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Inspection on 05/02/08 for Victoriana Residential Home

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

This inspection was carried out on 5th February 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

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 ofmoving and handling equipment in the correct way, and in general communicated well throughout these procedures. Observations of care throughout this inspection indicated that the staff know the residents they care for very well, and are committed to providing a friendly and caring environment. Individual rooms are furnished to personal taste, with photographs and possessions that reflect the personal history of the people who live in them. The systems for recruiting staff are robust so that people who live here are protected. The personal expenditure account records for three people who live in this home were examined, and all were found to balance correctly with the account funds remaining. Two members of staff had signed all transactions and there were receipts to correspond with all purchases recorded.

What has improved since the last inspection?

Pre admission assessments are now being completed prior to people moving into the home, so that they can be assured that there needs will be met. The Medication Administration Record (MAR) sheets for ten of the residents in this home were examined in detail. These were greatly improved from the previous inspection. Records were correctly signed, and reconciliation with stocks remaining was accurate Safeguarding issues are being reported and managed appropriately in this home so that people who live here are protected. All accident and incidents are now being reported appropriately via the regulation 37 processes, and in line with Safeguarding guidelines.

What the care home could do better:

Work is ongoing to review the information documents for this home. Care plans are in place for each individual who lives in this home. However more information relating to specific care instructions is required to ensure continuity of care. 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 social needs may not be fully met.This home provides a homely environment for the residents who live here, however some ongoing work is presently restricting facilities for some people in the home. Training in specialist areas remains ongoing to ensure staff are adequately skilled to care for all these residents.

CARE HOMES FOR OLDER PEOPLE Victoriana Residential Home 6 Lansdowne Road Luton Beds LU3 1EE Lead Inspector Sally Snelson Unannounced Inspection 5th February 2008 07:30 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.V355965.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.V355965.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 vacant post 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.V355965.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 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.V355965.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. 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. Evidence used and judgements made within the main body of the report include information from this visit. This was the second Key Inspection for this service this year. Regulatory Inspectors Mrs Louise Trainor and Mrs Sally Snelson carried it out on the 5th of February 2008, between the hours of 07:30 and 12:30 hours. The manager arrived on duty at approximately 09:00 hours and was then present throughout the inspection to assist as necessary. The focus of this inspection was to monitor compliance of the requirements made at the previous inspection in September 2007. There are presently nineteen permanent residents living at this home and one person who is staying for a period of respite care. Personal files and documentation for two of these people were examined in detail during this visit. The inspectors also had the opportunity to informally interview and chat with both people who live here and staff who work at the home. A tour of the premises was undertaken. Other documentation examined during this inspection included, documents relating to staff recruitment, training and supervision, Medication Administration Record (MAR) sheets and medication stocks, Personal Allowance records, and complaints. The inspector would like to thank everyone concerned for their assistance and support during this inspection. What the service does well: 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 Victoriana Residential Home DS0000045214.V355965.R01.S.doc Version 5.2 Page 6 moving and handling equipment in the correct way, and in general communicated well throughout these procedures. Observations of care throughout this inspection indicated that the staff know the residents they care for very well, and are committed to providing a friendly and caring environment. Individual rooms are furnished to personal taste, with photographs and possessions that reflect the personal history of the people who live in them. The systems for recruiting staff are robust so that people who live here are protected. The personal expenditure account records for three people who live in this home were examined, and all were found to balance correctly with the account funds remaining. Two members of staff had signed all transactions and there were receipts to correspond with all purchases recorded. What has improved since the last inspection? What they could do better: Work is ongoing to review the information documents for this home. Care plans are in place for each individual who lives in this home. However more information relating to specific care instructions is required to ensure continuity of care. 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 social needs may not be fully met. Victoriana Residential Home DS0000045214.V355965.R01.S.doc Version 5.2 Page 7 This home provides a homely environment for the residents who live here, however some ongoing work is presently restricting facilities for some people in the home. Training in specialist areas remains ongoing to ensure staff are adequately skilled to care for all these residents. 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.V355965.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.V355965.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, 2, 3, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Pre admission assessments are now being completed prior to people moving into the home, so that they can be assured that there needs will be met. However work remains ongoing to review the information documents for this home. EVIDENCE: We inspected the file of one person who had been admitted since the previous inspection. There was a pre admission for long-term care completed in this file. Information included details relating to the persons medical history prior to admission, and reasons for the admission to hospital just prior to admission to the home. It identified family and social contacts, pressure area care required, mobility assistance required, dietary needs and weight, including details of dentures, sleep pattern and aids required, medication, and communication abilities, which included the need for glasses. Victoriana Residential Home DS0000045214.V355965.R01.S.doc Version 5.2 Page 10 This document gave a detailed presentation of this individual, their level of need and any equipment required to fulfil their needs. A temporary care plan had been formulated from this information. The contract for this individual had not been fully completed, signed or dated. The manager of this home has recently returned from maternity leave and is presently in the process of working on the Statement of Purpose and the Service User Guide, to make the changes advised at the last inspection. This home does not provide an intermediate care service. Victoriana Residential Home DS0000045214.V355965.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 adequate. This judgement has been made using available evidence including a visit to this service. Care plans are in place for each individual who lives in this home. However more information relating to specific care instructions, are required to ensure continuity of care. EVIDENCE: Observations of care throughout this inspection indicated that the staff that work here know the residents they care for very well, and are committed to providing a friendly and caring environment. The residents were clean and tidy and interactions between staff and residents were respectful and familial, with friendly banter and joking passing between individuals, as well as conversations relating to individual’s families and personal circumstances. The two files examined during this inspection contained care plan documentation. The home is presently in the process of transferring to new care plan booklets, which also contain risk assessments. Victoriana Residential Home DS0000045214.V355965.R01.S.doc Version 5.2 Page 12 One of the two files examined was for a recent admission, and contained the new documentation fully completed. The other had been written in 2006 by a previous manager, and had not yet been transferred. In both cases, more detailed information is required to ensure that care is carried out with continuity and in a way that the individual prefers. Reviews need to be clearly documented to reflect how individual’s changing needs are being addressed. Problems/needs were clearly identified, however interventions required, were very limited in detail. One person’s file identified that they sometimes refuse food and medication, and that they sometimes become aggressive towards the staff. However there was no clear guidance as to how staff should manage these problems. The care plan stated, ‘full assistance is required from two care staff,’ but it did not give any detail as to the level of assistance required from these staff. The other file identified that this person had an electric wheelchair, which was important to maintain their independence, however during this inspection, this chair was not evident. There was also a care plan that identified this person had a catheter in situ, however there was no information relating to the size of catheter required, signs to look for that might indicate the need for it to be changed, or who to contact when it did. 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. The Medication Administration Record (MAR) sheets for ten of the residents in this home were examined in detail. These were greatly improved from the previous inspection. Records were correctly signed, and reconciliation with stocks remaining was accurate. However records for medication, such as ‘Paracetamol’ that was prescribed in variable dose form, did not clearly identify what doses had been given. We also noted three bottles of ‘Calogen’ in the drug trolley. There was storage guidance on the bottles, however this was not being followed accurately. The instructions stated ‘store in refrigerator’ and ‘use within 14 days of opening’. These bottles had not been dated on opening, and were being stored at room temperature in the drug trolley. There is a fridge in the kitchen, which is used for storing some medication. This is not kept locked and is easily accessible to anyone entering the kitchen. This would be more suitably placed in a locked area. On the day of the inspection there were eye drops, food supplements and insulin stored in this fridge. The eye drops had not been dated on opening. We also found a urine specimen in the fridge that was dated 06/11/07. This had clearly been forgotten about. There is presently no one in the home receiving ‘controlled drugs’. Victoriana Residential Home DS0000045214.V355965.R01.S.doc Version 5.2 Page 13 Victoriana Residential Home DS0000045214.V355965.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 social needs may not be fully met. EVIDENCE: As noted at previous inspections, social activities are somewhat limited in this home. There is no activity coordinator employed in this home and although there are occasional entertainers invited into the home, generally the social arrangements and activities are dependant upon the care staff and the time they have left when other priority duties are completed. The manager discussed her ideas about allocating someone specific to activities each shift; this would be encouraging to see. On the morning of the inspection there was no evidence of organised activities. Staff in this home would benefit from some specialist skills training to enable them to integrate meaningful activities into the homes daily routines, particularly for people with dementia. Victoriana Residential Home DS0000045214.V355965.R01.S.doc Version 5.2 Page 15 The manager showed us a copy of a rolling four-week menu she had just produced and is due to implement at the end of this week. It had a wide range of meal choices, and included a cooked breakfast every day. On the day of the inspection choices were available, however they were somewhat limited, the mid day meal offered pork with a crust, or cheese and onion pasty, both served with potatoes and vegetables, with a fruit crumble to follow. All of these choices were very ‘pastry based’. It was also disappointing to see tinned fruit pie filling being used rather than fresh fruit for the crumble. The lack of fresh produce in particular fruit was discussed with the manager, whose intention it is to integrate more fresh produce into the new menus. The cook on duty, has been working in the home for six years, and was very accommodating to all the residents at breakfast time. One gentleman came to the table and when asked what he would like to eat, said. “I never go without my cooked breakfast”, she immediately served him fried eggs, tomatoes and mushrooms, which he appeared to thoroughly enjoy. We were however a little concerned that people with cognitive impairment or communication problems may not be given the same choices, as they could not make specific requests such as this. We suggested the use of picture menus and displayed menu boards for these people. The home presently practices ‘Protected Mealtimes’ which means that visitors are not permitted to visit across mealtimes. The manager informed us that she feels that mealtimes are an important social event, and is in the process of changing this policy to encourage making meals a more social occasion where a family member could join their loved one for an occasional meal. Victoriana Residential Home DS0000045214.V355965.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 good. This judgement has been made using available evidence including a visit to this service. Safeguarding issues are being reported and managed appropriately in this home so that people who live here are protected. EVIDENCE: Safeguarding issues are being appropriately reported; all the staff have a clear understanding of related procedures, their roles and the detail required when completing the reporting forms. The local Safeguarding team have worked closely with this home over the past few months and helped them to achieve these improvements. All staff have now attended Safeguarding training. There had been no formal complaints to this home since the previous inspection. However the complaints file did contain details relating to an incident involving an agency carer and the way she had conducted herself in the home. This had been addressed appropriately. Victoriana Residential Home DS0000045214.V355965.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. This home provides a homely environment for the residents who live here, however some ongoing work is presently restricting facilities for some people in the home. EVIDENCE: The entrance hall in this home is welcoming and displays numerous photograph boards that reflect outings and events that have taken place over the years. This home generally provides a clean and comfortable environment for the people who live here. A tour of the premises was undertaken during this inspection. Although there was an offensive odour noticeable on arrival at the home at 07:30 hours, this was much improved by the time we left at 12:30. The domestic staff clearly work hard to keep the home as clean and fresh as they can. However we did Victoriana Residential Home DS0000045214.V355965.R01.S.doc Version 5.2 Page 18 note that one room in particular, on the ground floor, remained rather ‘stuffy and musty’. This room is at the front of the building, and has full-length windows that do not have restrictors on them; therefore leaving them open to air the room may compromise safety in the home. We suggested restrictors might resolve this problem. The home was generally tidy and had a homely, relaxed feel to it. Bedrooms 1-7 on the ground floor all have hand basins and toilets or commodes in them, but the bathing/showering facility for these rooms is presently out of order due to refurbishments that are in progress. This means that the residents who live in these rooms have to go up to the first floor to bathe or shower. One person who resides in one of these rooms did say. “I would like to have more baths”. It is hoped this work will be completed imminently. The remainder of the rooms on the ground floor have en suit shower rooms. Individual rooms are furnished to personal taste, with photographs and possessions that reflect the personal history of the people who live in them. There had recently been a leak in the roof of the main lounge area. This had been repaired, however there is still cosmetic work required to make good the décor in this area. Victoriana Residential Home DS0000045214.V355965.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. The systems for recruiting staff are robust so that people who live here are protected; however training in specialist areas remains ongoing to ensure staff are adequately skilled to care for all these residents. EVIDENCE: There have been no new staff employed since the previous inspection, however the files of two new bank staff, presently going through the recruitment process were examined. All the appropriate documents were present in each of these files, including, fully completed application form with employment history, various forms of identification, photographs and interview notes. The manager was waiting for Criminal Records Checks and references to be returned before giving formal offers of employment. Staff on duty appeared competent and compassionate in their duties. Observations of care indicated that they knew their residents well. However many of the residents in this home have a diagnosis of Dementia and many staff have not as yet completed any specialist training in this area of care. The manager informed us that training is booked for this specialist subject in March 2008, and it is planned that all the staff would attend. Victoriana Residential Home DS0000045214.V355965.R01.S.doc Version 5.2 Page 20 The manager has also booked training sessions in all mandatory subjects to ensure that all staff have up to date training and refresher courses where appropriate. There is presently four care staff rostered on duty during the daytime and two at night. We were concerned that two staff on duty at night for twenty residents, many of which require the assistance of two care staff, maybe insufficient, as during staff rest periods, care could be compromised due to there only being one carer available. The layout of this home also makes it difficult for two staff to effectively and efficiently care for everyone in this home safely. Victoriana Residential Home DS0000045214.V355965.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 adequate. This judgement has been made using available evidence including a visit to this service. The manager is working with confidence to improve systems in the home so that both the people who use this service, and the staff are protected. EVIDENCE: The manager in this home was only appointed at the end of the summer in 2007 and then went on Maternity leave. She returned two weeks ago. Since her return she has worked hard towards implementing essential changes in procedures to improve the standard of care in the home, and this was reflected in the findings of this inspection. She is confident and keen to progress, focusing on a Person Centred Approach to care, and we hope her enthusiasm Victoriana Residential Home DS0000045214.V355965.R01.S.doc Version 5.2 Page 22 will be contagious throughout the team. Since the previous inspection, staff that were intending to leave the home, have now made the decision to stay and work to support this manager to improve the standards. This was very encouraging. She has already addressed staff supervision, although this initial progress must continue to achieve the required standards. Meanwhile comments from staff indicated that they feel well supported by this manager and are pleased with her return to the home. One said. “We’re all delighted with her, she has a wonderful disposition, we can approach her anytime”. The personal expenditure account records for three people who live in this home were examined, and all were found to balance correctly with funds remaining. Two members of staff had signed each transaction and there were receipts to correspond with all purchases recorded. All accident and incidents are now being reported appropriately via the regulation 37 process, and in line with Safeguarding guidelines. The manager is in the process of giving out questionnaires to people who live in this home and their families, in order to collect views and opinions on the service provided in the home, so that she can formulate an improvement plan. All outstanding requirements on this report are partially met, and we felt that had the manager been back at the home for longer, full compliance would have been achieved. We are now confident that this manager will meet the reviewed compliance timescales. Victoriana Residential Home DS0000045214.V355965.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 2 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 2 2 3 Victoriana Residential Home DS0000045214.V355965.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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. Previous timescale 01/11/07 partially unmet. Care plans for people who live in this home must give clear care instructions for staff to follow and must be reviewed regularly to reflect changing needs. People who use this service must be offered, and encouraged to participate in, activities that are suitable for their specialist needs. Previous timescale 31/10/07 partially unmet The people who live in this home must be cared for by staff that are suitably qualified and competent to do their jobs. Previous timescale 31/10/07 DS0000045214.V355965.R01.S.doc Timescale for action 31/03/08 3. OP7 15 29/02/08 6. OP12 16(2)(n) 31/03/08 10. OP30 18(1)(a) 31/03/08 Victoriana Residential Home Version 5.2 Page 25 partially unmet. 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. The home should consider introducing a second choice of a healthy nutritious meal each day, and consider picture menus to enable residents with cognitive impairment. 2. OP15 Victoriana Residential Home DS0000045214.V355965.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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.V355965.R01.S.doc Version 5.2 Page 27 - 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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