Care Home: Victoria Court

Similar services:

• Byars Care Home
• St Marys Nursing Home
• Bramble Lodge
• Parkmanor Residential Home
• Thornham Grove
• Hunter`s Lodge
• London Road Neurological and Specialist Care Unit
• Carlton Care Home

What the care home does well Information gathered from the people living at Victoria Court and their visitors indicated that the support and services provided were of a good standard. Comments included, " Everyone`s been lovely, I`ve made lots of friends. Staff come when I press the buzzer, they usually come quickly" and " it`s marvellous to be here". People living at Victoria Court were asked to provide information that they would like staff to know about them such as their life history, which included information about their family, previous employment and interests and hobbies. This information gave each person an identity, which supported the staff team in getting to know them. This demonstrated that each person was treated as individuals with their own knowledge, skills, interest, likes and dislikes. The information gathered regarding each persons support needs was very detailed and in general provided the staff with the information they needed to support each person in their daily lives. The meals provided were received positively and impressive comments were made regarding the standard of the meals. Such as "All the meals are first class. Plenty of choice and variety" and "Meals are superb, better than some 5 star hotels". What has improved since the last inspection? Risk assessments for people who choose to self-administer their medication are now in place. However it is advised that these are more specific in detail. New fire alarms and door closures had been fitted to each person`s flat door. New garden furniture had been purchased since the last inspection visit and new soft furnishings, such as curtains and new dining chairs. What the care home could do better: Some information within the care plans seen conflicted with other information provided. This needs to be addressed to ensure staff have clear guidance regarding each person. Not all records relating to Fire safety checks and assessments had been undertaken in accordance with the homes policies. This should be addressed to ensure the safety of everyone at Victoria Court isn`t compromised. CARE HOMES FOR OLDER PEOPLE Victoria Court Nesfield Road Ilkeston Derbyshire DE7 8AY Lead Inspector Angela Kennedy Unannounced Inspection 12th March 2008 10:00 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 Victoria Court DS0000020113.V360054.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. Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Court Address Nesfield Road Ilkeston Derbyshire DE7 8AY 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) 0115 9322303 keri.sherwood@anchor.org.uk sharon.blackwell@anchor.org Anchor Trust Keri Sherwood Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2006 Brief Description of the Service: The Home provides 40 places for older people of both genders requiring personal care, in a building that was built and commissioned in 1987 for residents who have retained a relatively high level of independence, yet who needed some levels of support. With the passage of time, however, referrals for care have been for people who have become increasingly more dependent and frail. The original culture of the Home has persisted to a degree and all residents occupy single ‘flats’ with en-suite facilities provided rather than ‘bedrooms’. The flats are all equipped with a refrigerator and, in some cases a kettle, so that residents can retain a degree of independence. The Home offers 24 hour staffed care, 3 meals per day, personal laundry and a range of leisure activities and social events. Information regarding the weekly fees at Victoria Court and what is not included, were taken from the Service user guide provided at this inspection visit. The full fee for the home is £383.00 per week. All residents who are funded by the local authority are required to pay a ‘top up’ of £15.00 per week. The cost of the following is not included in the fee: Your own telephone bills or private calls. Private Chiropody. Hairdressing. Holistic Therapy. Personal transport to access any medical services, where the NHS does not provide transport. Staff escort for your private events, e.g. family social occasions, escort to the and G.P appointments. A contribution to some social events Victoria Court DS0000020113.V360054.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 2 star. This means the people who use this service experience good quality outcomes. This key inspection was unannounced and took place over approximately seven hours. Key inspections take into account a wide range of information and commence before the site visit by examining previous reports and information such as any reported incidents. The site visit is used to see how the service is performing in practice and to meet with the people using the service. The inspection was focused on assessing compliance with defined key National Minimum Standards. A second inspector was also present at this inspection visit and assisted the lead inspector throughout the visit. On the day of this inspection the registered manager was not on duty, therefore the administrator and a senior member of the care staff team assisted the inspectors with any records required. Some of the people living at Victoria Court were spoken with, regarding the care, support and services provided to them. Surveys were sent out to some of the people living at Victoria Court prior to this inspection visit. Nine surveys were returned and the information provided in those surveys, is included within this report. Staff were spoken with to ascertain their views on the care and services provided, and their opinion of the training and support offered to staff. At this inspection visit four people were case tracked. Case tracking is a method used to track the care of individuals from the assessments undertaken before they are admitted to a service through to the care and support they receive on a daily basis. This includes looking at care plans and other documents relating to that persons care, talking to staff regarding the care they provide and if possible talking to the individual. Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Some information within the care plans seen conflicted with other information provided. This needs to be addressed to ensure staff have clear guidance regarding each person. Not all records relating to Fire safety checks and assessments had been undertaken in accordance with the homes policies. This should be addressed to ensure the safety of everyone at Victoria Court isn’t compromised. Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 7 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. Victoria Court DS0000020113.V360054.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 Victoria Court DS0000020113.V360054.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information provided enabled prospective residents to make an informed choice about the service, and decide if the service was right for them. The pre admission assessment undertaken, ensured the service could be confident that each persons needs could be met before admission was agreed. EVIDENCE: The service user guide has been updated since the last inspection visit and contains all of the required information. However some of this information needs to be updated, such as some staff named in the staff complement no longer worked at Victoria Court. The inspection report summary within the service user guide was not from the Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 10 homes previous inspection undertaken in November 2006 but from the inspection undertaken in February 2005. All of the four people living at Victoria Court had pre admission assessments in place. These assessments were detailed and addressed all areas of need. In general the information provided was clear. However one assessment seen did provide some conflicting information regarding needs, and this assessment did not state the date of the initial needs assessment. Comments made either on the day of the inspection visit, or within the surveys received indicated that the people living at Victoria Court, had received enough information prior to moving into the home. This allowed them to make an informed choice about the home before making a decision to move in. It was also indicated that an open and welcoming environment enabled prospective residents and their families to look around the home, without prior agreement. Comments included “ I knew instantly that it was right! Arrived without prior warning and was made to feel welcome immediately”. Victoria Court DS0000020113.V360054.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual’s health, personal and social care needs were set out within their plan of care and demonstrated that health care needs were met. EVIDENCE: The service was in the process of transferring their care planning documentation to a new format. Of the four peoples care files seen two of these had been transferred to the new system and two remained on the old care planning system. The new format included the individual’s life history and generally these were detailed and provided staff with sufficient information about each person. This information gave each individual an identity, which supported the staff team in, getting to know them and demonstrated that each person was treated as an individual with their own knowledge, skills, interests, likes and dislikes. Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 12 However the information regarding one person’s life history had not been fully transferred from the old care plan format. Key workers were allocated to each individual. The key worker was responsible for ensuring that each area of need was reviewed monthly and any changing needs were addressed and recorded. Of the four peoples files, three had been allocated a key worker. Records stated that no key worker had been allocated to the other person due to staff vacancies. The care plans seen identified the strengths and needs of each person, including the areas where support and assistance was required, and ensuring that strengths were maintained to promote independence. In general the information provided was good and centred around each individual’s needs. However some information conflicted with other information provided. Such as one persons care plan, which stated that they needed certain foods cutting up for them in one document and in another document stated that they were able to eat and drink unaided. Another example of conflicting information related to a persons pain relief, which stated ‘no pain assistance needed’ but this person was prescribed two different types of pain relief medication. One person spoken with said that they were told by staff when their bath day was. This person said that they would like to bathe more often. This information was passed to the team leader on duty. Assessments were in place that identified areas of risk and how these were to be managed. These were generally well detailed, but again there was some conflicting information. One person with a medical condition that could be affected by diet, had a care plan that stated that they had no dietary needs resulting from their medical condition. However discussions with this person confirmed that certain foods would affect their medical condition. The cook was aware of the majority of these food types but stated that they were not aware of all the foods that this person stated they were unable to eat. Another example of conflicting information was relating to a person who had been recently admitted to the service due to falls. Although this person had not fallen since admission, it had been identified that there was no need for a falls assessment to be in place. Of the records seen monthly reviews had not taken place on all areas of care identified. However looking at the records of reviews that had taken place, it appeared that any changing needs had been identified and reviewed. This may suggest that all areas of care were being reviewed, but only areas of need identified as requiring changes were being recorded. Records should be in place to demonstrate that all areas of care and support are reviewed, even when there are no changes to the support provided. Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 13 Evidence was seen to demonstrate that six monthly review meetings were being undertaken and these meetings included the individual and their family or representative. Health care needs had been addressed within the four files seen and records were kept of visits from doctors and other health care professionals The medication practices at Victoria Court were assessed and in general were satisfactory. One of the four medication administration records seen did not have a photograph, identifying the individual. It was stated that this person had only been at the home for two months and a digital photograph had been taken but not printed. However the purpose of a photograph is to ensure that staff can clearly identify each individual prior to administering medication. This is more beneficial when new people are admitted to the service, as staff will not ‘know them’. The people that chose to self-administer and retain their own medication had risk assessments in place. The purpose of these assessments is to demonstrate each person’s capacity to administer and store their medication safely. The risk assessments seen should have further detail to demonstrate each person’s ability and understanding of their medication. The service had notified us of a medication error that had occurred in October 2007. During this inspection visit records were looked at regarding how this incident was addressed, and the actions that were taken. The records demonstrated that the appropriate actions were taken to ensure the safety of people receiving medication was maintained. All individual’s had access to a telephone, although some people at Victoria Court had chosen to have their own telephone line within their private accommodation. Comments made both within surveys and on the day of the inspection visit, indicated that the people living at Victoria Court felt that staff treated them respectfully and respected their privacy and dignity. However there was two separate occasions when staff were observed entering a person’s private accommodation. On one occasion knocking but not waiting for a response before entering the room. This person was able to respond to staff, but was not given an opportunity to do so. The other occasion a member of staff entered the person’s private accommodation without knocking. Although it is appreciated that staff may be busy they must be mindful of ensuring each person living at the home receives staff respect at all times, to ensure their privacy and dignity is respected and their autonomy preserved. Victoria Court DS0000020113.V360054.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 good. This judgement has been made using available evidence including a visit to this service. The people living at Victoria Court are able to participate in activities that are meaningful to them. Visitors are made welcome, which enables relationships to be maintained and promotes well-being. EVIDENCE: An activities coordinator was available at the home for 24 hours a week. Discussions took place with the activities coordinator regarding the types of activities that were undertaken. Records were seen, which were completed each day to show who had participated in activities and who had chosen not to participate, but may have observed the activity being undertaken. Activities included; arts and crafts, bingo, pampering days, quizzes, reading groups, table top games and film afternoons. The activities coordinator discussed how she encouraged individuals to participate in activities and said that this often included one to one time with individuals. Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 15 The surveys returned by the people living at Victoria Court indicated that activities were available for those that wished to join in. The people spoken with on the day of the inspection visit also confirmed that there were always activities available at Victoria Court. Different churches within the area provided services at Victoria Court each month for anyone who wished to attend. Visiting at Victoria Court was open and individuals were able to receive their visitors either within their private accommodation or within the communal areas provided. A facility for making drinks was available to the people living at the home and their visitors both within each person’s private accommodation and within the communal areas. Advocacy services were available to the people living at Victoria Court and information regarding local advocacy services was available in the entrance area of the home. Comments received from the people living at Victoria Court were positive, and indicated that the quality and variety of meals provided was very good. Comments included, “All the meals are first class. Plenty of choice and variety” and “Meals are superb, better than some 5 star hotels”. Breakfast was available to residents as and when it was required, to ensure that each individual was able to rise at their preferred time. A list of each person’s likes and dislikes, in relation to meals was kept in the kitchen. Special diets were catered for such as gluten free diets, and this was seen during a tour of the kitchen. Victoria Court DS0000020113.V360054.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. Complaints are listened to, taken seriously and acted upon. The safeguarding practices in place ensure that people using the service are protected. EVIDENCE: The service has received two complaints since the last inspection visit in November 2006. Records were seen of both of these complaints. The actions taken and outcome of the complaints demonstrated that they had been dealt with satisfactorily. The complaints procedure provided our website address but did not include our telephone number or regional address. This limits people’s opportunities to raise any concerns they have about the service with the Commission. The written complaints policy for Victoria Court does not give clear confirmation that complaints will be responded to within 28 days. Therefore consideration should be given to amending the wording used. The surveys received and people spoken with were confident that any concerns they had would be addressed by the home. Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 17 The service has made two safeguarding referrals since the last inspection visit and was able to demonstrate that they took the appropriate action to ensure the people living at Victoria Court were protected. Training records demonstrated that throughout 2007 sixteen members of staff had undertaken training in Safeguarding Adults. On discussions with one member of staff, it was clear that they had a good understanding of the procedure to follow in the event of any safeguarding concerns. Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people at Victoria Court lived in a safe well-maintained environment that was kept clean. EVIDENCE: A partial tour of the building was undertaken and the general maintenance of the home was good. Some bathrooms and shower rooms were seen and provided the appropriate moving and handling equipment. It was noted that these rooms were quite ‘clinical’ looking in décor. The kitchen was seen and although quite small in size housed the appropriate equipment. The general standards of cleanliness noted in the kitchen were satisfactory. Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 19 Some private accommodation was viewed, with the permission of the individual’s living in that accommodation. All private accommodation had an ensuite and all had tea and coffee making facilities. New fire alarms and door closures had been fitted to each person’s flat door. New garden furniture had been purchased since the last inspection visit and new soft furnishings, such as curtains and new dining chairs. The people living at Victoria Court and the comments in the surveys returned indicated that the home is always kept fresh and clean. Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 20 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 good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of the staff team enables the needs of each individual to be met. EVIDENCE: The numbers of staff on shift were four care staff and one team leader in the mornings, three or four care staff with one team leader in the afternoon, one activity coordinator that worked twenty–four hours over five days and two waking night staff and a senior on call throughout the night. At the previous inspection there was also a sleep- in available at the home each night. Discussions took place regarding the numbers of staff available throughout the night with regard to the layout of the building. However it has been confirmed that the senior member of staff on call has never been called out. This suggests that there is sufficient staff on duty throughout the night to meet each person’s needs. Discussions with the manager, following this inspection visit confirmed that, should the needs of the people living at Victoria Court change, the night staff numbers would then be reassessed. Of the people spoken with and the surveys returned it was stated that there were sufficient staff available to support individuals in their personal care needs. Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 21 It was confirmed that the service has now met the National targets regarding National Vocational Qualification training, as 50 of the care staff team have now achieved a National Vocational qualification in care at level 2 or above. An NVQ certificate was seen in one staff file looked at. The recruitment records of two members of staff were looked at and all had the required documents in place. However it was noted that one member of staff had commenced work prior to the service receiving a satisfactory Criminal Records Bureau (CRB) check. This person did have a POVA first check in place that was satisfactory, which demonstrates that no convictions relating to vulnerable adults has been made. There was evidence to demonstrate that this member of staff was undertaking induction training. It was confirmed that this member of staff was working under the supervision of an experienced member of staff. However there was no evidence on the staff rota to confirm this. Training records were looked at and in general demonstrated that mandatory training was provided to staff as required. No records were in place regarding infection control training. Discussions with the manager following the inspection visit confirmed that infection control was covered within health and safety training. One member of staff spoken with confirmed that they received mandatory training as required. On discussion with this member of staff it was clear that they had a good understanding of the procedure to follow in the event of any safeguarding concerns. Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Victoria Court is well managed and run in the best interests of the people who live there, as their views and opinions are regularly sought. The financial interests of the people using the service are safeguarded. EVIDENCE: The registered manager was not on duty on the day of this inspection visit. Comments made regarding the manager’s ability to run the home were positive. The Quality assurance systems in place at Victoria Court were assessed. Meetings for the people living at Victoria Court were held monthly, and the minutes of these meetings were seen. The actions taken from previous Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 23 meetings were recorded and demonstrated that the views of the people living at the service were taken seriously and acted upon. Questionnaires had been sent out to relatives and friends in November 2007 and the records showed that twenty-five had been returned. The results of these questionnaires had been assessed and were regarding the level of hospitality, efficiency and communication at Victoria Court. Surveys were also sent out to the people living at Victoria Court in May 2007 and the records showed that these surveys related to views on personal care and house keeping support. The results of surveys and any actions that were being taken were discussed at the monthly meetings and evidence was seen of this within the minutes looked at. The financial transaction records were examined. All transactions undertaken were documented correctly and signed by two people. Small amounts of money was kept for individuals and stored securely, any additional monies were banked within an interest free account. A new company policy was in place dated November 2007, which stated that monies should be accessible to each person 24 hours a day. However it was confirmed by the administrator that only the manager and administrator were able to access personal accounts. As this is the policy of the service, consideration should be given as to how this can be achieved, whilst ensuring resident’s financial interests remain secure. The homes policy also stated that each individuals financial records should be printed off and given to them on a monthly basis. The administrator said that this was not done, as the people living at the home did not want a monthly print out of their financial records. Again as this is the policy of the service, this should be given further consideration. Some of the safe working practices of the home were assessed. This included weekly fire alarm tests. The records for these tests did not demonstrate that weekly checks had been undertaken, for example the records showed that the fire alarms had been tested three times in December, once in January and twice in February. March records were up to date. Other safety checks were looked at and the majority were up to date. However some records were not. This included monthly fire checks last recorded in May 2007 and the annual fire risk assessments last undertaken October 2006. The last recorded Health and Safety risk assessment was September 2006. Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 24 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 25 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. 2 3 Refer to Standard OP1 OP7 Good Practice Recommendations The Service User Guide should be amended as required, to provide up to date information for service users and prospective service users. Information provided in care plans, risk assessments must be kept up to date, so that staff know the persons current needs and wishes. All people living at Victoria Court should be allocated a key worker to ensure care plans, risk assessment and other documents are kept up to date. To ensure that staff know the person’s current needs and wishes. All areas of care identified on care plans must have a record to demonstrate that monthly reviews have been undertaken. Risk assessments for people choosing to self-administer their medication, should provide detail to demonstrate their understanding of the medication, the dose to take and the importance of securely storing their medication. DS0000020113.V360054.R01.S.doc Version 5.2 Page 26 OP7 4 5 OP7 OP7 Victoria Court 6 7 OP10 OP16 8 9 OP16 OP29 10 11 OP38 OP38 Staff should knock and wait before entering anyone’s private accommodation. This is to ensure that each person’s privacy and dignity is maintained. The Commissions regional telephone number and address should be included on the Complaints policy. This is to ensure there is more than one method of contact available, for anyone wishing to refer a concern to us. The complaints policy should be amended to clearly state that complaints will be responded to within 28 days. The staff rota should show that any new member of staff commencing employment with a satisfactory POVA first check but without a satisfactory CRB in place, is being supervised at all times. This is to ensure the protection of the people living at Victoria Court. Weekly fire alarm tests and monthly fire checks should be undertaken and recorded. This is to ensure the safety of everyone in the building is promoted and protected. A fire risk assessment should be undertaken annually to ensure the safety of everyone at Victoria Court is not compromised. Victoria Court DS0000020113.V360054.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact 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 Victoria Court DS0000020113.V360054.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!