Inspection on 18/08/05 for Victoriana Residential Home

This inspection was carried out on 18th August 2005.

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

Victoriana Residential Home 19/01/09

Victoriana Residential Home 05/02/08

Victoriana Residential Home 26/09/07

Victoriana Residential Home 23/02/07

Victoriana Residential Home 24/02/06

Victoriana Residential Home 17/01/05

Victoriana Residential Home 08/04/04

Victoriana Residential Home 29/07/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Victoriana Residential Home 6 Lansdowne Road Luton Beds LU3 1EE Lead Inspector Leonie Milton Unannounced 18 August 2005 th 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 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. Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Victoriana Residential Home Address 6 Lansdowne Road Luton Beds LU3 1EE 01582 484177 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Heritage Care Homes Ltd Mrs Jane Roe Care Home 24 Category(ies) of OP Old Age - 24 registration, with number of places Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14.01.05 Brief Description of the Service: The Victoriana was located in a pleasant residential suburb of Luton that was close to Wardown Park and a library. The town centre, which was a short bus or car ride away, had shops and national rail and bus links. The home had been owned for a number of years by Mr and Mrs Hussain. They had formed a limited company Heritage Care Homes Ltd two years ago to operate the Victoriana and two other care homes in the vicinity. Mrs Jane Roe had managed the home for a number of years. The home was registered to provide for 24 older persons. The registration to care for those with dementia will need to be included in the registered conditions. The property was originally a domestic dwelling that had been converted and extended to provide a homely and comfortable environment. There were twenty-four single bedrooms. The bedrooms were fitted with washbasins and call bell systems. Eleven had ensuite toilet facilities. The home had three floors with a shaft lift and staircases for access. Communal accommodation comprised of two lounge/diners on the ground floor, one of which was a large room that overlooked the garden. A third lounge/diner was located on the first floor. Toilet and bathing facilities were located for easy access near to the lounges and bedrooms. There was a total provision of three bathrooms, one shower room and seven toilet facilities. One of the baths however was not in use. The room had been used as a staff locker room since the previous inspection. Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over 7.10 hours. The manager was present throughout to assist. The methods of inspection included a review of the documentation in relation to the care of three service users, conversations with two of these persons and with one other service user. The private accommodation for three service users was assessed, as were communal facilities. Sundry other records relevant to the operation of the home were assessed. Conversations took place with two members of staff and the manager. Observation of the lifestyle in the main lounge and the evening meal in progress took place over one and a half hours. What the service does well: The home had a welcoming atmosphere that was enhanced by the cleanliness of the areas of the building seen at this inspection and the homely appearance of the communal accommodation. Service users were provided with a choice of lounges. The largest lounge overlooked the garden and had a busy atmosphere. The other two provided quieter environments and an area for private meetings. It was reported that the lounge on the upper floor was rarely used because service users preferred the atmosphere on the ground floor. As had been noted at previous inspections, the core members of the team had worked at the home for a significant period and were well versed in the needs of service users and the home’s operational systems. There was a recognisable senior team to provide guidance and support for the team. Sufficient ancillary personnel were employed, one member having a dual role as carer and domestic. Members of staff on duty presented as professional and caring. They were observed to go about their business in a quiet but confident manner. Service users spoken to at this inspection in the main were satisfied with the service they had received. Positive comments were passed about the food, accommodation and the day-to day lifestyle in the home. One service user said that she felt that she “had been treated like a human being”. Another remarked on the kindness of the staff and confirmed that they responded promptly to requests for assistance. One other service user also remarked on the kindness of staff but was a little disgruntled about some aspects of her Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 6 care. She felt that a member of the night staff had been unsympathetic about her need for assistance at night. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 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 standard(s) 1,,3,4, Service users or where appropriate their representatives had been provided with sufficient information to make an informed choice about moving into the home. EVIDENCE: A comprehensive statement of purpose that outlined arrangements as specified by this standard provided a clear and user-friendly guide to the service provision. It was reported that copies had been placed in each bedroom. The manager explained that copies were available to prospective service users on request. Assessments of need for those admitted after the introduction of the National Minimum Standards (NMS) in 2002 had incorporated the details specified by the NMS. The home did not provide an intermediate care service. Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,10,11. There was sufficient written guidance in place in relation to each service user to enable staff to properly care for them. EVIDENCE: Care plans had been developed to provide a user-friendly guide to care needs based on a thorough assessment of need and risk. Account of service users’ life history had been included in the plan, which had had been written in a style that was sympathetic to frailties, resulting needs and respectful of personal dignity. The main document however was a flowing narrative that did not easily allow for changes in need to be added. It is recommended that the format for care planning documents be reviewed so there is space in the documents to identify how changes in need will be met. Records indicated that plans had been reviewed on a regular basis and that appropriate referrals had been made to health care professionals for routine medical appointments but also to promptly to service users’ doctors as need be. Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 10 Observation of practice showed that service users were treated with respect and that approaches to service users with cognitive impairment was sensitive to this aspect of their abilities. Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 Service user had been supported to experience a lifestyle that met their expectations and took account of their needs. EVIDENCE: Service users confirmed that there were satisfied with the daily routines in the home and the provision of recreational activities. One service user stated that there were “ no rules to have to live by.” Conversations with service users, minutes of meetings and posters of scheduled entertainment indicated that service users had been given the opportunity to join in activities such as bingo, quizzes, sing-a-longs and similar. There had been an event with an external entertainer most months and a recent garden fete. On the day of the inspection service users in the main lounge were listening and singing along to old time music. A game of dominoes was also in progress. Visitors were noted to come and go during the inspection. Each was made welcome by the staff. Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Service users were able to raise concerns and were appropriately protected from harm by the home’s protection procedures and its overall philosophy of care. EVIDENCE: Previous inspections had noted that the home had robust complaints and protection procedures. A summary of the complaints procedure was available to service users through the written guidance to the home. Records indicated that there had been no formal complaints for more than a year. The central log showed that complaints were few and that where necessary appropriate investigation and action had taken place. Two service users stated that they felt able to complain if the need arose. The majority of personnel had undertaken training in protection procedures. One member of staff showed that she understood the necessity of this training and confirmed that it had increased her awareness of service users’ rights to respect. Two personnel files were assessed. They identified that appropriate checks had been carried out before new employees had commenced duties in the home. Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25, The home on the whole provided a comfortable, safe and clean environment that was suitable for the service users’ needs. EVIDENCE: The home was homely in appearance and well decorated. The layout of the building predominately met the National Minimum Standards with the exception of access to the toilet on the ground floor for disabled persons, which was at some distance from the main lounge, and the numbers of adapted bathing facilities. There had been no changes to the layout of the bedrooms since the previous inspection, which had noted, “two bedrooms were rather small but met the standard when the communal space was taken into account. One bedroom only provided a limited view of the outside world.” The bedrooms seen at this inspection were well decorated and contained service users’ personal items, photographs, ornaments and similar. Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 14 Those areas of the building seen at this inspection were clean and orderly. A few of the armchairs in the main lounge were showing signs of wear and tear and will need to be replaced in the near future. The carpet in the main lounge had worn by the door to the kitchen. A section had been replaced with a door mat type covering that is not usual for a lounge. The upholstery of a commode in one bedroom was split and had exposed that foam beneath. This must be dealt with promptly because of the hazard of the spread of fire. Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 There had been sufficient numbers of skilled staff on duty to ensure that service users had been cared for properly. EVIDENCE: Care staffing arrangements had met the standard for minimum staffing arrangements set by the previous regulatory authority. Sufficient ancillary staff had been scheduled. Care staff had carried out cooking duties at weekends but had been rostered separately to perform these tasks. There was an identifiable senior team to support care and ancillary personnel. Ten of the twenty care staff held National Vocational Qualifications in care (NVQ). It was reported that five others were working towards an NVQ award via the organisation and the two other members of staff were working independently towards an award. The standard of training for personnel was satisfactory with the exception of induction, which was a little brief. Records indicated that although there was no overall training and development plan for each member of staff, there were individual records of achievement so that gaps in training and any required updates could be identified. The organisation utilised the knowledge of another of its care home managers, who was a qualified trainer, to provide the majority of training and updates for staff. The manager at the Victoriana stated that training was planned in conjunction with the internal trainer. The Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 16 manager was advised to review the induction and training provision against the specifications of the National Training Network to determine that the provision met required standards. Recruitment procedures were mainly satisfactory. One record showed that references had not been sought from the manager of care home where the applicant had been employed previously but from another employee in that establishment. The manager was advised that references must be sought from the manager/senior person of an organisation. Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,34,36,37,38. An experienced and skilled manager had managed the home to the benefit of service users. EVIDENCE: The manager had worked in the home for sometime and had contributed significantly to the development of its philosophies and underpinning written procedures. The manager held an NVQ in management and was working towards the care component of this qualification. Service users stated that the manager was approachable. A member of staff described her as being supportive and fair. It was evident that the manager’s hands on approach to her role had enabled her to lead by example and influence the service delivery with its emphasis on friendly and supportive care. Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 18 It was also evident that the manager was on good terms with her staff and had met with them formally at staff meetings as well as informally on an ad hoc basis. There had however been no progress with staff supervision, which is a legal requirement. Whilst safety aspects of the home were not reviewed in total at this inspection, records indicated that staff had received instruction on health and safety issues, records had been maintained of fire safety checks and appropriate measures had been taken to protect service users from accidental burn, scald or falls from windows. Records had been well maintained in a methodical manner. The manager was advised about the confidentiality of service user records such as accident records and health care appointments, which must be maintained in individual records rather than in one book. Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 3 2 2 3 3 3 x 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 Standard No 16 17 18 Score 3 x 3 3 3 x x x 1 2 3 Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 20 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 8 Regulation 13(1)(b) Requirement An assessment by an occupational therapist must be requested for the service user who was identified to the manager in the written feedback issued at this inspection. The arrangements for the serving of meals must be reviewed so that each service user receives an appropriate level of support and that each course is served on a different plate. The registered person must provide supervision as specified by this standard and the legislation. The provision must include the manager.(Previous timescale of 30.06.05 had not been met) Ensure that records of accidents and health care appointments and treatments are maintained seperately for each service user. Timescale for action 30.09.05 2. 15 12(1)(b), 16(2)(i) 30.09.05 3. 36 18(2) 31.10.05 4. 37 17(1)(a) Schedule 3. 30.09.05. Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 21 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. 3. Refer to Standard 7 22 30 Good Practice Recommendations Review the format for recording care planning arrangements to take account of the need to update this record as needs change. Arrange for a qualified occupational therapist to assess the building in relation to environmental adaptations for disabled persons. Review the induction and training provision against the specifications of the National Training Network to determine that the provision meets required standards. Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Clifton House 4a Goldington Road Bedford MK40 3NF 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 Victoriana Residential Home I51 S45214 Victoriana V45214 180805 Stage 4.doc Version 1.30 Page 23 - 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. 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