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Inspection on 24/02/06 for Victoriana Residential Home

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

This inspection was carried out on 24th February 2006.

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

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 food menu was prepared in consultations with 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.

What has improved since the last inspection?

The manager had made efforts to meet the outstanding requirements and recommendations from the previous inspection report. The manager had coordinated with the Luton NHS primary care trust and disability resource centre to provide services to the service users` with occupational therapy needs. The care plans format had been revised to consider the changing needs of the service users`. The health care appointments and accident records were maintained separately for each service user. New cutlery was in use for dinning.

CARE HOMES FOR OLDER PEOPLE Victoriana Residential Home 6 Lansdowne Road Luton Beds LU3 1EE Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 24th February 2006 10:20 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Victoriana Residential Home DS0000045214.V281683.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Victoriana Residential Home DS0000045214.V281683.R01.S.doc Version 5.1 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 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Victoriana Residential Home DS0000045214.V281683.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th August 2005 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 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 DS0000045214.V281683.R01.S.doc Version 5.1 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 at 10.20am on 24/02/06 by Pursotamraj Hirekar over 3 ½ hours. The registered manager coordinated the inspection. The methodology of inspection included review of the status of requirements and recommendations from previous inspection report, study of care plans and risk assessments, discussion with the manager and staff, conversation with the service users’, partial tour of the home and study of relevant care documents managed by the home. What the service does well: What has improved since the last inspection? What they could do better: Staffs’ supervision system and procedures had been developed and actioned. However, needed improvements to incorporate elements of mutual benefit that enhanced staff skills and improved quality of care delivery. Care plans preparation and review should cross-reference and record the contribution of all professionals participating in the care assessment and delivery of the service users’. All service users’ care plans to be updated covering all aspects of care. Arrange for a qualified occupational therapist to assess the building in relation to environmental adaptations for disabled persons. Victoriana Residential Home DS0000045214.V281683.R01.S.doc Version 5.1 Page 6 The home should also, take assistance from the British Dietetic Association – Nutrition Advisory Group for the Elderly People to conduct nutritional assessments of the service users’. The home’s medicine policy needed to be reviewed and updated in the light of the department of health guidelines. 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 DS0000045214.V281683.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoriana Residential Home DS0000045214.V281683.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Victoriana Residential Home DS0000045214.V281683.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9 The health care needs of the service users were met and the home need to review and update it’s medicine policy in the best interest of service users’. EVIDENCE: The manager of the home coordinated with the Luton NHS primary care trust, CART – team, disability resource centre and the family member of a service user whose, occupational therapy needs were identified during the assessment and continued to follow up. The work was in progress. The care plans format had been revised to consider the changing needs of the service users. The health care appointments and accident records were maintained separately for each service user. Victoriana Residential Home DS0000045214.V281683.R01.S.doc Version 5.1 Page 10 Initial assessments and comprehensive care plans were prepared. The key staff members carried out monthly reviews of care plans. Care plans preparation and review should cross reference and record the contribution of all professionals participating in the care delivery of the service users’. Also, the home should engage professionals in addition to the staff in the care plan review as and when needed. The home’s medication policy was dated 1999, 2000 and 2002, which perhaps needed to be reviewed and updated in the light of the department of health guidelines. Victoriana Residential Home DS0000045214.V281683.R01.S.doc Version 5.1 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 the following standard(s): 14, 15 Service users’ were satisfied with the food. However, the home may undertake nutritional assessments of all service users’ and provide individual specific diet that meets the goals of balanced diet. EVIDENCE: The home had made arrangements to consider and record individual service users choices in relation to their cultural and religious choices which, included food, clothing, time of food, hair dressing, smoking, drinking, visitors and death wish in the care plans. The home had arrangements for regular consultations with the service users’ regarding the choice of the food menu, time and place to serve. The service users’ have expressed their satisfaction with the choice and variety of food menu. The home should also, take assistance from the British Dietetic Association – Nutrition Advisory Group for the Elderly People to conduct nutritional assessments of the service users’. Basing on nutrition assessments and needs covering details such as eating time and habits, weight, vitamins C, D, fibre and iron. The home should incorporate the above information into the care plans and need to be actioned. Victoriana Residential Home DS0000045214.V281683.R01.S.doc Version 5.1 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 the following standard(s): None EVIDENCE: Victoriana Residential Home DS0000045214.V281683.R01.S.doc Version 5.1 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 the following standard(s): 22,26 The home had made adequate efforts to provide necessary support to the service users’ that helps promote their independence. EVIDENCE: The home was clean, pleasant and maintained hygienically. The manager had said that the recommendation made in the previous inspection report to engage an occupational therapist to assess the building in relation to environmental adaptations for disabled persons was not addressed and planned to do after the completion of the new building work which, is in progress. It is perhaps sensible to do now for the existing building instead waiting completion of the new building and avoids any unanticipated risk for the service users’. The manager had agreed to approach the owner and organise the above before the end of March 2006. Victoriana Residential Home DS0000045214.V281683.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 The staffs’ skills complement and meet the needs of the service users’. EVIDENCE: The manager said that the home had engaged Learn direct training company to provide staff induction, which perhaps was intensive and useful to the new staffs employed. The home had also made arrangement with distance learning programme of Milton Keynes’s college to train staffs in safe handling of medicines. The home continued to coordinate with the in-house human resources and organise suitable training programmes for the staffs. Victoriana Residential Home DS0000045214.V281683.R01.S.doc Version 5.1 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 36, 37 The home was managed well and made appropriate arrangements to supervise staff. However, staffs’ supervision needed improvements that helped staffs and service users’. 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. The food menu was prepared in consultations with the service users’. The manager, staff 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. However, for better clarity of purpose, the manager had agreed to develop staff supervision schedule and a note that describes purpose Victoriana Residential Home DS0000045214.V281683.R01.S.doc Version 5.1 Page 16 and line of authority. The content of supervision should include, improvements to incorporate elements of mutual benefit that enhanced staff skills and improved quality of 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. The health care appointments and accident records were maintained separately for each service user. New cutlery was bought for dinning. Victoriana Residential Home DS0000045214.V281683.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X 2 X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 2 3 X Victoriana Residential Home DS0000045214.V281683.R01.S.doc Version 5.1 Page 18 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Care plans preparation and review should cross-reference and record the contribution of all professionals participating in the care assessment and delivery of the service users’. All service users’ care plans to be updated covering all aspects of care. Arrange for a qualified occupational therapist to assess the building in relation to environmental adaptations for disabled persons. The home should also, take assistance from the British Dietetic Association – Nutrition Advisory Group for the Elderly People to conduct nutritional assessments of the service users’. The staffs’ supervision content should include, elements of mutual benefit that enhanced staff skills and improved quality of care delivery. The home’s medicine policy needed to be reviewed and updated in the light of the department of health guidelines. 2. 3. OP22 OP15 4. 5. OP36 OP9 Victoriana Residential Home DS0000045214.V281683.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Bedfordshire & Luton Area Office 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 DS0000045214.V281683.R01.S.doc Version 5.1 Page 20 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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