Inspection on 20/06/06 for Old Vicarage Nursing Home

This inspection was carried out on 20th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Old Vicarage Nursing Home 06/02/08

Old Vicarage Nursing Home 02/09/05

Old Vicarage Nursing Home 07/06/05

Old Vicarage Nursing Home 09/12/04

Old Vicarage Nursing Home 11/08/04

Old Vicarage Nursing Home 12/11/03

Old Vicarage Nursing Home 18/06/03

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Old Vicarage Nursing Home Norwich Road Ludham Norfolk NR29 5QA Lead Inspector Ann Catterick Unannounced Inspection 20th June 2006 09:30 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 Old Vicarage Nursing Home DS0000015669.V300989.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. Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Vicarage Nursing Home Address Norwich Road Ludham Norfolk NR29 5QA 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) 01692 678346 01692 678565 Hewitt-Hill Limited Position Vacant Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That appropriate care and accommodation can be provided for up to three (3) service users who are under 65 years of age. Twenty-nine (29) older people may be accommodated. One service user suffering from dementia may be accommodated. Date of last inspection 2nd September 2005 Brief Description of the Service: The Old Vicarage is a care home with nursing for older people, and is situated in the village of Ludham. Hewitt-Hill Limited owns the home. The cost of a placement at the home is between £338 and £525 a week. This information was correct on 20/05/06 The cost of rooms is included in the Service User Guide. The majority of service users require nursing as well as personal care and the staffing ratios reflect this level of care, with a nurse on duty at all times. The 29 bedrooms are situated over two floors with access via a shaft lift. Some of the ground floor bedrooms open direct to the gardens. The communal areas consist of two lounges and one conservatory that can double as a dining area. The grounds consist of surrounding lawns, shrubs, large trees and flowerbeds, with a small patio area and pond, all of which can be accessed by service users. There is ample car parking at the front of the premises. Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced key inspection and the site visit took place on the 20th June 2006. The visit lasted for 8.5 hrs. The information for this report was obtained from information collated since the last inspection, a pre inspection questionnaire, comment cards from service users, relatives and professionals as well as the site visit. The inspector was able to speak with service users, staff and visitors, inspect files, care plans and other documents as well as having a tour of the building. Nine comment cards were received from service users and most comments were positive with satisfaction in all areas either always or usually. The only criticism identified by three service users was that they sometimes had to wait longer than they would like when they rang the call bell. Eight comment cards were received from relatives and all stated that they were satisfied with the overall care. Three were of the opinion that there were not always enough staff on duty at all times. One relative stated, “The care is very good. The staff are lovely, very polite and helpful. I can leave my relative knowing they are in good care.” Some stated that they were not aware of how to access inspection reports but on the day of the site visit a copy of the last inspection report was near the signing in book. The comment card from health professionals was positive. Within the pre inspection questionnaire the manager had identified areas where improvement had and still is taking place. Also included was a copy of the home’s Clinical Governance Development Plan for 2006/2007. This gave the general aims and plans for the home over the 12-month period. Since the last inspection the CSCI received one anonymous referral relating to general concerns about staffing numbers and management availability. This was appropriately investigated by the manager and found to be unsubstantiated. At the site visit all of those service users spoken to were very positive about the staff and the care they received. Staff appeared to enjoy their work and the way they were seen to work with service users was very good. Since the last inspection there have been significant improvements in many areas and the overall quality of care in the home is good. Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Since the last inspection there have been many improvements within the home. The home now has a manager who is competent and able to develop the service looking to improve all aspects of care provided. Good assessments are completed by the home and received from professionals prior to admission. The home now has resident and relative forums to discuss any issues and look at what it is felt that the home does well and to ask if there are any areas for change or improvement. There are now regular staff meetings to encourage good teamwork and to keep staff informed and to share information. Training is promoted and encouraged and the home now has links with the nutritionist from the hospital and also links with the staff who are involved with the gold standards framework for caring for those who are coming towards the end of their lives. The home is to train some of its own staff as moving and handling trainers. There are more staff on duty at any one time and this ensures that the care needs of service users are being met. There has been some decoration completed and new furniture has been bought for the bedrooms and this includes a lockable bedside cabinet. Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Old Vicarage Nursing Home DS0000015669.V300989.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 Old Vicarage Nursing Home DS0000015669.V300989.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides the appropriate information to prospective service users and their families to enable them to make an informed choice as to whether or not they believe the home will meet their needs and preferences. Before a prospective service user is offered a place at the home assessments are made to ensure that the home can meet identified needs. The home does not offer intermediate care. EVIDENCE: At the entrance to the home there are copies of the Statement of Purpose and Service user Guide. These documents give all the information needed to enable prospective service users and their families to be able to make an informed choice as to whether the home would meet their needs in a way that suited them. The documents are easy to understand and written in plain Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 10 English. Once admitted service users can have their own copies of these documents. A copy of the most recent inspection report was also at the front of the home near where visitors signed in. Of the nine comment cards received by service users 7 indicated that they had received enough information about the home prior to admission, 1 made no comment and 1 felt that the hospital had sent them straight to the home and they had little information about it. This last service user had been admitted to the home in 2004 and practice has changed since that time. The files of two service users who had recently been admitted to the home were inspected and included the appropriate assessments. For example and assessment of need had been completed by the manager prior to admission. An assessment from the social worker involved was comprehensive and there was also a transfer summary from the hospital ward from where the service user was being discharged. Old Vicarage Nursing Home DS0000015669.V300989.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users have an individual care plan that includes details of individual need therefore enabling care and nursing staff to have the information about personal and nursing need and how these needs should be met. The home has a policy and procedure for dealing with medicines and those observations of practice and recording seen on the day of the sight visit were generally good with some opportunity for improvement. All of those service users spoken to on the day of the site visit said that staff treated them with respect and promoted their dignity. The home is to sign up to the Gold Standards Framework for the care of the dying as a way to promote and ensure good knowledge and practice in this area. This was seen as good practice. Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 12 EVIDENCE: Three care plans were looked at in detail and the overall quality of the care plans was good. The home is in the process of changing where care plans are kept. The practice has been that daily records are kept in the service user’s bedrooms and care plans are kept in the office. The manager is aware that care plans should be available to service users as well as staff and is changing practice so that care plans and running records are kept in the service user bedrooms. Bedroom doors are not lockable and the manager needs to ensure confidentiality in this area. The content of care plans was thorough and clear specific details of personal and nursing needs were identified. Information with regard moving and handling, health and nutrition, pressure care and personal risk assessments was seen on file as well as more general needs and preferences. Information with regard social history was also seen on care plans, giving relevant information that would support and inform staff when having social interaction with service users. The manager has devised a nursing information sheet for nurses to complete to ensure good communication between nurses who work in the home and community nurses that may come to assess service users health needs. This form also ensures that the health needs are clearly identified recorded and reviewed. Care plans were reviewed on a regular basis. Service users had not signed their care plans and it this made it difficult to assess how involved service users and their families were in the completion of the care plans. A recommendation has been made in this area. Of the 9 comment cards received from service users 4 ticked that they always received the care and support they need and 5 ticked that they usually received the care and support needed. Where comments had been made they referred to the fact that on some occasions service users had to wait for the buzzer to be answered and on occasions if need was urgent this could cause some distress. All of those service users spoken to said that their care needs were being met and spoke very positively about the home. A visitor spoken to said that they believed the care their relative received in the home was very good. The medication policy was last reviewed in 2005 and the present manager is in the process of auditing all procedures to ensure they are accurate and support good practice. All service users have a locked drawer in their bedrooms and a risk assessment would be completed if a service user chose to care and administer their own medication. Some areas of medication practice were seen on the day of the site visit. Four medications were audited and for three it was easy to cross reference how many tablets had been received and how many tablets had been administered and how many tablets were left. Three were correct and for one a previous medication administration record (MAR) could not be found. It was felt another nurse had put this in a different place therefore this medication could not be audited. Tablets being administered from the nurses hand to the service user was observed and this is not good Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 13 practice as tablets should be given straight from the there bottle or packet or transferred from packet to pot to service user to ensure no cross contamination of medication. There were a couple of squares on MAR charts that were not filled in and staff need to ensure they always record when medication is given or not. A recommendation has been made in this area. Storage of medication is appropriate for all medication, including controlled drugs and the fridge in the medical cupboard was of the correct temperature and checked on a daily basis. All of those service users spoken to said that they were treated with respect and their privacy and dignity were maintained. One service user said that staff always knocked on his door before entering. Service users were having their hair done on the day of inspection and service users personal appearance and wellbeing was seen to be promoted and encouraged. Staff were seen to speak and care for service users in a supportive and respectful way. At lunchtime, where assistance was given to service users, it was given in a quiet and unobtrusive way. The GP visited at lunchtime and needed to offer a physical examination to a service user who had just started his lunch. The inspector was in the room and left but felt that this, less than ideal situation, could have been avoided. Staff were aware that the service user needed to see the GP and that the visit was often at lunchtime. Person centred care would have been to offer lunch a little early or suggest he have lunch after the Doctor’s visit. A recommendation has been made in this area. The manager has made links with those community health staff who promote the good care of the dying and is to sign up for the Gold Standards Framework This offers good practice training and guidelines for caring for those who are coming to the end of their lives. This was seen as good practice. Old Vicarage Nursing Home DS0000015669.V300989.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users spoken to said that they found that the lifestyle experienced within the home met their needs and all seemed satisfied with their daily lives. Family and friends are encouraged in the home and made welcomed by staff. Wherever possible staff aim to encourage and empower service users to exercise choice and have control over their own lives. The food provided in the home is wholesome and well balanced. The communal space for service users to eat their meals is limited. EVIDENCE: Those service users spoken to felt satisfied with their lifestyle within the home. The home has two lounges, one with a TV and video and another with a radio and cassette. Most service user have a TV and/or radio in there room. Some service users stay in their room and others use the communal facilities. Some social activities are offered and staff have some time to socialise with service users. This is an area that the manger hopes to develop further. Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 15 Some of the service users have significant nursing and personal care needs spending much of their time quietly in their rooms. The visitor’s book suggested that the home has lots of visitors and those visitors spoken to stated that they were always welcomed into the home. Eight relative/visitors comment cards were received and they all ticked to say they were always welcomed into the home. The home also has resident/relative forums to encourage communication and to ask if there are any areas that the home could improve or further develop. The home also has a newsletter for relatives and service users. The work in this area has been commended. The meals provided in the home are made using local produce and shops whenever possible. The menus were included with the pre inspection questionnaire (PIQ) and offer a wide and varied choice. If service users do like the main choice there is always alternatives to choose from. Eight service users responded to the question on the comment card about meals. Six said they always liked the food and 2 said they usually liked the food. On the day of the site visit service users were seen to be enjoying their lunch and their tea. The designated dining area is a conservatory and although the ambience is good it is often too cold in the winter and too hot in the summer. This means that service users have no dining area for much of the year. Service users have their meals in their rooms, if they choose, or on a small individual table in the lounge. This is not ideal and a requirement to improve this situation has been made. Old Vicarage Nursing Home DS0000015669.V300989.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is made available to service users and their families and the home takes its responsibilities with regard complaints seriously. The home has a policy and procedure to protect service users from abuse. EVIDENCE: The home’s complaints procedure is on display at the entrance of the home and is included in the Service User Guide. It was revised in 2006. The home had received three complaints since the last key inspection and had dealt with these in a positive and appropriate way. Evidence suggested that service users concerns or complaints are always taken seriously. An example of one of the complaints was that a visitor thought that their relative’s teatime meal was too small a portion. This was discussed and the complainant was satisfied with the outcome. Where an anonymous complaint was made to the CSCI the manager dealt with this appropriately and the complaint was investigated and found to be not substantiated. Those service users spoken to said that they would feel happy sharing any concerns they had with senior staff or the manager. The Adult Protection policy was revised in 2005 and included all relevant information. The manager is aware of local procedures and protocol. Those staff spoken with said they would be confident to report any concerns about Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 17 abuse to the manager and all staff had received training in this area. The home has a whistle blowing policy for staff. Old Vicarage Nursing Home DS0000015669.V300989.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 25 and 26 The quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It is adequate as some although some areas are poor the manager a proprietor plan to address these issues. If there were no changes in these areas at the next inspection the quality of this outcome area would move to poor. Most parts of the home are safe and well maintained but some areas need further improvement. Usable communal space is limited for much of the year due to the fact that the conservatory area is often too hot or too cold to use. Bathrooms are not all used for there stated purpose and would benefit from refurbishment. All bedrooms seen were comfortable and met the needs of the occupants. Most areas of the home are safe for service users but improvements need to be made in some areas. Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 19 On the day of the site visit the home was clean and free from any offensive odours. EVIDENCE: The home has developed a programme that identifies were routine maintenance and repair needs to take place but this does not appear to be reviewed or monitored in any meaningful way. This is completed by the handyperson and deputy of the home and with minor tinkering could be used as a way of monitoring quality and planning for improvement in this area. The building complies with local fire regulations and the last visit by the fire service was 21/04/06. The recommendation from the fire service was to improve on risk assessment documentation. The grounds are well kept and offer a pleasant environment to sit out in when the weather is good. The home has two lounge areas and a large conservatory. The conservatory is cold in the winter and the radiators in there do not offer sufficient heat to allow the room to be used. In the summer if the weather is warm it becomes too hot and service users are once again unable to use it. This was the case on the day of the site visit. The inspector was only able to spend about 10 minutes in the conservatory before it became too hot to remain. The proprietor has long term plans to further develop the communal areas, however in the interim period, which could be some time, he needs to ensure that the conservatory is usable. The manger plans to order new blinds that will keep the room cooler in summer and the proprietor said he would look at ways to make the conservatory warmer in winter. On the day of the site visit the conservatory was too hot for service users to use, the hairdresser was setting hair in the TV lounge and this left only the second lounge for service users. All service users have their meals in their bedrooms or in the lounges. The accessible communal space is not adequate. A requirement has been made in this area. The home has four bathrooms although one is used as a storeroom. The bath in this bathroom is low, against the wall and would meet the needs of few, if any service users. This leaves only three bathrooms for 29 service users. They were all cluttered with one housing the linen trolleys. These would have to be move out and placed somewhere else before the bath could be used. Other bathing or toileting paraphernalia was in the bathrooms and made them feel unwelcoming and institutionalized. A requirement has been made in this area. The water outlets do not have pre set values that control the water temperature locally but valves at the boiler site. This makes individual water temperatures throughout the home hard to control. Record showed that on Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 20 many occasions the temperature of water was over 50 degrees centigrade. The exact temperature had not been recorded as the thermometers only went up to 50 degrees. Appropriate thermometers need to be purchased. This area needs to be addressed and risk assessments completed. A requirement has been made in this area. All radiators seen were covered, although most of these covers are not attractive and would benefit from being replaced with covers that are less institutionalised. A recommendation has been made in this area. In one bedroom assisted technology was being used to ensure safety for the service user. This was good practice but the floor mat had to be plugged into the call bell system point and meant that if the mat was in use the call bell could not be. An additional connection needs to be provided for in this bedroom. A recommendation has been made in this area. On the day of the site visit the inspector was able to visit most areas of the home and other than the cluttered bathrooms all areas were clean and tidy and there were no offensive odours in the building. Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are enough skilled and competent staff employed at the home to ensure that the needs of the service users are being met. The home encourages staff to complete NVQ qualifications and some of those staff who do not have NVQ have equivalent qualifications. Three staff files were looked at in some detail. All documentation required was either on file in the process of being sought. Within their first three months of work staff received a comprehensive induction programme. Staff are also encouraged to complete further training to improve their skills and increase their knowledge. EVIDENCE: A copy of the rota was sent to the inspector before the visit and there appears to be sufficient staff on duty at any one time to meet need. The manager is a nurse and office based Monday to Friday. One nurse is always on duty and three days a week two nurses are on duty for three shifts a week. Between 6 or seven care staff are on duty for the early shift and 4 or 5 carers for the evening shift. A nurse and two care staff are on duty each night shift. All laundry is washed and ironed on site and this is done by the care staff. This Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 22 takes care staff away from their carer’s role and this should be considered when completing the rota. The manager said that when additional needs are identified she would have more staff on duty. Two examples were given. On the day of the site visit an additional staff member was on duty to work alongside a new member of staff. The following day and additional member of staff was on duty as it was known that one member of staff would be out of the building as a service user needed an escort when attending a day appointment at the hospital. This was seen as evidence of good practice. The home was clean and tidy suggesting that there are sufficient domestic staff. The manager felt that additional kitchen staff in the afternoon would give care staff more opportunity to offer social and one to one care to service users instead of being responsible for serving afternoon tea. Overall the rota is managed well and would meet with the nursing staffing notice that was issued to the home by the local Health Authority. The home has not achieved 50 of staff trained to NVQ level 2 or above but is well on the way to meeting this. Some overseas staff do not have their NVQ level 2 but are experienced qualified nurses in their own country and their knowledge and experience is of a high standard. Training is encouraged and three staff are due to commence NVQ level 2 and 3. The home has a policy and procedure for the recruitment and selection of staff. This was last reviewed in 2005. The manager has recently completed an audit of staff files as many of the staff were employed prior to her being in post. She noted that some of the staff from overseas had police checks completed in their own country but there was no evidence of police checks being completed in this country. CRB forms have now been completed and sent off and those staff who did not have a CRB have had POVA first clearance. Most of the CRB forms are also back. All other documents required were seen on file, including references and application forms. Four staff were interviewed and all spoke of a comprehensive induction that included a week of shadow shifts and three months induction and further training. These inductions were completed prior to the present manager being in post and the records of the induction could not be found. The induction form for a new member of staff was seen and was detailed and comprehensive offering all that was needed to ensure that a staff member received a full and beneficial induction. All of those service users spoken to felt that staff were trained and competent in their roles. This was supported by observations of staff made on the day of the site visit. Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36 and 38 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is not registered but is fit, competent and has the skills and knowledge to discharge her responsibilities in full. Service users and staff spoke positively about her approach to management role. The home is run in the best interests of the service users and the manager has begun to quality assure the service. Service users have their financial interests protected by the homes systems for looking after money. Individual formal supervision does not take place although there are plans for this to be implemented in the near future. The health and welfare of service users is promoted and protected by the homes policies and procedures in these areas. Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager is a registered nurse who has experience in management within social care services. The plan is that a new manager will be appointed to the Old Vicarage and Sonia Baker will take on a role that would have her overseeing all of the homes owned by the company. She would no longer have daily involvement but would be in a position to support the manager and developing the service. Prior to the site visit the manager sent a document called the Clinical Governance Development Plan for 2006 and 2007. This identifies general planned improvements and achievements for the home in a formal way. The home has resident and relative forums, staff meetings and training days. There has been some work in auditing the environment and the manager has audited care plans and staff files. Policies and procedures have started to be updated and there is a general feel of improvement and positive outcomes in the home. The manager needs to collate the information in a way that can be published and is easy to understand. The work started in this area is very positive. The proprietor has a responsibility to complete regulation 26 visits to the home as described in the Care Home Regulations 2001 but these have yet to take place. A requirement has been made in this area. The home looks after some money for the service users. The home has a new full time administrator who audited the accounts when she commenced her role. Three service users money was checked and cross references made and all was in good order with clear recording and information. The manager has staff meetings but as yet has not started supervision. She has plans to develop this in the near future and had been devising a supervision policy and procedures. A requirement has been made in this area. The home provides mandatory training with regard moving and handling and fire safety. Those staff spoken to said that this was included as part of their induction. All staff who work in the kitchen have completed their food hygiene certificate. The staff have a good understanding of infection control and good practice was observed in this area. The inspector does not feel competent to inspect against the outcomes for standard 38.4 however policies and procedures as well as training appeared to be in place in these areas. Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 25 Risk assessments are carried out for the individual but there are no general risk assessments for the home. There were some areas of the home were a general risk assessment was needed, for example near some isolated stairs. A requirement has been made in this area. Evidence was seen of accidents, injuries and incidents being recorded and the manager fulfils her responsibilities under section 37 of the care home regulations. Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 26 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 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 1 1 x 3 x 2 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 3 2 x 3 1 x 2 Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 27 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 OP20 Regulation Requirement Timescale for action 01/09/06 2 OP21 3 OP25 4 OP33 5 OP36 23.2(g), The registered person must (h) and (i) ensure that the home provides adequate communal space for service users. This requirement has been repeated from the last inspection report. 23(j) The registered person must ensure that all service users have access to a bathing facility that meets their needs. This requirement has been repeated from the last inspection report. 13.4 (a) The registered person must ensure that the hot water from taps and baths to which service users have access is kept at recommended temperatures and risk assessments are completed where necessary. 26 The registered person must ensure that regulation 26 visits are made to the home as described in regulation 26 of the Care Home Regulations 2001. 18.2 The registered person must ensure that staff are offered formal supervision. DS0000015669.V300989.R01.S.doc 01/09/06 01/08/06 01/08/06 01/09/06 Old Vicarage Nursing Home Version 5.2 Page 28 6 OP38 13.4 (c ) The registered person must ensure that where appropriate general risk assessments are completed to promote the safety of service users. 01/08/06 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 4 Refer to Standard OP7 OP9 OP9 OP10 Good Practice Recommendations It would be seen as good practice to encourage service users and/or their families to sign care plans to evidence they have been involved in there completion. That staff do not handle medication any more than is necessary. That staff make a record in the MAR sheets whenever medication is given or not given at the times of administration. That if the GP attends to visit service users at lunchtime that thought is taken as to how any loss of dignity can be avoided. For example for lunch and examination not to take place in the bedroom at the same time. That those radiator covers that are of poor quality be replaced. That all rooms are lockable to give service users the choice as to whether or not they wish to lock their bedroom doors. That additional connection points are placed in rooms were assisted technology is used as at the present time the safety mat or the call bell can be plugged in but not both together. 5 6 7 OP19 OP24 OP25 Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 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 Old Vicarage Nursing Home DS0000015669.V300989.R01.S.doc Version 5.2 Page 30 - 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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