria Residential Care Home DS0000018952.V266631.R01.S.doc Version 5.0 Page 24 5 OP30 18 (c) The Registered Person must ensure all staff receive appropriate training in the work they perform The Registered Provider shall visit the home at least once a month they must supply a copy of the report to the Commission. 01/12/05 6 OP32 26 01/12/05 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 2 Refer to Standard OP18 OP36 Good Practice Recommendations It is strongly recommended that all staff receive training in prevention of abuse, particularly ancillary staff It is strongly recommended the registered provider carries out supervision of the manager at least 6 sessions per year. It is strongly recommended that all domestic staff receive COSHH (Care of Substances Hazardous to Health) training It is strongly recommended that all policies and Procedures are reviewed on an annual basis. 3 4 OP38 OP37 Victoria Residential Care Home DS0000018952.V266631.R01.S.doc Version 5.0 Page 25 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.V266631.R01.S.doc Version 5.0 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!