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Inspection on 23/02/07 for Victoriana Residential Home

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

This inspection was carried out on 23rd February 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

What has improved since the last inspection?

9 new bedrooms including a conservatory added to the ground floor lounge and registered. Building entirely recarpeted & decorated. Garden / patio area was repaved, hairdressing room, staff room, new office room and 2 staff toilet facilities added. Every fortnight yoga activity has been introduced for the service users`.

CARE HOMES FOR OLDER PEOPLE Victoriana Residential Home 6 Lansdowne Road Luton Beds LU3 1EE Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 05:45 23 February 2007 rd X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Victoriana Residential Home DS0000045214.V329468.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 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 DS0000045214.V329468.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoriana Residential Home Address 6 Lansdowne Road Luton Beds LU3 1EE 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) 01582 484177 Heritage Care Homes Ltd Mrs Jane Roe Care Home 33 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (33) of places Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th February 2006 Brief Description of the Service: 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 two and half 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 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. Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out on 23/02/07 over 3 ½ hours by Pursotamraj Hirekar. The manager coordinated the inspection through out. The method of inspection included study of care plans, risk assessments, personnel records, staff deployment duty rota, relevant care delivery documents, discussions with responsible individual, manager and staff, conversation with service users’ and partial tour of the building. This inspection report also includes information from the service users’ survey carried out by the commission and pre-inspection information provided by the home. What the service does well: The manager of the home was qualified, experienced and had appropriate skills for delivery of the care to the service users’. The home was kept clean, tidy, and hygienic. The manager and staffs’ had good working relations with the service users’. What the Service users’ and their family members have said to the service users’ survey carried out by the commission are as follows: Service user –1 said ‘I have noticed all patients are attended to very quickly when needed. On several occasions I have noticed staff very patiently attempting to engage my wife in conversation, and occasionally obtaining some reaction, she ignores me’. Service user – 2 said ‘as the husband I am fully informed, on arrival, as to my wife’s medical condition if she has been unwell and whether or not she has been given medication’. Service user –3 said ‘having lived here since 17/11/2000 I feel secure and well looked after. The staff are so kind and attentive’. Service user – 4 said ‘I would like you to know that the Victoriana has provided dad with excellent care on a timely home from home environment. My family has gone through turbulent times recently, culminating into the death of my mother this month and through out this the staff at the home have been totally supportive, caring and compassionate both to dad and myself’. Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangements for informed decision by the potential service users’ and their needs were assessed prior to admission. EVIDENCE: The home had 5 new admissions since the previous inspection. The home does not provide intermediate care and only provides long-term care and support. On this inspection 3 new admissions temporary care plans were seen and found that the home had prepared temporary care plans for all the 3 service users’. Service user –1 date of admission 08/02/07, service user – 2 date of admission 16/02/07 and service user – 3 date of admission 15/02/07. These temporary care plans included information in the areas of; assistance level, continence requirements, dietary requirements, eyesight, hearing, oral care, Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 9 communication/social care, pressure area care, night care, mobility, medication, medical history and special notes for staffs. The manager prepared all the temporary care plans, which were based on an initial assessment, social services assessment, and comprehensive assessment carried out by the home. In addition to the temporary care plans the home had recorded valuable personal effects and obtained the signature of the relative on the inventory of service user’s possession on admission as well. The commission had undertaken service users’ survey prior to this inspection, to get the feedback from the service users’ and their family members about the care and services they get from the home. A pre-inspection questionnaire was also used for the responsible individual/manager to provide information to the commission with regard to various aspects of care provision and delivery they undertake. 8 service users’ have responded to the service users’ survey undertaken by the commission, of which all the 8 service users have said that they had prior information about the home, before they moved in and had signed the contract of services. Service user – 1 said ‘received some information from a relative of a patient. Information received was very favourable’. Service user – 2 said ‘I visited 4 homes before we decided. JR was the only manager that had fine for us’. Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangements to meet the personal and health care needs of the service users’. EVIDENCE: The home had developed and used the comprehensive tool for assessment and preparation of care plans. On this inspection in addition to 3 temporary care plans 3 more care plans were seen. Their details are as follows: Service user –1 date of admission 03/09/04, The care plan covered areas such as assistance level, continence requirements, dietary requirements, eyesight, hearing, chiropody, communication, social care, pressure area care, night care, mobility and manual handling, medication, medical history as known, identified risks in the area of manual handling, dietary and social isolation, financial affairs, and the intended goals to be achieved. The copy of the care plan was sent to the solicitor, as there is no next of kin in contact with the service user. Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 11 The current plan had incorporated the changes and developments that had taken place in the life of the service user since the previous plan. The changes included; the dementia continued to progress and the service user is now fully dependent on staff for all functions of daily living. She no longer had contact with her daughter and minimal contact with other daughter and son. Her close friends regularly visit and provide support. 2 senior staffs’ now provide the care. Service user – 2 date of admission 23/11/06. Service user, daughter of the service user, senior staffs from the home and social services have contributed in the preparation of the care plan. The care plan covered areas such as assistance level, continence requirements, dietary requirements, eyesight, hearing, chiropody, communication, social care, pressure area care, night care, mobility and manual handling, medication, medical history as known, identified risks in the area of manual handling, dietary and social isolation, financial affairs, and the intended goals to be achieved. The daughter of the service user signed the care plan. The home had carried out monthly service user’s care plan review and had incorporated the changing needs of the service user which included in the areas of personal hygiene, continence requirements, diet, hourly check in the night and input from the district nurse. Service user – 3 date of admission 06/07/05. Service user, daughter, lime trees assessment unit, Luton, and Dunstable hospital, senior staff from the home, and cart assessment team have contributed in the preparation of the care plan. The care plan covered areas such as assistance level, continence requirements, dietary requirements, eyesight, hearing, chiropody, communication, social care, pressure area care, night care, mobility and manual handling, medication, medical history as known, identified risks in the area of manual handling, dietary and social isolation, financial affairs, and the intended goals to be achieved. The daughter of the service user signed the care plan. The home had carried out monthly care plan reviews and incorporated the changing needs of the service user into the care plan which included; more assistance from the staff, cellulites in her right leg, noted deterioration in her mobility, back problem, and visits of her family members. The recent monthly review had reported that the service user continues to require the assistance of 1 staff member. Continence remains the same, and continue to require minimal assistance at times for diet, but is improving and becoming more independent again. The input from the district nurse was no longer required as the wound to leg has now healed. Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 12 The home had made appropriate arrangements to meet the personal and health care needs of the service users’. This was evident from the above 3 service users’ information and various responses the service users’ have provided to the service users’ survey. Of the total 8 service users’ 6 service users have said that they always receive the care and support they need and 2 service users said they received usually. However, when asked do they receive medical support they need, 6 service users’ said they received medical support always. 2-service user’s said usually. Service user –1 said ‘I have noticed all patients are attended to very quickly when needed. On several occasions I have noticed staff very patiently attempting to engage my wife in conversation, and occasionally obtaining some reaction, she ignores me’. Service user – 2 said ‘as the husband I am fully informed, on arrival, as to my wife’s medical condition if she has been unwell and whether or not she has been given medication’. Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had variety of activities that match wide range of needs of the service users’. The home needs to have robust consultations to take into account the choice of food of all the service users’ at all times. EVIDENCE: Of the 8 service users’ who responded to the commission’s survey, of which 2 service users’ have said they always like the meals at the home and 6 said usually they like the meals at the home. The home needed to have appropriate consultative dialogue with the service users’ for the choice of food. The home had very recently put up a notice, which read ‘meal time restrictions for service users family members and visitors in the interests of service users, as this makes service users’ conscious and they do not eat well and medication time is also disturbed as well’. The activities run by the home are quite adhoc except for the monthly parties with a musical entertainer. Of the 8 service users’ who responded to the commission’s survey, of which 3 service users said they always participate in Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 14 the activities and 4 service users’ said they usually and 1 service user said sometimes participate in the activities the home conducts. Some quotes in the words of the service users; Service user –1 said ‘available but unable to take part due to blindness and dementia and mobility’. Service user – 2 said ‘a live musical entertainment she will show signs of enjoyment. Any other form of entertainment she is not mentally capable of taking part. On occasion she shows some reaction to television, the home do their best’. Service user –3 said ‘her appetite varies considerably. Sometimes she won’t eat anything. As this report is being completed she is eating well. At one period when her appetite was poor she was given a special supplement and weighed weekly. She has to be hand fed. She is kept very clean. There is no food on her clothes’. Service user – 4 said ‘ dad is quite passive and doesn’t tend to take part, but I have been to the events at Christmas and Easter which are always well organised’. Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a comprehensive complaints policy and procedures and the service users’ and their relatives were aware of the same. EVIDENCE: The home had a comprehensive complaints policy and procedures, which was displayed on the notice board. There was no complaint since the previous inspection. Of the 8 service users who responded to the commission’s survey, of which 7 service users’ have said that they always speak to if they were not happy with any of the service at the home and also were aware how to make a complaint. Service user –1 said ‘unable to answer this question the manageress or a senior nurse is always available and prepared to answer questions. In conversation with staff it would appear that they try to discern if a patient is unhappy’. ‘As the husband if I see something that appears to be out of order I have no difficulty in raising the matter. So far anything that has arisen have only been very minor matters’. Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had maintained the home clean and tidy with out any offensive odours. EVIDENCE: The home had confirmed through the pre inspection questionnaire (PIQ) that the fire officer’s last visits reports of 23/01/07 requirements have been implemented. Fire equipment manufacturers last check was carried out on 12/06/07 and the most recent fire drill and fire alarm test had taken place on the 26/01/07. The fire strategy was reviewed and updated under chapters fire safety over view, means to escape, fire safety systems, and management. Fire safety maintenance checklist provided by fire safety department was carried out monthly. The environmental health officer visit of 31/07/06 recommendations were implemented were confirmed in the PIQ. Gas Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 17 installation, central heating system, and emergency lighting checked on 06/10/06. Appliances inspection was carried out and a certificate issued was valid until January 2008. Hoist checks were carried on 21/02/07. Water temperature checks were carried out monthly of all the rooms, bathrooms, WC’s including disabled WC’s. Of the 8 service users’ those who have responded to the service users’ survey 6 have said that the home is always fresh and clean and 2 service users’ have said that usually. Service user –1 said ‘friends and relatives, after visits, have always commented on how fresh and clean the home is in particular there is no smell or bad odour. Staff are always most pleasant and cheerful’. Service user –2 said ‘now and again her room has an odour and carpet needs hovering’. Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager, staffs’, and service users’ had good working relations. However, the home must improve staff deployment ratio to meet with the changing and current needs of the service users’. EVIDENCE: The home had maintained a 3-shift system for staff deployment. Currently, the home had 12 service users’ with dementia, 15 service users’ with mental health needs, 16 service users’ with incontinent of urine, 3 service users with incontinent of faeces, 3 service users’ who are doubly incontinent and 6 service users’ who use a wheelchair. However, the home had the deputy manager on maternity leave, and had deployed 4 staffs for the 7.00am to 2.00pm shift, 4 staffs’ for the 2.00pm to 9.00pm shift and 2 staffs for the 9.00pm to 7.00am shift. The issue of low level of staff deployment in relation to the above service users’ needs was discussed with the manager and the provider on this inspection and was agreed that the home would increase the staffing level to a minimum of 5 staffs for the 2 shifts and a minimum of 3 staffs during the night shift. Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 19 The staffs’ have had received their mandatory trainings, of which 21 staffs’ have received training in dementia awareness. However, another home manager in the name of Galaxy of Care provided the staffs’ training on dementia. The home must ensure that, the trainer had required accreditation to carry out such training in the best interest of the service users’. The manager was in the process of reassessing staffs’ training needs and develop training calendar which would include refresher trainings as well. Currently, the home had deployed 5 staffs with NVQ3, 3 staffs doing NVQ3, 4 staffs with NVQ2 and 5 staffs doing NVQ2. On this inspection 3 staffs’ recruitment records were seen and found their CRB, references were in order. Of the 8 service users’ those who have responded to the commissions’ survey 6 have said that the staff listen and act to what the service users’ say and are always available when they need them. 2 service users said staffs are available usually. Service user – 2 said ‘If there are basic requirements staff will try to understand and endeavour to understand signs of what is required’. Service user – 3 said ‘however – have to remind them periodically about the same problem. Communication seems to break down between shifts’. Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager of the home was qualified, experienced and had appropriate skills for delivery of the care and in meeting the assessed needs of the service users’. The manager, staffs’, and service users’ had good working relations and the service users expressed satisfaction with the services provided by the home. EVIDENCE: The manager of the home was qualified, experienced and had appropriate skills for delivery of the care and in meeting the assessed needs of the service users’. The home was kept clean, tidy, and hygienic. Despite, the food menu was prepared in consultations with the service users’, the service users’ needed further improvements to take into account the wishes of all the service Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 21 users’ all the time. The manager, staffs’, and service users’ had good working relations and the service users expressed satisfaction with the services provided by the home. Staff supervision had been actioned. The manager, deputy manager, senior carers were involved. The manager had reviewed the content of staff supervision and made improvements to incorporate elements of mutual benefit that enhanced staff skills and improved quality of care delivery. The staffs have received regular supervision, which appeared to have helped in improved care delivery. All financial management arrangements were recorded in the individual care plans and separate passbook and receipts were maintained to record expenses relating to hairdressing, toiletries, and chiropody. As part of the quality assurance the home had received feed back from the chiropodist, district nurse and service users’ relatives and their suggestion to improve care services and their delivery was taken on board and implemented in the best interest of the service users’. However, the home needs to regularise the regulation 26 visits and develop a detailed annual business plan. Service user –1 had said ‘my name is IC, and I am very happy at the Victoriana, the staff really look after me, I have lived here for the past 18 months, and all my needs are taken care of’. Service user – 2 said ‘there is a very good atmosphere about the home. It appears to be very well run with good staff teamwork who are always very polite and friendly towards both patient and visitors. I believe my wife has gained admission to a very good home which can and does cater for all her needs’. Service user –3 said ‘having lived here since 17/11/2000 I feel secure and well looked after. The staff are so kind and attentive’. Service user – 4 said ‘I would like you to know that the Victoriana has provided dad with excellent care on a timely home from home environment. My family has gone through turbulent times recently, culminating into the death of my mother this month and through out this the staff at the home have been totally supportive, caring and compassionate both to dad and myself’. Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 2 3 X X 3 Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP27 Regulation 18 (1) (a) Requirement The home must ensure the ratio of care staff to service users must be determined according to the assessed needs of the service users’. Timescale for action 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP15 OP34 Good Practice Recommendations The home should have regular consultations with all the service users’ and ensure that there is a menu offering choices of meals to all the service users’. The home should develop a business plan taking into consideration the views of key stakeholders and how the home is achieving quality of life goals for service users. Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Victoriana Residential Home DS0000045214.V329468.R01.S.doc Version 5.2 Page 25 - 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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