Inspection on 11/03/08 for Manor Park Care Home

This inspection was carried out on 11th March 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Manor Park Care Home 30/01/09

Manor Park Care Home 13/09/07

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Victoria Road Care Home 52 Victoria Road Keighley West Yorkshire BD21 1JB Lead Inspector Nadia Jejna Key Unannounced Inspection 11th March 2008 10:00 Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 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 Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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 Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Road Care Home Address 52 Victoria Road Keighley West Yorkshire BD21 1JB 01535 680410 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) Mr Olu Femiola Mr Olu Femiola Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (17), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (5) Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia - Code MD and Code MD(E) The maximum number of service users who can be accommodated is: 22 13th September 2007 2. Date of last inspection Brief Description of the Service: Victoria Road has been registered as a care home since April 1989. In March 2007 it was bought by Mr Femiola who is now the registered provider and manager. Victoria Road care home is in Keighley, close to the town centre and local services such as shops and public houses. It is easily accessible by public transport, being a short walk from the nearest bus stop. The home provides accommodation, personal care and support to people between the ages of 18 and 65 with a history of mental illness. Nursing care is not provided and the home will work with district nurses and community psychiatric nurses if this type of support is needed. The home is detached building that stands in its own grounds. The main building is a Victorian house that has had extensions added to it over the years. Accommodation is provided in mainly single rooms over two floors. The main entrance is up a short flight of steps; people living at the home need to be mobile and able to manager stairs as there are no lifts or facilities for disabled people. There are two lounges, a separate dining room and adequate provision of toilet and bathing facilities. Information about services provided by the home is available in the Service User Guide. Copies can be provided on request. A copy of the most recent inspection is available in the office. Information about the weekly charges for staying at the home were not provided in the AQAA and the acting manager was not able to provide this information when the visits were made to the home in September 2007. Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This report consists of a review of information received and held by us since the inspection in September 2008 and the findings made during a visit to the home. This visit was made on 13th March 2008. Feedback was given to the acting manager during the visit. An additional visit was made in December 2007 as a result of information received about care provided to older people who live in the home. There were no new requirements made as a result of it. Staff on duty at the time of the visit took appropriate action to make sure that the changing needs of people as they get older were identified and support requested from other healthcare professionals such as the district nurses. The provider and the acting manager for the home met with us in February 2008 to discuss the outcomes of the visits and gave reassurances that action would be taken to meet requirements and improve outcomes for people living in the home. It was agreed that the timescales for meeting some of the requirements would be extended because the acting manager had only been at the home for a short time and there had been staffing difficulties, which meant that staff had concentrated on making sure peoples needs were being met. The purpose of this visit was to make sure that the home was being managed for the benefit and wellbeing of the people using the service and to monitor progress made towards meeting requirements made at the inspection in September 2007. Following the poor outcomes of this inspection, the provider was asked to complete and return an improvement plan to us. An outline plan was sent as guidance. At the point of writing this report the provider has sent a letter stating that action will be taken to meet the requirements made and improve outcomes for people living in the home. During the visit we talked to people living in the home and staff on duty. We observed care practice, looked at various records such as staff files, complaints and accidents records and looked round the home. What the service does well: The atmosphere in the home was cheerful, welcoming and friendly. It was clear that there are good relationships between staff and people living in the home. People told us that: • They were satisfied with the services provided by the home. Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 6 • • • The staff were kind and helpful. They enjoyed the meals provided and got enough to eat. They made their own decisions about what they wanted to do each day. Some people are supported and encouraged to maintain social, leisure and educational activities. For example people had been to college to learn computer skills, others went out to social clubs or to play football with their friends. The home was clean and tidy and there were no smells. People said their rooms were kept clean and some kept their own rooms clean. What has improved since the last inspection? What they could do better: The provider must make sure that the home is run and managed in the best interests of the people who live there and that the health, safety and well being of people is protected and promoted. This can be done by: • Making sure that people have detailed individual care plans that tell staff about their needs, abilities and personal preferences and how to meet them. • Making sure that medications are dealt with and looked after safely. • Making sure that there are enough staff on duty to meet people’s personal, health, social and psychological care needs. • Making sure that staff receive the training they need to equip them to do their job properly, understand people’s needs and how to meet them. Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 7 • • Informing us what action they are going to take to improve outcomes for people living in the home in a written action plan with timescales. Making sure that there are safe systems in place for looking after and dealing with people’s finances if the provider has been asked to do so by the individual. 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. The summary of this inspection report can be made available in other formats on request. Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Peoples needs are identified and assessed before they move in to the home and they can ‘try it out’ before making decisions about moving in. EVIDENCE: The Service User Guide was updated in January 2008. It is available to people on request. It is clear that the provider has tried to make it a document that will be useful to people who use the services provided in the home but there are still some sections with ‘technical jargon’ that the lay person might not understand. There have been no new permanent admissions since the last key inspection in September 2007. One person had come in for a short stay with a view to longterm placement if they liked it. They were not at the home when we visited. The manager said the pre-admission process was unchanged and he would make sure that: • Copies of any care and mental health needs assessments were obtained before agreements to provide care were made. • The person would be encouraged to visit the home, meet other people and staff to see if they liked it. Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 10 • The manager would visit them to carry out a pre admission assessment of their needs to make sure that the home would be able to meet them. Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People can make decisions about their daily life and staff will have more knowledge of people’s needs and abilities when the care plans are updated and more detailed. EVIDENCE: The provider and manager have recognised that the new care plan formats they introduced last year are not the easiest for staff to use consistently. They have decided that these documents will be used as an assessment tool to help produce detailed individual care plans for people. The documents include a risk assessment booklet which is a brief grading of risks that looks at things such as self-harm, harm to others, self-neglect and vulnerability. There is room to add detail about a person’s emotional state and their social situation. There are sections for a risk management plan, identified strategies to reduce risk and monitoring arrangements. It has the potential to Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 12 be a good tool to use and pages can be added to it for each identified area of risk. They need to make sure that all areas of potential risk such as smoking and going out alone are addressed. The manager and a recently employed senior carer were working on the care plans. They told us that this is a work ‘in progress’ and hope it will be completed within the next few months. A file with detailed individual daily records is now being kept. This means that accessing information about an individual and any changes or problems that may have occurred is now easier for all staff. Care staff have been asked to be key workers for up to two people each and they will be responsible for: • Keeping care plans up to date • Working with the individual, keeping them involved with all aspects of their care • Making sure the plans are individual to that person and that it looks at their social needs as well as personal and psychological care needs. People living in the home said that they made their own decisions about what they wanted to do each day. During the visit people were going about their daily lives, for some this was going into town to shop, going to a local centre to play bingo, visit the pub or for a game of football with friends. The manager said that people would tell staff when they were going out and what time they expected to come back. This was not detailed in the care plans/risk assessments looked at. There were no risk assessments for people who smoked. Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are encouraged and helped to be part of the local community and take part in appropriate leisure activities. EVIDENCE: People who were not going out either watched TV or listened to music. The manager said that they were going to introduce a system of weekly 1 to 1 sessions lasting between 1 and 2 hours per week for people with their allocated key worker. This would be used to talk about any concerns they might have as well as to plan and do activities. People living in the home are helped and supported by staff to learn new skills and take part in appropriate activities. One person regularly attended a local day centre, another had a regular routine of social activities that included meals out and going to play bingo. Another had attended college and gained various educational qualifications, such as using a computer. Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 14 People can maintain contact with friends and family, including relationships with partners/loved ones. People told us that: • They were satisfied with the services provided by the home. • The staff were kind and helpful. • They enjoyed the meals provided and got enough to eat. The cook has got a four weekly menu cycle. There is one choice at lunch and teatime but alternatives are always available and staff know what people like and dislike. Special diets can be catered for, for example they are providing meals for somebody of Hindu faith who does not eat beef. They provide halal meat and vegetarian options. The cook is given a budget for shopping, which she does twice a week. The cupboards were well stocked when we visited. We talked to the manager and the cook about enriching meals and providing small nourishing snacks for some of the older people in the home whose appetites are poor and they are getting frail. The cook knew about adding using full fat milk and adding cream or butter to different types of foods. They were advised to look at the CSCI website for guidance and information that has been produced around nutrition and mealtimes as well as to contact the dietician for additional advice and support. People can have snacks and drinks on request. Through the day people came to the kitchen to check what meals were going to be made and to get drinks and snacks. Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s healthcare needs are monitored and appropriate action is usually taken if help and support from healthcare professionals is needed. This will be better evidenced when detailed, individual care plans are in place. EVIDENCE: Staff told us they aware of individual needs and abilities. It was clear that there were good relationships between staff and people living in the home. People living in the home said that staff were ‘nice’ and understanding and that they helped them in ways that suited them. The records looked at showed that people’s healthcare needs are monitored and looked after. People can arrange their own GP/dentist/optician visits if they want to or staff will help them. Some people living in the home receive support from community psychiatric nurses and attend out patient’s appointments to see their psychiatrists. District nurses see other people regularly to provide medication support. Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 16 At a meeting in February 2008 the provider told us that all staff dealing with medication had received appropriate certificated training. The records for two senior carers confirmed this. A new senior carer told us that they and another senior carer would be looking after medications in the home. They said they had completed training about medication that would help them to do this. From talking to them it was clear they understood their responsibilities and what they needed to do to make sure medications were dealt with safely. We looked at the medication administration records (MAR’s). These showed that: • The sections for recording when supplies had been received were not being used. • There were some gaps on the charts where people had not signed to say the medication had been given or used a code to show why it had not been given. • There was not a list of the people who could give medication with examples of their signatures. The medication for somebody who wants to look after their own medicines are now being dispensed in a weekly dosette box. This means that staff are no longer putting tablets into other containers and the process is now much safer. The risk assessment and care plan around self medication had not been completed. The senior carer said she would make sure it was dealt with straight away. The storage facilities for medication need to be looked at as they are kept either in the metal-wheeled drugs trolley, which is satisfactory, or a wooden wall cupboard, which is not safe. The manager was advised to look at the revised Royal Pharmaceutical Guidelines around the safe handling of medication in social care settings to make sure that all practices and policies around dealing with medications are safe and up to date. Two people living in the home are getting older and need help with continence problems. We were told that the district nurses have been contacted for advice and support for people with continence problems and who might be at risk of developing pressure sores. They said that continence products, a pressure relieving mattress and cushions have been provided. One person has fallen five times since early January 2008. The care plans and accident records did not tell us what action had been taken or if advice had asked for from the falls prevention team. The manager was advised to contact the falls prevention team as they can supply specialist advice, support and equipment as well as training for staff. This will help to reduce the risk of further falls and might identify why they are happening. As people using the service get older the manager should take into consideration their changing needs and make sure appropriate healthcare assessments are carried out and advice sought from healthcare professionals. Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There is a risk that people might not be protected from abuse or harm because staff have not received appropriate training. EVIDENCE: A new complaints procedure has been put in place. It is clear and easy to follow but includes CSCI as part of the home’s process. The manager said he would change the wording to show that in the first instance the person in charge or the manager would deal with the complaint. If they were not satisfied with the outcome it would them be referred to the provider. Contact details for funding local authorities would also be added so that people could contact them if they wanted to. Minutes of a staff meeting said there had been one complaint since the last inspection. This was about clothes that needed to be dry cleaned and was an issue that was resolved with the individual’s relatives. People told us that they knew who to speak to if they had any concerns and that they would be dealt with. A copy of the local authority adult protection policy was seen in the staff office. Not all staff have received training about abuse awareness and adult protection. The manager said that it had been arranged for some of the staff and hoped that all would have had it within the next six months. The manager and the provider are booked on the local authority adult protection unit’s two Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 18 day course for care providers. They hope to have one person compete a train the trainer course so that this training can be done in house and staff will not have to wait to attend courses. Some people living in the home have their benefits paid directly into the provider’s bank account and after the home’s fees have been paid their personal allowances are returned to them. The records looked at were not clear about how much benefit people received, how much was paid to the fees and how much was personal allowance. The books kept to show people had been given their personal allowance was purely a record saying how much had been given to them on a particular day signed by the individual. The manager was told to look at the records kept as this had been identified as an issue at the last inspection. The home operates a residents/mobility fund that some people contribute to but not all. The money is used to run a mini bus that is used for outings and to take people to hospital/doctors appointments. The previous homeowner was operating this system and the provider continued with it when he took over ownership of the home. There was no information about how the fund was to be managed and how people contributing to it were to receive an equitable return from it. There were no agreements in place between the home and the people contributing to it. The records kept showed that it had been used generally in the home and when used for taxis did not say who they were for. The provider was advised that there should be a policy about the fund saying how it will be managed and kept equitable for the people contributing towards it. People contributing towards it should be consulted about how it will be managed and there should be contracts/agreements between the home and people who contribute to it as well as detailed records of monies received and used. The provider had told us that he would consult with people about the future of this fund and how it will be managed. When we visited no further action had been taken regarding this account. The manager was told to look at this as it had been identified as an issue at the last inspection. Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home needs to be redecorated and refurbished so that people will have a safe, comfortable environment to live in. EVIDENCE: The provider has told us that plans are in place to refurbish and redecorate the home over a period of time. This will include: • Improving the grounds so that people would have nice gardens to use. Walls would be built to improve security. • Making sure that all radiators are guarded and any damaged walls are repaired. • A new laundry room/area as its current position off the dining room is not good for reducing the risks of cross infection/contamination. Since the visit in September 2008 there have been some changes made to the home, such as: Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 20 • • • • • Laminate flooring has been put down in the smokers’ lounge. The smokers’ lounge has been painted and now looks fresher and brighter. One of the bathrooms is changing use and will become the manager’s office. One of the large communal toilets has had a bath fitted so that the number of bathrooms in the home remains unchanged. Wall mounted electric heaters have been provided because there had been a problem with the central heating system. This made sure that people would be warm while the problem is being dealt with. The home was clean and tidy and there were no smells. People said their rooms were kept clean and some kept their own rooms clean. The laundry has new washing machine with a sluice cycle on it and a dryer. But soiled laundry is rinsed in a sink before it goes in the machine because there is no sluice and water soluble red PVC bags have not been provided to place soiled laundry in. This means that the risks of cross infection are not being reduced as much as they could be. A copy of the Department of Health infection control assessment tool and guidance ‘Essential Steps’ was seen in the office. The manager was advised to use this to audit the home’s infection control policies, procedures and practices. This will help him to identify if any action needs to be taken to improve infection control measure in the home. Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There is a risk that people’s needs will not be met because there are not enough appropriately trained staff. EVIDENCE: When we met the provider in February 2008 we talked about training and the importance making sure there was a training programme that enables staff to do their job safely and effectively, such as: • Induction training to Skills for Care standards. • ‘Mandatory training’ that equips staff to maintain the health, safety and well being of people who live in the home and themselves, including health and safety, moving and handling, fire safety, first aid, food hygiene, infection control and abuse awareness/adult protection. • Specialist training needed to help staff meet people’s needs such as dealing with medication, mental health. • Training and guidance about the Mental Capacity Act 2005. • NVQ training. The provider told us that he was looking at putting a training programme together and looking for suitable training providers. Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 22 During the visit we found that that some training courses have been arranged, including adult protection and mental health awareness. New staff have been given a workbook that covers the Skills for Care common induction standards but cannot cover all the areas required because the training has to be provided by suitably qualified people/training providers. The manager knows there are still large gaps in training provision and is looking for suitable training providers and dates for different courses. At the meeting in February 2008 the provider said that all required pre employment checks were now in place for all staff and that new people did not start to work until they were received. We looked at three staff files. They showed us that: • Application forms had been completed. • Written references had been requested and at least two had been received for each person. But the references seen were not dated in any way so it was it was not possible to check when they had been sent out, written by the referee and received back at the home. The manager was advised to look at this. The information asked for in the reference letter was very basic and would not be helpful in deciding if the person was suitable for a caring role. The manager said he had identified this and was looking at ways of improving the information asked for. • The most recently employed carer had started work the day after their POVA (Protection of Vulnerable Adults) first check had come through and the CRB (Criminal Records Bureau) disclosure had been received nine days later. • Interview records were not seen and one person had not supplied an employment history or an up to date CV (Curriculum vitae), this means that it was not possible to check for any gaps in employment or the reasons for them. There were sixteen people living in the home on the day of the visit. There were three care staff and the manager on duty. Monday to Friday there is also a domestic for five hours per day and a cook every day for five hours. The manager said that there are usually two or three care staff on weekday mornings, two care staff on the late shift and one waking night carer with a person ‘sleeping in’ in case of emergency. The staff rota showed that at weekends there were only two care staff on duty all day with no domestic cover. This means that care staff are doing the laundry work every day and additional cleaning at weekends. We were told that the cook dealt with breakfast and lunch but care staff dealt with teatime meals. This means that staff are regularly taken away from their caring and support role to carry out domestic duties. The inspection in September identified that there may not be not enough staff on duty to meet people’s needs. The manager was advised to look at the staffing levels over the seven day week as people’s needs do not decrease at weekends. Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, and 42. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Management arrangements for the home have improved recently. If this is maintained there should be better outcomes for people who live in the home. EVIDENCE: In February 2008 we told the provider that the home needed robust management systems and consistent leadership to guide staff and promote well being for the people who live there. This is because the registered manager/provider is not based in West Yorkshire. He lives in London and owns two other homes, one in Wales and one in Bridlington. At the meeting in February we were told that an acting manager has been at the home at least four days a week since February 2008 and the provider was looking for somebody to support him. He has been working for the provider in his other Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 24 homes and as well as being a registered nurse, he has got some experience of residential care. He was in charge when we visited. An experienced senior carer has been employed to provide support to the manager. Staff told us that the way things ran in the home had improved over the last few weeks it was better having a regular management presence in the home. This positive progress needs to be continued and a strong management team put in place that will provide effective leadership for staff as well making sure that the home is run and managed in the best interests of the people living in it. Because the provider took on a home with a number of problems and outstanding requirements from previous inspections there is a lot of work that needs to be done. Starting a process of internal audits to identify what needs to be done should be made a priority. Quality assurance surveys to find out what the views of people living in the home have not been done yet. The manager said they would be done around the anniversary of the provider taking over ownership of the home. Parts of the fire detection systems have been upgraded since the last inspection. The manager said he checks the system weekly. Records confirming this were seen. Staff in the home have been using the wrong documents for recording accidents. This means that: • Not all the required information has been recorded, • It is not clear what action has been taken as a result of the accident or if specialist advice has been asked for. • What the outcome of the accident is and what treatment was given by who. • Who last saw the person, the accident and when. The manager is aware of which incidents/accidents must be reported to us and makes sure that this is done. A copy of the new guidance and forms to use were given to the provider when we met in February 2008. Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 2 34 2 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 2 2 X 2 X X 2 X Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 26 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 YA20 Regulation 13 (2) Requirement Safe systems must be put in place around ordering, receiving, storing and administering medication for people living in the home. This must include making sure appropriate records are kept and take into account steps to be followed for people who want to look after their own medication. This will make sure that people are helped to receive their medications safely and in accordance with the doctor’s instructions. Timescales of 30/07/07 and 03/02/08 not met. It has been agreed to extend the timescale. 2. YA6 15 Detailed care plans must be put 30/08/08 in place for each person living at the home that will provide staff with guidance about what the person’s health, personal, psychological and social care needs are and how to meet DS0000069182.V361575.R01.S.doc Version 5.2 Page 27 Timescale for action 30/05/08 Victoria Road Care Home them. Timescale of 03/02/08 not met. It has been agreed to extend the timescale. 3. YA23 13(6) All staff must receive appropriate training about abuse awareness and adult protection. This will make sure that people living in the home are protected from abuse and that staff will know what to do if they witness or suspect abuse is taking place. Timescale of 30/01/08 not met. It has been agreed to extend the timescale. 4. YA23 17, In order to protect people who 30/05/08 20Schedule have asked the provider to look 4 (9) after their finances steps must be taken to make sure that there are systems in place which clearly identify: * How much benefit/money is paid into the provider’s account and that this account is not used in connection with the carrying on or management of the home. * How much of this is paid as the agreed weekly cost for living at the home. * How much money is left over as the individual’s own personal allowance. When and how much money is returned to the individual, which includes their signature and that of the person returning money to them. If valuables are taken into safekeeping there must be systems in place for recording when they have been received and returned to their owner. 30/08/08 Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 28 Timescale of 03/02/08 not met. It has been agreed to extend the timescale. 5. YA23 17, In order to protect people who 20Schedule have agreed to pay money into 4 (9) the mobility/residents fund steps must be taken to make sure that: People contributing towards it are consulted and agree about how it will be managed. A policy is put in place after the consultation setting out how the fund will be managed, what money can be used for and how it will be made equitable for the people who contribute. There are contracts/agreements between the home and people who contribute. Detailed records of monies received and used are kept. Timescale of 03/02/08 not met. It has been agreed to extend the timescale. 6. YA24 23 (1)(2) In order to make sure that people are living in a clean, safe and comfortable home that is suitable to their needs a programme of repairs, redecoration and refurbishment must be implemented. 31/12/08 30/05/08 7. YA35 18 (1)(c) (2)(b)(4) 30/09/08 All staff must receive appropriate training that helps them to maintain the health, safety and well being of people living in the home and themselves. This must include training about the specialist needs of people especially mental health. Steps must be taken to make sure are aware of their responsibilities under relevant legislation that applies DS0000069182.V361575.R01.S.doc Version 5.2 Page 29 Victoria Road Care Home to people living in the home for example the Mental Health Act 1983 and the Mental Capacity Act 2005. New staff must receive induction training that is to Skills for Care common induction standards. People who provide training must be qualified and competent to do so. Timescale of 30/08/07 was not met and next timescale was not due to expire at time of the visit. It has been agreed to extend the timescale. 8. YA33 18 (1)(a) There must be enough staff on duty at all times to meet the physical, personal, social and psychological care needs of people living in the home. Timescale of 03/02/08 not met. 9. YA34 19 To protect people living in the home pre employment checks must include obtaining a full work history and exploring the reasons for any gaps in employment. An action plan must be provided to us showing how requirements will be met within the given timescales and what action will be taken to improve outcomes for people living in the home. 30/05/08 30/05/08 10. YA39 24 30/05/08 Victoria Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 30 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 YA1 Good Practice Recommendations The provider should make sure that people have access to all the information needed about services provided by the home in the Service User Guide and that it is available in formats that will be easily understood. The provider should make sure that detailed risk assessments are carried out for all areas of activity that might present risk to people living in the home. This should include going out alone and smoking. This will help to promote peoples independence and maintain safety. In order to monitor and maintain the personal and healthcare needs of people as they get older the provider should assess their health care needs at regular intervals and make sure that appropriate health care professionals are consulted for support and advice as needed. In order to make sure that staff have access to up to date guidance on how to deal with medications safely the provider should revise the medication policies in line with the Royal Pharmaceutical Guidelines – Safe Handling of Medication in Social care Settings. In order to reduce the risk of cross infection and contamination the provider should provide water soluble red PVC bags for staff to use when dealing with soiled laundry and when planning the new laundry the provider should consider installing a sluice facility The provider should look at introducing systems of auditing the home that will include obtaining the views of people living there and other stakeholders. The accident records should contain information about when the person was last seen before the accident and by whom, full details of the accident, what action was taken and what the outcome was. This information could be used to prevent future accidents and will be useful as part of the quality assurance/auditing systems. DS0000069182.V361575.R01.S.doc Version 5.2 Page 31 2. YA9 3. YA21 4. YA20 5. YA30 6. YA39 7. YA42 Victoria Road Care Home Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Road Care Home DS0000069182.V361575.R01.S.doc Version 5.2 Page 32 - 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. 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