Inspection on 05/03/06 for Victoria Residential Care Home

This inspection was carried out on 5th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 10/01/07

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 Kathleen Mcall Unannounced Inspection 5th March 2006 12:20 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.V275633.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 DS0000005634.V275633.R01.S.doc Version 5.1 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.V275633.R01.S.doc Version 5.1 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. 2nd November 2005 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.V275633.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over the course of a Sunday afternoon. The registered manager and a senior carer accompanied the inspector throughout the inspection process. Care plans, assessment documentation, medicines and their storage were examined. The inspector spoke with several residents, and two relatives who were in the home at the time of the inspection and spoke with members of staff. There were sixteen residents in the home at the time of the inspection. Residents told the inspector that they were very satisfied with the care they received and that care staff always treated them respectably. What the service does well: What has improved since the last inspection? Since the last inspection the registered manager had reviewed care plan documentation to include nutritional needs, oral health care needs and foot care. Sample signatures of those staff responsible for medication administration had been put in place since the last inspection. At a previous inspection the registered manager was required to review the menu so that all meals provided were nutritious, with alternative menu choices. Since the last inspection the registered manager had appointed a new cook, reviewed the menu and ensured that a hot and cold alternative was offered at the teatime meal. Victoria Residential Care Home DS0000005634.V275633.R01.S.doc Version 5.1 Page 6 Since the last inspection the registered manager had put a complaints record in place, which detailed the nature of the complaint, the investigation and how the complaint had been resolved. There had been no complaints since the last inspection. Since the last inspection a copy of Trafford Council’s Adult Protection Policy had been made available to all staff and staff had acquainted them selves with its contents. Since the last inspection the registered manager had complied with the recommendations of the Environmental Health Department and had replaced the refrigerator and made adaptations to kitchen units. Since the last inspection the registered manager had completed a full training audit of care staff to ensure that all mandatory training was up to date. 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.V275633.R01.S.doc Version 5.1 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.V275633.R01.S.doc Version 5.1 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 4. Service users’ care needs were fully assessed before admission and they were satisfied with the care provided. EVIDENCE: As part of the inspection a selection of service user files were examined. These contained a sufficient amount of assessment information in respect of each service user. It was the practice of the home that service users were assessed prior to their admission. Assessments were obtained from social workers and 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. The home had pre and post admission assessments. The pre admission assessment was used to take basic information about a prospective resident a more detailed needs assessment was then completed on the admission of the new resident. The registered manager along with the company’s general manager were in the process of reviewing admission and care planning documentation to look at developing an assessment document which requested more detailed and appropriate information on which to develop care plans. Victoria Residential Care Home DS0000005634.V275633.R01.S.doc Version 5.1 Page 9 The inspector saw an example of the intended documentation that the home would be using, which included a nutritional assessment, oral health and foot care. Both service users and relatives told the inspector that they were quite satisfied with the way in which the home met service users care needs. Care staff demonstrated a good understanding of service users’ care needs. Victoria Residential Care Home DS0000005634.V275633.R01.S.doc Version 5.1 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. Service users’ health and personal care needs were identified through care planning and met by care staff. EVIDENCE: All service users had a care plan. Care plans seen were detailed and individualised to each service users’ care needs with information held in one accessible document. Care plans included health needs, personal care needs, mobility, social interests and weight monitoring. Care plans were reviewed on a monthly basis. Daily records were detailed and gave a full picture of how the home was meeting service users care needs and how service users had spent the day. Since the last inspection the registered manager had reviewed care plan documentation to include nutritional needs, oral health care needs and foot care and there were plans to gradually introduce this document. Risk assessments were in place to address the risk of falls and service users moving and handling issues. At a previous inspection the registered manager was required to review risk assessments on a monthly basis. Whilst there was some evidence that this practice had begun, risk assessments in the main were Victoria Residential Care Home DS0000005634.V275633.R01.S.doc Version 5.1 Page 11 only updated when a change was identified or required. The registered manager had a discussion with the inspector regarding this practice. Reviews of care plans and risk assessments need to be linked and take place on a monthly basis to provide an up to date picture of service users needs and to provide accurate information for care staff. Victoria had specialist equipment in place to meet the needs of service users. Service users and their relatives confirmed that they had access to GP support, district nursing services, optician and chiropody services when required. One relative told the inspector that nothing was too much trouble for the staff and that staff were very good at contacting her mothers GP if she needed to see him. Medication was provided in the Vena link system, this was stored appropriately. Medication records were in the main accurately maintained with the exception of handwritten medications, which must be verified by a second member of staff. The home did not have a dedicated refrigerator for the storage of medication. Service users’ medication was stored appropriately in a domestic refrigerator and fridge temperatures were monitored on a daily basis. Sample signatures of those staff responsible for medication administration had been put in place since the last inspection. Service users told the inspector that staff treated them well and they were very satisfied with the care they received. Care staffs’ approach towards service users was observed to be respectful, sensitive and caring at all times. A large number of service users were unable to comment on the quality of care provided due to levels of dementia and short term memory loss. Consequently the inspector spent time observing the practices of staff and the daily routine of the home and observed that staffs’ approach towards service users was sensitive and caring. In addition the inspector observed that the service users looked physically well cared for. Victoria Residential Care Home DS0000005634.V275633.R01.S.doc Version 5.1 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. The day-to-day routine of the home including mealtime arrangements was relaxed and informal and met the majority of service users needs and expectations. EVIDENCE: Victoria offered a flexible routine to service users. Staff encouraged service users to make choices as to how they spent their time, whether they wished to join in activities or not, what they ate and what clothes they chose to wear. Some service users preferred to spend time in their rooms and others preferred to use one of the two lounge areas. 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. Some service users expressed a degree of dissatisfaction with the activities provided and others said that they would like visits by local churches and clergy as there had been none since Christmas. Visitors were made welcome at the home and service users kept in touch with family and friends. Meals were served at regular intervals and were usually taken in the dining room area, though service users did have the choice of having their meals in Victoria Residential Care Home DS0000005634.V275633.R01.S.doc Version 5.1 Page 13 their bedrooms. The lunchtime meal was the main meal of the day with a lighter snack type meal being offered at teatime, when either a hot or cold option was available. At a previous inspection the registered manager was required to review the menu so that all meals provided were nutritious, an alternative menu choice was offered and that a record was maintained to confirm that choice was offered to the residents. Since the last inspection the registered manager had appointed a new cook, reviewed the menu and ensured that a hot and cold alternative was offered at the teatime meal. Several service users told the inspector that they had enjoyed their lunch. Others said the food was ‘very good’ and that a good choice and selection was provided. One relative had a discussion with the inspector regarding the homes arrangements for providing a soft diet for her mother. Discussions with the registered manager and observations of the care plan confirmed arrangements were in place to meet this need. Victoria Residential Care Home DS0000005634.V275633.R01.S.doc Version 5.1 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 Service users felt confident that their complaints would be taken seriously and acted upon. Staff had begun to undertake appropriate training in adult protection, which ensured the protection of service users. EVIDENCE: The home had a policy and procedure for responding to complaints. A requirement was made at a previous inspection that a complaints record, which detailed the nature of the complaint, the investigation and outcome of complaint investigation, must be put in place. Since the last inspection the registered manager had put a complaints record in place. There had been no complaints since the last inspection. Service users with whom the inspector spoke said that they knew who to complain to if they had a problem and all felt confident that the problem would be resolved in a satisfactory manner. The home had an internal policy on the protection of adults from abuse and a copy of Trafford Council’s Protection of Adults from Abuse Policy. Since the last inspection the registered manager had ensured that all staff were familiar with Trafford Council’s policy and had signed to say they had read it. Three members of staff out of a team of seventeen had completed training in the Protection of Vulnerable Adults and further training was planned. Care staff on duty at the time of the inspection demonstrated a clear understanding of their responsibilities with regard to reporting abuse and poor practice. Victoria Residential Care Home DS0000005634.V275633.R01.S.doc Version 5.1 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, 24 and 26 The home was well maintained and provided comfortable living accommodation for service users. EVIDENCE: The home was well maintained throughout and provided comfortable accommodation. Since the last inspection the registered manager had complied with the recommendations of the Environmental Health Department. A number of service users’ rooms were seen, these were also furnished and equipped to a comfortable standard, many had been personalised by the occupants. At the time of the inspection the home was clean, tidy, bright and airy throughout and was free from any unpleasant odours. Victoria Residential Care Home DS0000005634.V275633.R01.S.doc Version 5.1 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, 28, 29 and 30. The home was sufficiently staffed with a staff group that was trained to undertake their duties. Recruitment procedures did not confirm that service users were protected. EVIDENCE: At the time of the inspection the home was sufficiently staffed with a staff that was trained to meet the assessed needs of service users. A staff rota showing, which staff were on duty and in what capacity, was kept at the home. Staffs’ recruitment files and information were not available at the time of the inspection. Care staffs’ recruitment files were stored at Kara House, one of the companies other homes. It had been a requirement at the previous inspection that this information must be stored at Victoria and made available at future inspections. The registered manager advised the inspector that the company’s new general manager was looking at the future storage of this information in the home. Evidence provided on inspection confirmed that care staff had undertaken training to assist them in their role as carers including incontinence care, basic first aid, moving and handling and food hygiene. Care staff confirmed that they had completed an induction programme at the commencement of their employment. Since the last inspection the registered manager had completed a full training Victoria Residential Care Home DS0000005634.V275633.R01.S.doc Version 5.1 Page 17 audit of care staff to ensure that all mandatory training was up to date. Victoria Residential Care Home DS0000005634.V275633.R01.S.doc Version 5.1 Page 18 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): 32, 33, 36 and 38. The home was well managed, however care staff were not appropriately supervised. EVIDENCE: The registered manager, 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. Ms Hamlett had an open and approachable management style with both staff and service users. Relatives confirmed that Ms Hamlett was very approachable and care staff told the inspector that the manager was very supportive. Informal supervision arrangements were in place. Staff confirmed that they had handovers at the change of each shift and if they had any difficulties during their work they could approach the manager or other senior member of Victoria Residential Care Home DS0000005634.V275633.R01.S.doc Version 5.1 Page 19 staff on duty. However formal supervision arrangements were not in place at the home and staff were not formally supervised on a regular basis. At a previous inspection a requirement was made that the responsible individual must conduct monthly unannounced, regulation 26 visits to the home and produce a report, in writing and forwarded to the CSCI. Since the inspection it has been confirmed that CSCI had not received such reports and so the requirement remained outstanding. Since the last inspection the registered manager had ensured that the home complied with the requirements of the fire authority and maintained records in respect of fire safety at the home. Since the last inspection the registered manager had sought the advice of the fire authority in respect of fire safety in the home and had ensured that the home complied with the requirements of the fire authority and maintained records in respect of fire safety at the home. It had been a requirement at a previous inspection that the registered person keep the homes fire risk assessment up to date. At the time of the inspection it was observed that the home’s fire risk assessment had not been up dated or reviewed and so the requirement remains outstanding. Care staff did not up date their fire safety training on an annual basis. Care staff had updated their training in safe handling and moving procedures, food hygiene and basic first aid. Victoria Residential Care Home DS0000005634.V275633.R01.S.doc Version 5.1 Page 20 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 X X 3 3 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 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 2 X 2 Victoria Residential Care Home DS0000005634.V275633.R01.S.doc Version 5.1 Page 21 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 registered person must ensure that risk assessments are reviewed on a monthly basis to take account of any changes. (Timescale of 15/12/05 not met) The registered person must ensure that handwritten recordings on MAR charts are checked and signed by a second member of staff. The registered person must consult with service users about the programme of activities provided at the home and take into account the religious needs and preferences of service users. The registered person must provide training in Adult Protection to all care staff employed at the home. The registered person must ensure that all records held in respect of persons working at the home as listed in Schedule 2 of the Care Homes Regulations 2001 are made available for inspection. (Timescale of 15/12/05) Timescale for action 05/05/06 2. OP9 13 05/03/06 3. OP12 16(2) 05/06/06 4. OP18 13(6) 05/12/06 5. OP29 Schedule 2 05/09/06 Victoria Residential Care Home DS0000005634.V275633.R01.S.doc Version 5.1 Page 22 6. OP33 26 7. 8. OP36 OP38 18 23 9. OP38 23 The Responsible Individual must conduct monthly unannounced visits to the home and produce a report in writing, a copy of which must be forwarded to the CSCI in accordance with Regulation 26 of the Care Homes Regulations 2001 each month. (Timescale of 15/12/05 not met) The registered person must ensure that all staff receive formal at least six times a year. The registered person must ensure that the home’s fire risk assessment is dated and subject to consistent reviews. (Timescale of 14/11/05 not met) The registered person must ensure that all care staff receive suitable training in fire safety on an annual basis. 05/06/06 05/09/06 05/03/06 05/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Victoria Residential Care Home DS0000005634.V275633.R01.S.doc Version 5.1 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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