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Inspection on 26/09/07 for Victoriana Residential Home

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

This inspection was carried out on 26th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Staff were observed using a variety of moving and handling equipment in the correct way, and in general communicated well throughout the procedure. All of the residents had been registered with a GP, and a visiting community nurse confirmed that the staff reported any medical concerns to them in a timely fashion.During the inspection service users were witnessed being treated with respect by all the staff, including the ancillary staff. Generally the bedrooms were clean and tidy, and were furnished with individuals` personal photographs and ornaments that reflected their life histories. Documentation identified that the fire call points checks are carried out weekly in this home by a nominated person, as is emergency lighting. Equipment was signed to confirm it was last checked in June 2007. A fire safety checklist is also completed each month to identify anything that requires attention.

What has improved since the last inspection?

There were no notable improvements since the previous inspection.

CARE HOMES FOR OLDER PEOPLE Victoriana Residential Home 6 Lansdowne Road Luton Beds LU3 1EE Lead Inspector Mrs Louise Trainor Unannounced Inspection 26th September 2007 07:15 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.V351577.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.V351577.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 victoriana@heritagecarehomes.co.uk Heritage Care Homes Ltd 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.V351577.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd February 2007 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. 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 Statement of Purpose provided at the inspection suggested the fees for the home were £450-£490 per week. Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users’ 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. The inspection of Victoriana was a key inspection, was unannounced and took place from 07.15am on 26th September 2007. The inspection was undertaken by Louise Trainor, lead inspector, and Sally Snelson The acting manager Mrs Afsheen Ahmed was present from 8am and the proprietor, Mr SM Hussain also joined the inspection. Feedback was given throughout the inspection. During the inspection the care of four people who used the service was case tracked. 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, staff and visitors were spoken to and their opinions sought. Any comments received from staff or service users about their views of the home plus all the information gathered on the day was used to form a judgement about the service. The inspector would like to thank all those involved in the inspection for their input and support. What the service does well: Staff were observed using a variety of moving and handling equipment in the correct way, and in general communicated well throughout the procedure. All of the residents had been registered with a GP, and a visiting community nurse confirmed that the staff reported any medical concerns to them in a timely fashion. Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 6 During the inspection service users were witnessed being treated with respect by all the staff, including the ancillary staff. Generally the bedrooms were clean and tidy, and were furnished with individuals’ personal photographs and ornaments that reflected their life histories. Documentation identified that the fire call points checks are carried out weekly in this home by a nominated person, as is emergency lighting. Equipment was signed to confirm it was last checked in June 2007. A fire safety checklist is also completed each month to identify anything that requires attention. What has improved since the last inspection? What they could do better: The acting manager was unfamiliar with the concept of one to one supervision, which is not in place at the moment in this home. Certificates displayed in the home are out of date. They still identify a registered manager who left the home six months ago. This must be addressed immediately. The home provided prospective users of the service with information documents, but these have not been updated. Therefore it was not accurate information and could be misleading. The acting manager confirmed that where possible staff went to review prospective residents but sometimes, if they were being admitted for respite the staff would rely on the placing social workers assessment Care plans were not completed in such a way that they could be used as a working document. They were not always reviewed monthly which could lead to residents having different needs to those documented. Systems in place relating to the administration of medication were insufficient to protect the people who live in this home. There are some activities arranged for people living in this home, however on a day- to -day basis recreational interactions are limited so that their needs may not be fully met. Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 7 The systems in place regarding safeguarding issues in this home are insufficient to ensure people who live here are protected from abuse. On arrival at the home it was homely and inviting and free from offensive odours. However as one of the inspectors toured the building one particular area on the ground floor, had an overwhelming odour indicative of poor continence management. Training is in place for the staff in this home, however observations indicate that not all staff apply their knowledge and skills appropriately when carrying out care practices and procedures. The acting manager in this home has minimal management experience, and has lacked support and guidance in her role. Consequently the health, safety and welfare of the people who use this service may not always be protected. The accident book identified incidents that had not been appropriately reported to CSCI using the Regulation 37 process, or to the safeguarding team. The home did not have adequate procedures in place to prevent the spread of infection. 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.V351577.R01.S.doc Version 5.2 Page 8 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.V351577.R01.S.doc Version 5.2 Page 9 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): 1, 3, 4, 6. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home provided prospective users of the service with information documents, but these have not been updated. Therefore it was not accurate information and could be misleading. EVIDENCE: The Victoriana is registered to care for up to 33 service users of which 15 can have a diagnosis of dementia. The Statement of Purpose advises people that the home can also care for people with a mental disorder; this is not correct as the home is not registered for this category. Therefore a requirement is made that the Statement of Purpose is reviewed and altered to reflect this and the change of manager. Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 10 Certificates displayed in the home are out of date. They still identify a registered manager who left the home six months ago. This must be addressed immediately. The pre-admission assessments sampled were of varying quality. The acting manager confirmed that, where possible, staff went to review prospective residents but sometimes, if they were being admitted for respite the staff would rely on the placing social workers assessment. Those files sampled that had a pre-admission assessment completed by the previous registered manager, when she was in post, were of a better standard and should be used by the current staff as an example. At the time of the inspection Victoriana did not offer intermediate care. Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 11 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, 10, 11. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans were not completed in such a way that they could be used as a working document. They were not always reviewed monthly which could lead to residents having different needs to those documented. EVIDENCE: As with other documentation in the home, the care plans were of a varying standard. However none of the residents had a plan that had been written for every one of their care needs. There was limited detail of what care was needed, how it was to be provided and any eventual outcome or goal. The plans that had been written were reviewed, although we were told that those that had not been reviewed within the last month was because the key worker was on holiday. The reviewing of the care plans is a constant task and must continue even if the regular staff are not on duty, just as the care continues. Care plans were reviewed on separate documentation to the care plans and Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 12 alterations to care needs were not written onto the original plans. It was therefore doubtful that staff would be aware of the changes if they were not involved in the reviewing. Some of the files sampled included risk assessments. These were mainly for the risk of a resident holding a key to a bedroom and locking themselves in the room. It was noted that a resident who had had a number of falls and used a frame to walk did not have a falls risk assessment. Another resident was seen to be wearing ‘flip flop’ slippers while using walking frame to aid mobility. This practise must be risk assessed. Throughout the inspection service users were supported to move around the home, for example to the bathroom or the dining room. Staff used a variety of moving and handling equipment in the correct way, and in general communicated well throughout the procedure. However the care plans did not always identify the equipment to be used. All of the residents had been registered with a GP, and a visiting community nurse confirmed that the staff reported any medical concerns to them in a timely fashion. A resident who had been admitted to the home 23.8.07 had not been weighed until 12.9.07. A second weight, where the date had not been recorded, indicated a weight loss. We discussed the importance of having baseline observations for residents at the point of admission with the acting manager. A resident who needed to have a bed rail to prevent him/her falling out of bed, had not consented to this form of restraint. Prior to the inspection there had been an incident in the home where a resident had been caught between the bed rails. This may have been prevented if they had been told about the rails and why they were in place. None of the service users were self-medicating. During the inspection the inspectors witnessed two medication rounds. At the morning round, the inspector noticed a bottle which had a plain white label with an individuals name handwritten on it. This label was torn. There was no indication of what this medication was or when it expired. This bottle was being stored in the fridge in the kitchen. Later in the day, a relief manager from the pharmacy that provides the medication to this home was in the kitchen with a role of medication labels. When the inspector asked what she was doing, she stated that she had been in the home and done an audit earlier in the week, and knew some bottles needed new labels. It was very worrying that the medication with torn, handwritten labels had been left in the fridge despite the pharmacist’s awareness of their condition. This could have led to medication being inappropriately administered. Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 13 The Mediation Administration Record sheets (MAR) for the people living in this home were examined by one of the inspectors. There were a variety of errors found. These included; 1.One person’s medication had been allowed to run out before being reordered, so that the individual had to miss doses. 2.One lady had a prescription for medication twice a day. Only one dose had been signed for each day. 3. Another person was prescribed a certain drug to be given every day except Friday; it was signed to say it had been given everyday. 4. One persons prescription identified the drug should only be given on Fridays, this had not happened. It was impossible to reconcile the stocks with the charts due to the amount of errors. Reconciliation of the controlled medication took a long time, as the staff were unable to locate a full unopened bottle of Oramorph. The drug had last been administered two hours previously and legislation requires the amount held by the home to be checked and measured every time it is administered. Staff admitted that they had not done this, but had still signed to confirm how much was remaining. These issues and procedures are now all being monitored through safeguarding strategy meetings. In addition, the staff were in the habit of using creams and lotions that were not labelled or were not for the resident they were being used on. For example there was a tub of sudocream in the room of one resident that had the prescribing label removed and was not on that residents MAR sheet. Another resident had a thickening agent added to a drink from an unlabelled tin. During the inspection service users were witnessed being treated with respect by all the staff, including the ancillary staff. However at 07.30 hours, eight residents were sitting dressed in the lounge and many were sleepy. We asked one resident if he liked to be up early and he replied ‘It is a matter of necessity’ suggesting it might not have been his choice. At coffee time it was noted that a resident had a beaker of hot tea placed in one hand and a biscuit in the other, there was no table near-by and she was struggling to control her drink. Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 14 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 poor. This judgement has been made using available evidence including a visit to this service. There are some activities arranged for people living in this home, however on a day- to -day basis recreational interactions are limited so that their needs may not be fully met. EVIDENCE: It was not apparent that there were any planned activities for the day of the inspection and some of the programmes on the TV did not appear to be to the residents taste. For example during the morning they were watching a chat show about how many sexual partners a particular person had had. The hairdresser was available; she would take residents from the communal areas of the home to have their hair cut or washed. Staff reported that they had entertainers come into the home at least monthly and also organised other events such as clothes parties. There was a poster displayed, advertising a clothes party for the 17th of October 2007. Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 15 In between time, staff would, they said, play games with the residents or spend one to one time with them. However there was little evidence of this noted on the day of the inspection. A resident and a visitor both stated that they would prefer it if there was more to do. The cook in this home has been in post for many years and is clearly an important member of the team; however as already stated the cook was seen feeding residents their meals. This is not her role. She was also going back and forth from the kitchen to the laundry room at one point during the inspection. This is poor practice and not acceptable due to the risk of cross infection. Menus were viewed by one of the inspectors, and although over a week there was a wide variety of meals, there is only one main meal choice each day. For example on the day of the inspection the main meal was lamb stew, there was no other choice on the menu although one person was seen to be served sausages and another had egg on toast. The individual having egg on toast, allegedly has this every day. This was of some concern as he may not be receiving a nutritionally balanced diet over a longer period of time. At lunchtime the dining tables were laid well with cutlery, glasses and serviettes and cruettes on the table. A poorly resident was provided with a puree lunch, however the amount taken into her room was much in excess of what she would want to or be able to eat. Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 16 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 poor. This judgement has been made using available evidence including a visit to this service. The systems in place regarding safeguarding issues in this home are insufficient to ensure people who live here are protected from abuse. EVIDENCE: Windows of a bedroom at the front of the home were wide open when we arrived at the home at 07:15 hours. There was no security fixtures on these windows and we would have been able to enter the home via the window had we wished, without anyone being any the wiser. The complaints file was examined and there was no record of any complaints being made to or about the home since the last inspection. However one visitor to the home did comment to one of the inspectors, that she had raised concerns verbally, on several occasions, with the home about her loved ones room, and no action had been taken to rectify the problems. There were a number of reports of accidents in the accident book which suggested that referrals that should have been made under the safeguarding procedure and had not been made, this included unexplained injuries. Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 17 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, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally this home provides a clean and comfortable environment for the people who live here. However one specific area on the ground floor outside bedrooms 2, 5 and 6 requires urgent attention to remove an offensive odour. EVIDENCE: On arrival at the home it was homely and inviting and free from offensive odours. However as one of the inspectors toured the building one particular area on the ground floor, had an overwhelming odour indicative of poor continence management? There appeared to be a lack of storage space resulting in many of the en-suite bathrooms being used as storage. However there was an area on the top floor Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 18 of the building that could be used for storage removing any risks for the people who use this service. Generally the bedrooms were clean and tidy, and were furnished with individuals’ personal photographs and ornaments that reflected their life histories. However one relative did comment that her loved one’s bedroom was often smelly and while it was appreciated it may be due to incontinence, the carpet was very old and soiled and in need of changing. She also reported that clothes were not folded and often the wrong clothes were placed in the room. She also felt the pillows provided were old and lumpy. This relative said she had mentioned her concerns to staff, although not in the form of an official complaint but nothing had changed. The garden was laid to grass and a patio area and looked attractive but was spoilt by a discarded fridge and chair. Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 19 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, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Training is in place for the staff in this home, however observations indicate that not all staff apply their knowledge and skills appropriately when carrying out care practices and procedures. EVIDENCE: At the start of the inspection there were four care staff on duty and a cook. However it was noted that the cook also carried out care duties, such as feeding residents. There were currently 23 residents at the home. One member of staff was noticed to be pregnant. A risk assessment had been completed for this individual when she was eleven weeks pregnant. Three staff files were looked at in detail during this inspection. All three had fully completed application forms and appropriate references. Criminal Record Bureau checks and POVA First checks were also in place. There were varying forms of identification including passports and birth certificates in these files. Contracts of employment were signed and dated appropriately, with reviewed contracts in place where hours had been increased. Two of the three files had evidence that an induction had taken place, and all contained a variety of training certificates, including fire, POVA, food hygiene, medication administration and moving and handling. Some had evidence of Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 20 more specific training such as dementia care, effective customer care and bereavement. The third file was for a carer who had only been in post for three weeks. She had not done any training as yet, but was observed to be working under supervision throughout the inspection. Despite appropriate training being in place for staff, practices observed during this inspection did not always reflect that staff applied the information they had learnt from training into their practices. For example errors found on the MAR sheets did not indicate that the staff were knowledgeable and skilled in the procedure of administering medication. Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 21 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, 32, 33, 35, 36, 37, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The acting manager in this home has minimal management experience, and has lacked support and guidance in her role. Consequently the health, safety and welfare of the people who use this service may not always be protected. EVIDENCE: The deputy manager who has recently returned from maternity leave is presently managing this home. She has very limited management experience, and has not been provided with the appropriate support and guidance to carry out this role safely and efficiently. Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 22 The accident book identified incidents that had not been appropriately reported to CSCI using the Regulation 37 process, or to the safeguarding team. The home did not have procedures in place to prevent the spread of infection. For example a member of staff was seen getting out of the lift with a service user on one arm and soiled bed linen under the other arm. Some staff were not using protective gloves appropriately. The carer who opened the door to the inspectors at the start of the inspection had not removed the gloves she had been wearing to provide personal care. The cook was also noticed to be wearing gloves throughout the day, including while she was feeding a resident. During the inspection a foreign gentleman in very casual attire arrived at the back door. His command of the English language was very poor and he was only able to explain that he worked for Mr Hussein, the proprietor. It transpired that he had come to collect dirty laundry from this home, to take it to another home for washing. This dirty laundry was distributed in yellow clinical waste bags, and this individual was walking back and forth into the kitchen looking for a cup of tea, between handling these yellow bags. The inspector had to ask him to leave the kitchen area due to health and safety risks. Documentation identified that the fire call points checks are carried out weekly in this home by a nominated person, as is emergency lighting. Equipment was signed to confirm it was last checked in June 2007. A fire safety checklist is also completed each month to identify anything that requires attention. Although these checks are being carried out regularly and fire training is being attended by staff, the inspectors were concerned to find that no one in the home has participated in any evacuation training, and the acting manager was unaware that it was her responsibility to ensure that this procedure was familiar to everyone in the home. Some quality assurance questionnaires had been received earlier in the year. Evidence of feedback was given to those stakeholders that provided their names. There was evidence that staff had received some supervision. However this was ‘task supervision’, where staff were supervised doing specific tasks. The acting manager was unfamiliar with the concept of one to one supervision, which is not in place at the moment in this home. She herself had not received any supervision since returning from Maternity in May this year, despite the fact that she has returned to an unfamiliar role as home manager. This home holds personal allowance money for most of the people who live here. The records and funds for seven individuals were inspected. All balances were correct and receipts were present for all transactions, however there was only one signature applied. The manager was advised that a second counter signature should be considered. Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 23 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 1 X 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 2 2 2 2 2 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 2 X 2 1 1 1 Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4and 5 Requirement The people who use this service must have access to information that accurately reflects the services provided by the home. It should be kept under review and altered as circumstances change. Timescale for action 01/11/07 2. OP3 14(1)(a) People who use this service 01/11/07 should not be admitted to the home without a thorough preadmission assessment that clearly details how the staff team can meet their needs. Care plans must be thoroughly written for all areas of care provided to a resident to ensure that all staff are aware of the care needs, Staff must identify any risks to the people who use this service, and assess and document these risks. When medication is administered to people who use this service, it DS0000045214.V351577.R01.S.doc 3. OP7 15 01/12/07 4. OP8 13(4) 31/10/07 5. OP9 13(2) 12(1)(a) 31/10/07 Victoriana Residential Home Version 5.2 Page 25 must be clearly recorded to ensure people receive the correct medication. 6. OP12 16(2)(n) People who use this service must be offered, and encouraged to participate in, activities that are suitable for their specialist needs. People who use this service must be encouraged to make choices about all aspects of their daily life. People who use this service must be protected from any risk of harm and abuse. All areas of this home must be kept clean and free from offensive odours to ensure it is a pleasant environment for the people who live here. The people who live in this home must be cared for by staff that are suitably qualified and competent to do their jobs. People who live in this home must be cared for by staff who are appropriately supervised All records relating to people who live in this home must be kept reviewed and up to date. Any incidents that adversely affect the people who live in this home must be reported to the appropriate authorities. 31/10/07 7. OP14 12(2) 31/10/07 8. OP18 13(6) 31/10/07 9. OP26 23(d) 31/10/07 10 OP30 18(1)(a) 31/10/07 11. OP36 18(2) 31/10/07 12. OP37 17 30/11/07 13. OP38 37 31/10/07 Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 26 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 OP1 Good Practice Recommendations The manager should give consideration to producing the Service Users Guide in a format more suitable for those living at the home. Bed rails should not be used without the consent of the service user or a representative on their behalf. The home should consider introducing a second choice of a healthy nutritious meal each day. 2. 3. OP8 OP15 Victoriana Residential Home DS0000045214.V351577.R01.S.doc Version 5.2 Page 27 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.V351577.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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