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Inspection on 19/01/09 for Victoriana Residential Home

Also see our care home review for Victoriana Residential Home for more information

This inspection was carried out on 19th January 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

In the main the home provided a clean, comfortable and safe environment for the people who lived there. Prospective residents were assessed prior to being admitted to the home to ensure that the home could meet their needs. Each of the resident had a GP and where possible, because of the central position of the home, people were able to keep their family GP`s. The staff called GP`s appropriately and kept a record of GP visits. The home booked visits from community chiropodists and opticians as necessary.

What has improved since the last inspection?

Following the last inspection the manager had updated the Statement of Purpose and the Service Users Guide to provide more specific information about what the home provided. Over the last year there had been many changes to the staff team and the manager had persevered with this, and the unrest, and was now concentrating on consolidating and sustaining the changes that had been implemented.

What the care home could do better:

There were still areas that needed improvement, and despite the AQAA not reflecting that the manager was aware of where the shortfalls were she was able to demonstrate that she was aware of many of the changes that were needed. These improvements included:Staff should ensure that the documentation that supports a pre-admission assessment is signed and dated by the person making the assessment. Care plans must be written to indicate how staff will meet all of a service users needs. Staff must ensure that they continually monitor residents risks of developing pressure sores, malnutrition etc. The controlled drugs cupboard should be correctly secured to the wall. It should be possible to see that activities have been devised to suit the individual needs of the residents. The menus must be nutritious and varied. There must be some evidence that the home provides activities. The home must be kept in good order and there must be a maintenance programme. There must be an assessment that shows that there are sufficient staff on duty to meet the assessed needs of the residents. Staff should have a job description that clearly identifies their roles.There must be systems in place that measure the quality of the care provided.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Victoriana Residential Home 6 Lansdowne Road Luton Beds LU3 1EE     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Sally Snelson     Date: 1 9 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 31 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 31 Information about the care home Name of care home: Address: Victoriana Residential Home 6 Lansdowne Road Luton Beds LU3 1EE 01582484177 Telephone number: Fax number: Email address: Provider web address: victoriana@heritagecarehomes.co.uk Name of registered provider(s): Name of registered manager (if applicable) Post Vacant Type of registration: Number of places registered: Heritage Care Homes Ltd care home 33 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home The Victoriana was located in a pleasant residential suburb of Luton that was close to Wardon Park and a library. The town centre, which was a short bus or car ride away, had shops and national rail and bus links. Mr and Mrs Hussain had owned the home for a number of years. They had formed a limited company Heritage Care Homes Ltd to operate the Victoriana and two other care homes in the vicinity. There is presently no registered manager for this home. The property was originally a domestic dwelling that had been converted and extended to provide a homely and comfortable environment. The home had three floors with a shaft lift and staircases for access. The fees for the home at the time of the inspection were £431-£490 per week. Additional items such as hairdressing and chiropody had to be paid for as an extra. 0 0 Over 65 15 33 Care Homes for Older People Page 4 of 31 Care Homes for Older People Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This inspection was carried out in accordance with the Commission for Social Care Inspections (CSCI) policy and methodologies, which requires review of the key standards for the provision of a care home for older people. The methodology that takes account of residents views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. Sally Snelson undertook this inspection of the Victoriana. It was a key inspection, was unannounced, and took place from 11.00hrs on the 19th January 2009. Care Homes for Older People Page 6 of 31 Mrs Hussain the owner, and Erin Bermingham the manager were present for the inspection. Feedback was given throughout the inspection, and at the end. During the inspection the care of two people who use the service (residents) was case tracked in detail. This involved reading their records and comparing what was documented to what was provided. In addition to sampling files, people who lived at the home, visitors, and staff were spoken to, and their opinions sought. Any comments received from staff or residents about their views of the home, plus all the information gathered on the day was used to form a judgement about the service. We would like to thank all those involved for there assistance with the inspection. What the care home does well: What has improved since the last inspection? What they could do better: There were still areas that needed improvement, and despite the AQAA not reflecting that the manager was aware of where the shortfalls were she was able to demonstrate that she was aware of many of the changes that were needed. These improvements included:Staff should ensure that the documentation that supports a pre-admission assessment is signed and dated by the person making the assessment. Care plans must be written to indicate how staff will meet all of a service users needs. Staff must ensure that they continually monitor residents risks of developing pressure sores, malnutrition etc. The controlled drugs cupboard should be correctly secured to the wall. It should be possible to see that activities have been devised to suit the individual needs of the residents. The menus must be nutritious and varied. There must be some evidence that the home provides activities. The home must be kept in good order and there must be a maintenance programme. There must be an assessment that shows that there are sufficient staff on duty to meet the assessed needs of the residents. Staff should have a job description that clearly identifies their roles. Care Homes for Older People Page 8 of 31 There must be systems in place that measure the quality of the care provided. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 31 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents were assessed prior to being admitted to the home to ensure that the home could meet their needs. Evidence: Following the last inspection the manager had updated the Statement of Purpose and the Service Users Guide to provide more specific information about what the home provided. There was evidence in each of the files that we looked at that a prospective resident had been assessed before the decision to admit them to Vicotoriana was made. The pre-admission assessment took place either at the residents home, or at their current place of care. Staff must ensure that they date and sign the assessment documentation. On the day of the inspection the deputy manager was assessing a possible admission, and if it was agreed that if the home could meet the persons Care Homes for Older People Page 11 of 31 Evidence: needs a visit would be arranged for the prospective resident and/or their family so they could make an informed choice. Each file included a contract that had been signed and dated. Where the fee was payable by the placing authority this had been written into the contract. People using the service were made aware of the extras that they needed to pay for. Victoriana admitted residents for respite care but were not equipped to take people who needed intermediate care. Care Homes for Older People Page 12 of 31 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each individual had a plan of care that included the basic information necessary to deliver the persons care. However the instructions were not detailed and did not show that the resident had been involved. Evidence: We case tracked the care of two people using the service. One had been at the home for a number of years and had high needs, while the other had only recently been admitted and was still within their trial period. The month previous to our visit the manager had altered the care planning system, as the staff had not found the care planning books easy to follow. The system that had been introduced was not comprehensive enough and although it outlined a residents care needs and how these were to be met it did not provide sufficient detail. For example one of the residents whose care we tracked had a pressure sore that was being treated daily by the community nurses, and although the plan informed us of this, and indicated that it was necessary to turn the person, the frequency and the Care Homes for Older People Page 13 of 31 Evidence: order of the rotations was not described. This was particularly important as it became apparent that the community nurses had passed on information to one staff member which was not being followed by all. The new plans described the care but did not indicate that the resident had been involved and as the plans had only just been introduced it was not possible to assess how they were being reviewed. Whilst it is important that the care plans are considered suitable by the people who use them it must be clear how decisions are made and how care needs are planned and altered as conditions change. Therefore these plans need to be built upon. Also because all the plans followed on from one another on one page any associated documentation was not necessarily with the plan. For example the plan that we looked at detailed pressure relieving equipment, moving and handling processes and extra dietary requirements, but the assessments that accompanied these decisions were stored elsewhere. It was therefore not easy to see how the decision to provide food supplements had been reached because the relevant risk assessments and weight charts were stored elsewhere in the file. We would have preferred to see an individual page for each different plan of care, as we believe that as the plans alter this format could become very muddled. As already mentioned those residents that needed risk assessments had some in place but we would have expected to see more, such as nutritional screening, and risks for developing pressure sores for those considered at risk. For example not only those nursed in bed, but also those who had decreased mobility. Each of the resident had a GP and where possible, because of the central position of the home, people were able to keep their family GPs. The staff called GP appropriately and kept a record of GP visits. The home booked visits from community chiropodists and opticians as necessary. We looked at the medications and the medication records for a number of people in the home. Because the new stock had only just been signed in, and it was the first day of the cycle, it was not possible to reconcile the medications. Normally we would count the number of signatures and count the tablets left in the home to ensure that these reconciled. We were told that the home sends all medications back at the end of the cycle and signs in new medications, so nothing is carried forward. We did however look at the Medication Administration Records (MAR) for the previous month and noted that there had been a number of omissions of signatures. In addition that codes had not always been used correctly and that where codes, such as O for other had been used there was no explanation on the back of the MAR chart to define what was meant by other. Speaking to some of the senior staff who were responsible for the administration of medication it appeared that it was almost certain that the mediation had been given, and the staff had forgotten to return to the sheet to indicate the Care Homes for Older People Page 14 of 31 Evidence: administration with a signature. It is the responsibility of someone, usually the manager, to regularly audit medications and check MAR charts and reconcile medications, this obviously had not been done or these omissions would have been picked up. The manager and the seniors agreed to initiate this immediately. The controlled drugs were stored in an appropriate cupboard but the cupboard was free standing in another locked cupboard. In 2007 the law changed. All care homes, whether providing nursing or personal care, must now keep controlled drugs (CD) in a controlled drugs cupboard. In brief, the requirements for CD storage are; a metal cupboard of specified gauge,a specified double locking mechanism, the cupboard fixed to a solid wall or a wall that has a steel plate mounted behind it and fixed with either Rawl or Rag bolts. The manager told us that she would ask the handyman to correctly secure the cupboard immediately, so we did not leave an immediate requirement for this. We saw people being treated kindly and with respect and we noted that some people were referred to as Mrs so and so, while others preferred to be called by first or pet names. All personal care was provided in residents bedrooms. We were disappointed that as some people liked to have the TV on and others did not, that the first floor lounge was not being used. People were dressed in their own clothes and it was apparent that those who could dress themselves choose what they wanted to wear for themselves. Care Homes for Older People Page 15 of 31 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff had identified some social activities that would please and stimulate the people using the service, but these were not planned and relied on the staff on duty having the time and inclination. Meals were freshly prepared and there was a choice available. Evidence: During the inspection we did not see much evidence of activities. The manager told us that there was no formal activity plan and that no one member of staff had been detailed to co-ordinate the activities in the home. On the day of the inspection some staff were doing residents nails, and using this time to talk to them, but we did not see much else happening. We could not see from care plans what activities people would choose to do and be interested in. Two residents told us that they went out shopping with a staff member, but we were not able to ascertain how those who were less mobile, and suffered from dementia spent their time. The staff must also consider those people using the service with dementia, and impaired vision and hearing, when planning an activity programme. A relative told us as part of our survey that her relative would enjoy more activities such as old-time songs. We saw that relatives were welcomed into the home and were told that they could visit Care Homes for Older People Page 16 of 31 Evidence: at anytime. The inspection spanned lunchtime and we witnessed a social occasion with most of the residents choosing to have their meal at one of the dining tables. The dining tables were nicely prepared with jugs on the tables. People were asked to make a choice prior to the meal. The manager told us that picture menus had been produced, but these were not suitable to use with the current group of residents. We saw people being offered the choice between steak pie and a variety of fresh vegetables or omelettes for lunch, followed by apple pie or a whip. We were pleased to hear staff asking a resident who refused both options if she would like sandwich. Once again we were concerned that although the menu appeared nutritious and included the types of meals that the residents enjoyed, care was not taken about the variety. For example a pastry main course and dessert is not ideal. We also noted that the supper the night before had been egg based, as had the alternative to the steak pie, and eggs were planned for the evening meal. Fortunately a carer picked this up and made a pasta alternative for the evening meal. The home employed two cooks to cover the seven days. We noted that the kitchen was closed by 14.00hrs as the cooks worked 7-2 and that care staff had to prepare the evening meal. One of the cooks we spoke to felt it was busy in the kitchen, and it would be beneficial to have help with the washing up. However this may have been because from serving lunch to the end of the shift there was limited time to do all that needed doing. We were told that the cook prepared the breakfast and cooked the lunch, but did not prepare any vegetables, as this was done by the night carers, (see staffing section of this report) and did not prepare tea time meal as this was done by carers. Hot and cold drinks were made available at mealtimes and throughout the day. At the time of the inspection the cook managed to meet the requirements of diabetic and vegetarian residents and those who needed a soft or pureed diet. Care Homes for Older People Page 17 of 31 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints procedure and staffs understanding of safeguarding people kept the people living at the Victoriana safe. Evidence: The home had a complaints procedure that well publicised and allowed residents and visitors to make a complaint to the management of the home. The complaints procedure advised the complainant about the expected timescale for a response and offered alternative agencies if the complainant was not satisfied with the outcome. There had been one complaint made to the home since the last inspection and this had been dealt with correctly. Because of previous issues staff had been asked to report any incidents of unexplained bruising or injury to the local safeguarding (SOVA) team. The SOVA team were now happy with the standard of reporting and accepted that the manager and staff could identify when an injury could/ should have been prevented. All staff had had external training about safeguarding and were preparing to update their training. Staff were informing the relevant organisations of incidents and cooperated with any investigation. The manager showed that she knew the correct procedure for disciplining staff should Care Homes for Older People Page 18 of 31 Evidence: the need arise. Care Homes for Older People Page 19 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. In the main the home provided a clean, comfortable and safe environment for the people who lived there. Evidence: There had been no major changes to the environment since the last inspection with the exception of a spa bath being fitted into a bathroom that had a bath that was out of order at the last inspection. This means that there are now bathing/showering facilities on each floor. Generally the home was clean and tidy and pleasantly furnished, but there were some areas that required upgrading and redecoration. For example the curtains in some bedrooms needed to be replaced and some flooring needed replacing. A Carpet (not the washable type) in a bathroom was not suitable, and the floor tiles behind an ensuite were in a bad state. Care must be taken that hand drying facilities are available in all toilets. There was a second floor lounge that was not in use at the time of the inspection. As the numbers of residents rise this should become operational to allow people an alternative place to sit. We overheard two residents disagreeing as to whether the TV should be on or not. Therefore offering the use of the first floor lounge as a quiet area Care Homes for Older People Page 20 of 31 Evidence: would solve this. There had been some problems with the boiler and the plumbing in the home which had been rectified by installing a new boiler. On the day of the inspection there had been no hot water available. This was sorted out immediately and staffed managed the situation appropriately by using urns to provide the hot water for the morning washes. Many of the residents were unaware that there had been a problem. We noted throughout the inspection that the manager spent alot of time answering the phone to calls that were for the owner. This was because the head office (on the same premises) was not manned every day and when it was not manned calls meant for the owner came to the home. The laundry room was clean and tidy and on the whole people were satisfied with the laundry process. Care Homes for Older People Page 21 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff team were more settled and needed to work together to provide more activities and spend more time with residents. Evidence: There had been a number of staffing issues over the last year and 19 staff had left the home; some had not worked long before leaving. The manager was concerned about the unrest within the staff team and believed it was because she had to change a number of things when she returned back from maternity leave, and staff did not want some of the changes. The staff on duty at the inspection all appeared to be happy now and the have your say about questionnaires returned from staff confirmed this, but some relatives in their have you say about questionnaires felt the staff team were not as happy or friendly as in the past. Some staff who had left had contacted as they felt the manager was choosing a staff team of friends, the manager denied this and said she had worked with alot of the staff before but had not got rid of staff to make a job for individuals. We had heard from other sources that some staff appeared to spend time with the manager in the office, while others were excluded. We discussed this with the manager and she accepted the need to make changes and told us the next day that she had discussed this, and other issues raised at the inspection, with the staff team. Care Homes for Older People Page 22 of 31 Evidence: This home was staffed by a small team that appeared dedicated to the service users. We were told that agency staff were rarely required, although one had to be called to cover an unexpected absence on the day of the inspection. Staff spoken to confirmed that they were happy to cover each others absences where possible. During the daytime there were four care staff, on duty, supported by the manager and the deputy. At night there are only two staff. We were concerned that for the number of residents that required care during the night, and the extra duties such as ironing and vegetable preparation, two staff over three floors was not sufficient. The manager and owner used the residential homes forums tool for measuring the amount of staff needed per shift, but they must remember that the dependency of the residents must also be taken into account. Separate staff were employed for the cooking (but not all the kitchen duties) and cleaning but not laundry. Each member of staff had an individual training file that detailed the training they had done. The home along with other homes under the same ownership used a training company that kept them informed as to what training needed to be undertaken and when it needed updating, as well as delivering the training. Two staff files were picked at random during the inspection and examined. One was that of a member of staff who had recently been recruited. All files contained the appropriate recruitment documentation, which included; fully completed application forms, interview feedback sheets, two appropriate references, Criminal Records Bureau check, photograph identification, passport and home office documentation where appropriate, and contracts clearly signed and dated. It was clear that staff did not start work until all checks had been completed and returned as clear. New staff had an induction period, but this was not well recorded and the home did not have an induction policy to follow. Care Homes for Older People Page 23 of 31 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager needed to show that she could manage the home and make the necessary changes. Evidence: The manager had returned to the home approximately a year ago, following a period of maternity leave. When she returned to the home there were a number of concerns about the home and she had had to work hard to make the necessary improvements. During this time a number of the staff left and she had a difficult time keeping a happy staff team. During that time she tried a number of ways to involve staff ,including staff meetings and sending out quality surveys. She now needs to concentrate on consolidating the improvements she has made and building on them and ensuring that she managers the home efficiently. We would expect her to complete her NVQ level 4 and become the registered manager as a soon as possible. We discussed the managers perceived relationship with some of the staff with her, and she was aware of the need to be seen to be open and transparent with all staff. Care Homes for Older People Page 24 of 31 Evidence: As already stated the manager had sent out extra quality surveys but had not finished the process by evaluating them and producing a report. The annual survey was now due and this should be completed and acted upon. Failure to act on the surveys makes people feel that they are not worth completing. In July 2008 we had recognised that there were some problems with the Victoriana and other homes owned by the same owner that the owner was unaware of. We had therefore required him to complete the required Regulation 26 visits so that he could identify the shortfalls in the home for himself. This was done for two months, but has again stopped. We will be considering the action we take regarding this breach of regulation. The home only held small amounts of money on behalf of residents. Some residents finances were checked. The balances were correct and receipts were kept of all transactions. The standard of record keeping needs to be improved. This includes the need to accurately record details and ensure that documents, particularly medication records, are accurate. We were disappointed that the returned AQAA did not highlight any future plans the manager had for the home. We looked at health and safety documentation, including the fire log and maintenance book. There was evidence to indicate that fire call points and the emergency lighting were being tested on a regular basis, and that fire drills were carried out periodically Care Homes for Older People Page 25 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 This requirement is Regulation 15 (1) Care plans must be written in detail to indicate how a service users needs in respect to health and welfare are to be met. Care plans must be in sufficient detail to ensure that all staff provide the same level of care. 01/03/2009 2 8 12 Staff must ensure that 01/03/2009 residents risks of developing pressure sores, malnutrition etc are kept under review. This is to ensure that care plans change as care needs alter. 3 9 13 This refers to Regulation 13(2) The manager must ensure that medications are administered and stored correctly. 01/03/2009 Care Homes for Older People Page 27 of 31 This is so that medications in the home can be reconciled at any time. 4 12 16 This relates to Regulation 16 01/03/2009 (2) (m)and (n) There must be some evidence that the home provides activities. Activities are necessary to stimulate the residents. 5 15 16 This relates to Regulation 16 01/03/2009 (2) (i)The menus must be nutritious and varied. People should be offered choices and not provided with the same foods again and again. 6 19 23 This requirement relates to regulation 23 (2). The home must be kept in good order and there must be a maintenance programme. This is so that areas that need repair or replacement are identified it is recorded and a record of when the task is completed in kept. 7 27 18 There must be an assessment that shows that there are sufficient staff on duty to meet the assessed needs of the residents This requires to the night shifts. 8 30 12 There must be evidence that 15/02/2009 staff have completed and induction programme. 01/03/2009 01/04/2009 Care Homes for Older People Page 28 of 31 This is to ensure that all staff have been shown how the home operates and how it is expected that they should deliver care. 9 33 24 This also relates to regulation 26 There must be systems in place that measure the quality of the care provided. This is so that routinely problems can be identified and solutions found. 10 37 17 This refers to regulation 17(1) and schedule 3 and 4. All records must be completed accurately in line with the homes policy and procedures. This is so that the home has an accurate record of all events and care practises. 01/03/2009 01/03/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 3 Staff should ensure that the documentation that supports a pre-admission assessment is signed and dated by the person making the assessment. The controlled drugs cupboard should be correctly secured to the wall. It should be possible to see that activities have been devised to suit the individual needs of the residents. Staff should have a job description that clearly identifies their roles Staff should work the hours that meet the needs of the 2 3 4 5 9 14 27 27 Care Homes for Older People Page 29 of 31 service not those that suit them. 6 31 Consideration should be given to the manager becoming the registered manager, completing the necessary training and extending her knowledge. Care Homes for Older People Page 30 of 31 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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